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Langner-Wegscheider BJ, ten Dam-van Loon N, Mura M, Faridpooya K, de Smet MD. Intravitreal ganciclovir in the management of non-AIDS-related human cytomegalovirus retinitis. Can J Ophthalmol 2010; 45:157-60. [DOI: 10.3129/i09-262] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Lin YC, Yang CH, Lin CP, Yang CM, Chen MS, Chen MY, Sheng WH, Hung CC, Chang SC. Cytomegalovirus Retinitis and Immune Recovery Uveitis in AIDS Patients Treated with Highly Active Antiretroviral Therapy in Taiwanese. Ocul Immunol Inflamm 2009; 16:83-7. [DOI: 10.1080/09273940802056307] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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53
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Gharai S, Venkatesh P, Garg S, Sharma SK, Vohra R. Ophthalmic Manifestations of HIV Infections in India in the Era of HAART: Analysis of 100 Consecutive Patients Evaluated at a Tertiary Eye Care Center in India. Ophthalmic Epidemiol 2009; 15:264-71. [PMID: 18780260 DOI: 10.1080/09286580802077716] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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54
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Yoon CK, Woo SJ, Yu HG. Visual Outcome of Cytomegalovirus Retinitis in Korean Patients With Acquired Immune Deficiency Syndrome. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2009. [DOI: 10.3341/jkos.2009.50.1.92] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Chang Ki Yoon
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
| | - Se Joon Woo
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeong Gon Yu
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Sensory Organs, Medical Research Center, Seoul National University, Seoul, Korea
- Institute of Rheumatology, Medical Research Center, Seoul National University, Seoul, Korea
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Couch SM, Bakri SJ. Intravitreal triamcinolone for intraocular inflammation and associated macular edema. Clin Ophthalmol 2009; 3:41-7. [PMID: 19668543 PMCID: PMC2708981 DOI: 10.2147/opth.s4477] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Triamcinolone acetonide (TA) is a corticosteroid that has many uses in the treatment of ocular diseases because of its potent anti-inflammatory and anti-permeability actions. Intraocular inflammation broadly referred to as uveitis can result from several causes, including the immune system and after ophthalmic surgery. One of the most common reasons for vision loss with uveitis is macular edema. TA has been used for many years as an intravitreal injection for the treatment of ocular diseases. Several case control studies have been reported showing the efficacy of TA in the treatment of intraocular inflammation and associated macular edema caused by Behcet's disease, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia and white dot syndromes. It has also been shown efficacious in cases of pars planitis and idiopathic posterior uveitis. Some authors have reported its use in postoperative cystoid macular edema. Many of the studies on the use of TA in controlling intraocular inflammation and concomitant macular edema showed its effect to be transient in many patients requiring reinjection. Complications can arise from intravitreal injection of TA including elevated intraocular pressure and cataract. Rarely, it can be associated with infectious and non-infectious endophthalmitis. TA may be useful as an adjuvant in the treatment of uveitis and its associated macular edema, especially in patients resistant or intolerant to standard treatment.
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Affiliation(s)
| | - Sophie J Bakri
- Correspondence: Sophie J Bakri, 200 First Street SW, Rochester, MN 55905, USA, Email
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[Treatment of opportunistic infections in adolescent and adult patients infected with the human immunodeficiency virus during the era of highly active antiretroviral therapy. AIDS Study Group (GESIDA) and National AIDS Plan Expert Committee]. Enferm Infecc Microbiol Clin 2008; 26:356-79. [PMID: 18588819 DOI: 10.1157/13123842] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Despite the huge advance that highly active antiretroviral therapy has represented for the prognosis of infection by human immunodeficiency virus (HIV), opportunistic infections continue to be a cause of morbidity and mortality in HIV-infected patients. This is often the case because of severe immunodepression, poor adherence to antiretroviral therapy, failure of therapy, or the fact that patients are unaware of their HIV-positive status and debut with an opportunistic infection. This article updates the guidelines on treatment of acute episodes of various opportunistic infections in HIV-infected patients, including infections due to parasites, fungi, viruses, mycobacteria, and bacteria. This edition has a new chapter on imported parasite infections as well as additional information on endemic mycoses in the chapter on fungal infections, taking into account the growing number of immigrants in our setting. Lastly, the chapter on the immune reconstitution syndrome has also been updated, providing relevant data on a phenomenon that has clinical and diagnostic repercussions in patients who start antiretroviral therapy while they are severely immunodepressed (English version available at http://www.gesida.seimc.org).
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Multifocal electroretinography in HIV-positive patients without infectious retinitis. Am J Ophthalmol 2008; 146:579-88. [PMID: 18280451 DOI: 10.1016/j.ajo.2007.12.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Revised: 12/12/2007] [Accepted: 12/14/2007] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate early changes in the central retinal response in human immunodeficiency virus (HIV)-positive patients without infectious retinitis using multifocal electroretinography (mfERG). DESIGN Case control study. METHODS We evaluated three cohorts: HIV-negative controls and two groups of HIV-positive patients separated according to their nadir CD4 counts (>or= 100 cells/mm(3) and < 100 cells/mm(3) for a minimum of six months). mfERG first-order kernels (FOKs) and second-order kernels (SOKs) were analyzed separately by areas of rings, quadrants, and individual hexagons for each cohort. RESULTS Of 103 hexagon locations of FOK results, there were no significant differences in amplitudes of P1 and N1 across the groups (.05 < P < .50), although there was a trend for an overall reduction in the amplitudes. Similarly, latency N1 did not differ (.28 < P < .95). There were significantly delayed latencies of P1 between cohorts across 103 hexagons in both kernels. SOK results also showed significant delay in latencies of P1 and a trend of reduced P1 amplitudes across studied locations among cohorts (.24 < P < .08). CONCLUSIONS The results demonstrate widespread delay in latency in HIV-positive patients, especially in those with prolonged low (below 100 cells/mm(3)) CD4 nadir counts. These findings suggest early diffuse dysfunction of the inner retina results from severe HIV disease even in the HAART era.
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Cesaro S, Boaro MP, Pillon M, Calore E, Cermakova I, Perruccio K, Mengoli C, Messina C. Immune reconstitution complicated by CMV retinitis in a pediatric patient who underwent haploidentical CD34+-selected hematopoietic stem cell transplant for acute lymphoblastic leukemia. Int J Hematol 2008; 88:145-148. [PMID: 18604650 DOI: 10.1007/s12185-008-0126-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 05/22/2008] [Accepted: 06/04/2008] [Indexed: 12/28/2022]
Abstract
We describe two episodes of CMV retinitis in a pediatric patient who underwent a CD34+ selected graft from his haploidentical father. Both recipient and donor were cytomegalovirus (CMV) seropositive. Both episodes occurred late post-grafting during a phase of complete immunological recovery with sufficient numbers of circulating CMV-specific clones. Antiviral treatment with foscarnet and ganciclovir was successful but prolonged treatment was required to prevent relapses. We hypothesize that this complication was more related to an immune reconstitution process than to an immune-deficient state post-grafting. We conclude that CMV retinitis is a late complication of HSCT that can occur despite satisfactory immune reconstitution. Usually, it is responsive to antiviral therapy. Dilated fundoscopic examination is essential both for examining patients with reduced visual acuity and for screening asymptomatic patients.
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Affiliation(s)
- Simone Cesaro
- Pediatric Hematology Oncology, Department of Pediatrics, University of Padova, Via Giustiniani 3, 35128, Padova, Italy.
| | - Maria Paola Boaro
- Pediatric Hematology Oncology, Department of Pediatrics, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
| | - Marta Pillon
- Pediatric Hematology Oncology, Department of Pediatrics, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
| | - Elisabetta Calore
- Pediatric Hematology Oncology, Department of Pediatrics, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
| | - Ivete Cermakova
- Service of Pediatric Ophthalmology, Department of Pediatrics, University of Padova, Padova, Italy
| | - Katia Perruccio
- Division of Hematology and Clinical Immunology, Department of Clinical and Experimental Medicine, IRCCS Foundation on Transplantation Biotechnologies, University of Perugia, Perugia, Italy
| | - Carlo Mengoli
- Department of Histology, Microbiology and Medical Biotechnology, University of Padova, Padova, Italy
| | - Chiara Messina
- Pediatric Hematology Oncology, Department of Pediatrics, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
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Jacobson MA, Tan QX, Girling V, Poon C, Van Natta M, Jabs DA, Inokuma M, Maecker HT, Bredt B, Sinclair E. Poor predictive value of cytomegalovirus (CMV)-specific T cell assays for the development of CMV retinitis in patients with AIDS. Clin Infect Dis 2008; 46:458-66. [PMID: 18173357 DOI: 10.1086/525853] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND We examined the potential clinical utility of using a cytomegalovirus (CMV)-specific T cell immunoassay to determine the risk of developing new-onset CMV retinitis (CMVR) in patients with acquired immunodeficiency syndrome (AIDS). METHODS CMV-specific T cell assays were performed by multiparameter flow cytometry using stored peripheral blood mononuclear cells that had been obtained in an observational study 2-6 months before new-onset CMVR was diagnosed in case patients (at a study visit during which a dilated ophthalmologic examination revealed no evidence of CMVR) and at the same study visit in control subjects (matched by absolute CD4(+) T cell count at entry) who did not subsequently develop retinitis during 1-6 years of study follow-up. RESULTS There were no significant differences in CMV-specific CD4(+) or CD8(+) T cell interferon-gamma or interleukin-2 expression in peripheral blood mononuclear cells from case patients and control subjects. Although there were trends toward lower percentages and absolute numbers of CMV-specific, cytokine-expressing CD8(+) T cells with a "late memory" phenotype (CD27(-)CD28(-)) as well as with an "early memory" phenotype (CD27(+)CD28(+)CD45RA(+)) in case patients than in control subjects, these differences were not statistically significant. CONCLUSIONS Many studies have reported that CMV-specific CD4(+) and CD8(+) T cell responses distinguish patients with active CMVR (i.e., who lack CMV-protective immunity) from those with inactive CMVR after immune restoration by antiretroviral treatment (i.e., who have CMV-protective immunity). However, the multiple CMV-specific immune responses we measured do not appear to have clinical utility for predicting the risk for patients with AIDS of developing new-onset CMVR with sufficient accuracy to be used in guiding therapeutic management.
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Affiliation(s)
- Mark A Jacobson
- Positive Health Program, Department of Medicine, University of California San Francisco, CA, USA.
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60
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Holland GN. AIDS and ophthalmology: the first quarter century. Am J Ophthalmol 2008; 145:397-408. [PMID: 18282490 DOI: 10.1016/j.ajo.2007.12.001] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Revised: 11/26/2007] [Accepted: 12/01/2007] [Indexed: 12/13/2022]
Abstract
PURPOSE To describe changes in the acquired immunodeficiency syndrome (AIDS) epidemic that are important to ophthalmologists, to provide an overview of issues relevant to current evaluation and treatment of human immunodeficiency virus (HIV)-related eye disease, and to identify problems related to the eye and vision that require continued study. DESIGN Literature review and commentary. METHODS Selected articles from the medical literature and the author's clinical and research experiences over 25 years were reviewed critically. RESULTS The AIDS epidemic has had a profound impact on ophthalmology since the ophthalmic manifestations of AIDS were first described in 1982. The introduction of highly active antiretroviral therapy (HAART) has markedly reduced the incidence of cytomegalovirus (CMV) retinitis, but has not eliminated new cases altogether. Treatment strategies for CMV retinitis have evolved over the past decade. Current issues of importance include choice of initial anti-CMV drugs; time at which anti-CMV drug treatment is discontinued in patients who achieve immune recovery; strategies for monitoring patients at risk for disease reactivation; and management of complications (retinal detachment, immune recovery uveitis). Attention also is being directed to the problem of visual disturbances (reduced contrast sensitivity, altered color vision, visual field abnormalities) that can occur in HIV-infected individuals without infectious retinopathies. CONCLUSIONS Ocular disorders associated with HIV disease remain important problems in the United States, despite HAART, and increasingly are important worldwide. The approach to management of CMV retinitis has evolved from short-term treatment of a preterminal infection to the long-term management of what has become a chronic disease. Many challenges remain to be addressed.
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Hot A, Schmulewitz L, Viard JP, Lortholary O. Fever of unknown origin in HIV/AIDS patients. Infect Dis Clin North Am 2008; 21:1013-32, ix. [PMID: 18061087 DOI: 10.1016/j.idc.2007.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fever of unknown or uncertain origin (FUO) constitutes a common clinical challenge in patients infected with HIV. It is usually caused by disseminated opportunistic infection, and the relative frequency of each cause of FUO is influenced by multiple factors including CD4 count, geographic setting, and local prevalences of infectious agents, which may provide clues to the diagnosis. Infections presenting as FUO in the HIV population occur most often in the late stages of the disease and high diagnostic suspicion for mycobacterial disease should be maintained when evaluating these patients, particularly in areas of high prevalence. This article discusses the causes, diagnosis, and treatment of FUO in HIV-infected individuals.
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Affiliation(s)
- Arnaud Hot
- Université Paris V, Service des Maladies Infectieuses et Tropicales, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, 149 rue de Sèvres, 75743 Paris Cedex 15, France
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Eid AJ, Bakri SJ, Kijpittayarit S, Razonable RR. Clinical features and outcomes of cytomegalovirus retinitis after transplantation. Transpl Infect Dis 2008; 10:13-8. [PMID: 17511815 DOI: 10.1111/j.1399-3062.2007.00241.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Cytomegalovirus (CMV) infection of the retina is a rarely encountered end-organ disease after transplantation. In order to describe the clinical characteristics and outcomes of CMV retinitis after hematopoietic stem cell and solid organ transplantation, we performed a retrospective review of all cases of CMV retinitis at the Mayo Clinic (Rochester, Minnesota) during 1990-2004. During this 15-year period, CMV retinitis was diagnosed in 14 eyes of 9 patients who had received kidney (n=5), liver (n=2), heart (n=1), and autologous hematopoietic stem cell transplant (n=1). The mean age of the patients was 58 (standard deviation+/-11) years; 6 were male. The median time to diagnosis of CMV retinitis was 9 months (range, 4 months to 13 years) after transplantation. Four (44%) patients had concomitant pneumonitis or hepatitis. Five (55%) patients had bilateral retinitis. Retinal involvement was <or=10% in 8 eyes, >10% but <or=50% in 4 eyes, and >50% in 2 eyes. All patients received induction therapy with intravenous ganciclovir (n=8) or foscarnet (n=1) for a median of 43 days (range, 14-100 days) followed by maintenance therapy with intravenous or oral ganciclovir for a median of 88 days (range, 36-943 days) in 6 (67%) patients. One patient developed bilateral immune recovery uveitis during treatment, and later on progressed to develop rhegmatogenous retinal detachment. During the mean follow-up period of 20 months, visual acuity improved in 4 (28.5%), was stable in 4 (28.5%), and worsened in 6 (43%) eyes. CMV retinitis recurred in 2 patients. In conclusion, CMV retinitis is a rare, progressive, and highly morbid infectious complication of transplantation. The severity of clinical disease at the time of diagnosis may predict poor outcome. Hence, early intervention may be crucial to prevent its progression to irreversible visual loss.
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Affiliation(s)
- A J Eid
- Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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63
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Holland GN, Vaudaux JD, Shiramizu KM, Yu F, Goldenberg DT, Gupta A, Carlson M, Read RW, Novack RD, Kuppermann BD. Characteristics of untreated AIDS-related cytomegalovirus retinitis. II. Findings in the era of highly active antiretroviral therapy (1997 to 2000). Am J Ophthalmol 2008; 145:12-22. [PMID: 18154751 DOI: 10.1016/j.ajo.2007.09.040] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Revised: 09/17/2007] [Accepted: 09/17/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE To describe host characteristics (use of highly active antiretroviral therapy [HAART]; CD4+ T-lymphocyte count; HIV ribonucleic acid [RNA] blood level) of people who were diagnosed with AIDS-related cytomegalovirus (CMV) retinitis after HAART became available and to investigate effects of HAART on ophthalmic findings. DESIGN Retrospective, observational case series. METHODS We collected demographic, medical, laboratory, and ophthalmic data for all patients with AIDS and newly diagnosed, untreated CMV retinitis from January 1997 through December 2000 at 10 sites in Los Angeles and Orange Counties, California. RESULTS The proportions of Hispanic and African-American patients were equivalent to or greater than their prevalences in the AIDS and general populations of Los Angeles County. Most patients (n = 80; 63.5%) were known to be receiving HAART at the time of CMV retinitis diagnosis; only 22 patients (17.5%) were HAART-naïve. Median CD4+ T-lymphocyte count was 15 cells/microl and median HIV RNA blood level was 103,000 copies/ml for all patients, but in 10 patients, CMV retinitis developed despite good immunologic and virologic responses to HAART. When compared with HAART-naïve patients, HAART-failure patients with CMV retinitis had more asymptomatic disease (P = .073), better visual acuity in the better eye (P = .003), more bilateral disease (P = .007), less zone 1 involvement (P = .042), and lower lesion border opacity scores (P = .054). CONCLUSIONS Most patients with AIDS and newly diagnosed CMV retinitis in an urban setting are HAART-experienced. HAART may influence characteristics of new CMV retinitis lesions at presentation, despite laboratory evidence of treatment failure, possibly because of residual CMV-specific immunity.
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Affiliation(s)
- Gary N Holland
- Ocular Inflammatory Disease Center, the Jules Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA.
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Moschos MM, Mostrou G, Psimenidou E, Spoulou V, Theodoridou M. Objective analysis of retinal function in HIV-positive children without retinitis using optical coherence tomography. Ocul Immunol Inflamm 2007; 15:319-23. [PMID: 17763130 DOI: 10.1080/09273940701375154] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE To assess the retinal nerve fiber layer thickness in children with human immunodeficiency virus disease without cytomegalovirus retinitis or visual symptoms. METHODS Thirty-eight eyes of 19 human immunodeficiency virus-positive children (group A) with visual acuity of 20/20 or better, normal color vision testing and no ophthalmoscopically detectable disorders were prospectively examined. All subjects of group A had no history of cytomegalovirus retinitis and CD4 counts consistently above 100. Patients in group B (40 eyes of 21 patients) were human immunodeficiency virus-negative age-matched control subjects. Thickness of retinal nerve fiber layer along a 3.4-mm-diameter circle centered on the optic nerve head was evaluated using third-generation optical coherence tomography. CD8 T-lymphocyte count, presence of systemic infection, hemoglobin, hematocrit and serum beta-microglobulin levels were also recorded. RESULTS The mean overall retinal nerve fiber layer thickness in groups A and B were 89.2 +/- 24.01 microm and 102.82 +/- 29.168 microm (SD) respectively. The difference was considered extremely significant (P < 0.0001). Group A had significantly thinner average nerve fiber layer in temporal, nasal, superior and inferior retinal areas. CONCLUSIONS Significant retinal nerve fiber layer thinning occurs in human immunodeficiency virus-positive children with no visual impairment or ophthalmologic evidence or retinitis.
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Tammewar AM, Cheng L, Hostetler KY, Falkenstein I, Beadle JR, Barron EC, Kozak I, Freeman WR. Intraocular Properties of An Alkoxyalkyl Derivative of Cyclic 9-(S)-(3-Hydroxyl-2-Phosphonomehoxypropyl) Adenine, An Intravitreally Injectable Anti-HCMV Drug in Rabbit and Guinea Pig. J Ocul Pharmacol Ther 2007; 23:433-44. [PMID: 17900229 DOI: 10.1089/jop.2007.0018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The aim of this study was to investigate intraocular properties and determine the highest nontoxic dose of hexadecyloxypropyl-cyclic-HPMPA (HDP-cHPMPA), a novel, potent, intravitreally injectable, slow-releasing crystalline drug for long-acting treatment of cytomegalovirus (CMV) retinitis. METHODS Various concentrations of HDP-cHPMPA were first studied in vitro in a human foreskin fibroblast (HFF) cell line infected with human cytomegalovirus (HCMV) to determine the EC50. In vivo, 9 pigmented rabbits and 3 doses (55, 100, and 550 microg/eye) were tested in triplicate in 1 eye of each animal. The eyes were monitored with slit lamp, tonopen, indirect ophthalmoscopy, electroretinography (ERG), and histology. A confirmation toxicity study with the dose equivalent to the highest nontoxic dose in rabbit was performed in 9 guinea pig eyes (a second species) to study the potential adverse effect on intraocular pressure (IOP). RESULTS In vitro testing in HFF cells showed an EC50 against HCMV of 0.02 microM, which is 75- and 60-fold greater than that of ganciclovir and cidofovir, respectively. All eyes injected with 550 microg/eye and 1 eye injected with 100 microg/eye of HDP-cHPMPA showed toxicity clinically (e.g., vitreous cells, disc edema, and retinal inflammation) as well as histologically (e.g., inflammatory cells in iris, vitreous, and retinal layers with disorganization). None of the eyes injected with 55 microg/eye of HDP-cHPMPA showed toxicity clinically (including ERG) and histologically. The equivalent dose (9.2 microg/eye) in the guinea pig eyes did not show toxicity either, including IOP evaluation (P > 0.05 at all time points after injection). CONCLUSIONS Intravitreal injection of the highest nontoxic dose of 55 microg/eye of HDP-cHPMPA in rabbit eyes yields a calculated intravitreal concentration of 65 microM, which is 3250-fold greater than the EC50 against HCMV (0.02 microM). Also, it does not cause hypotony in rabbit and guinea pig eyes and has a vitreous residence time of over 4 months.
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Affiliation(s)
- Ajay M Tammewar
- Jacobs Retina Center at Shiley Eye Center, University of California-San Diego Department of Ophthalmology, La Jolla, San Diego, CA 92037, USA
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Thorne JE, Holbrook JT, Jabs DA, Kempen JH, Nichols C, Meinert CL. Effect of Cytomegalovirus Retinitis on the Risk of Visual Acuity Loss among Patients with AIDS. Ophthalmology 2007; 114:591-8. [PMID: 17123624 DOI: 10.1016/j.ophtha.2006.08.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Revised: 08/01/2006] [Accepted: 08/02/2006] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To describe the prevalence and incidence of reduced visual acuity in eyes of patients with AIDS and without cytomegalovirus (CMV) retinitis at enrollment and estimate the proportion of incident vision loss attributable to new-onset CMV retinitis in this cohort. DESIGN Multicenter prospective observational study. PARTICIPANTS Three thousand fourteen eyes of 1507 patients with AIDS and without CMV retinitis at enrollment. METHODS Medical history, ophthalmologic examination, and laboratory testing collected at enrollment and at follow-up visits every 6 months thereafter. MAIN OUTCOME MEASURES Loss of visual acuity across the < or =20/50 and < or =20/200 thresholds and doubling of the visual angle; potential causes of this vision loss. RESULTS For eyes of patients without CMV retinitis at enrollment, the proportions with best-corrected visual acuity of < or =20/50 and of < or =20/200 were 3.9% and 1.8%, respectively. The incidence rates of vision loss to < or =20/50, < or =20/200, and to a doubling of the visual angle were 1.5/100 eye-year (EY), 0.8/100 EY, and 2.1/100 EY, respectively. Approximately 40% of the incident vision loss was attributable to CMV retinitis diagnosed during the follow-up period, and approximately 25% was attributable to cataract. CONCLUSIONS Although the development of CMV retinitis was the most common reason for visual acuity loss in eyes of our patients with AIDS, it accounted for less than half of the vision loss in our population (approximately 40%). Newly diagnosed cataract during the follow-up period accounted for a substantial amount of incident vision loss as well.
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Affiliation(s)
- Jennifer E Thorne
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Morrison VL, Kozak I, LaBree LD, Azen SP, Kayicioglu OO, Freeman WR. Intravitreal triamcinolone acetonide for the treatment of immune recovery uveitis macular edema. Ophthalmology 2007; 114:334-9. [PMID: 17270681 DOI: 10.1016/j.ophtha.2006.07.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Revised: 07/13/2006] [Accepted: 07/13/2006] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To evaluate the use of intravitreal triamcinolone (IVTA) for the treatment of macular edema secondary to immune recovery uveitis (IRU) in patients with AIDS. DESIGN Prospective, consecutive, interventional case series. PARTICIPANTS Eight eyes of 7 patients receiving 13 injections. METHODS Prospective, consecutive, interventional case series of 13 injections involving 8 eyes in 7 patients who underwent an intravitreal injection of 20 mg decanted triamcinolone acetate for fluorescein angiographically proven IRU-related macular edema. MAIN OUTCOME MEASURES The primary outcome measure was vision (using the Early Treatment Diabetic Retinopathy Study chart). Other outcome measures included fluorescein angiography and optical coherence tomography. RESULTS Visual acuity improved at all time points and was statistically significant at the 1-month and 3-month follow-up examinations. The average visual improvement was 3 lines at 3 months. Retinal volume and thickness improvement were statistically significant at all time points. All patients had a minimum follow-up of 9 months, and there were no cases of cytomegalovirus reactivation. CONCLUSIONS Previous studies showed that treatment with sub-Tenon repository steroids for the treatment of macular edema of IRU was only marginally effective. However, the current study shows that IVTA can be an effective short-term treatment for macular edema secondary to IRU in patients with AIDS. Longer follow-up is needed to assess the durability of the effect and to monitor for longer-term complications and outcomes.
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Affiliation(s)
- Victoria L Morrison
- Jacobs Retina Center, Department of Ophthalmology, University of California, San Diego, La Jolla, California 92093, USA
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Martin BK, Ricks MO, Forman MS, Jabs DA. Change over time in incidence of ganciclovir resistance in patients with cytomegalovirus retinitis. Clin Infect Dis 2007; 44:1001-8. [PMID: 17342657 DOI: 10.1086/512368] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Accepted: 12/28/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In the mid-1990s, the incidence of cytomegalovirus (CMV) resistance to ganciclovir was estimated to be approximately 25% by 1 year after diagnosis of retinitis in patients with acquired immunodeficiency syndrome. METHODS Two hundred fifty-seven patients with CMV retinitis were enrolled in a prospective observational study during 1993-2003 and were treated with ganciclovir. Demographic characteristics and data on CMV disease, antiretroviral therapy, and ganciclovir resistance were recorded for all patients. Human immunodeficiency virus (HIV) load and CMV load were measured for patients enrolled in 1996 or later. Kaplan-Meier and Cox proportional hazards regression methods were used to examine incidence of resistance. RESULTS The 2-year incidence of resistance was 28% among patients enrolled before 1996 and 9% among those enrolled in or after 1996 (P=.001). All cases of resistance occurred among patients with CD4+ T cell counts <50 cells/microL, and positive CMV culture results at baseline were associated with a approximately 4-fold increase in resistance. Among patients whose CMV and HIV loads were measured, a detectable CMV load at baseline and during follow-up was associated with increased risk of resistance, but a detectable HIV load was not. CONCLUSIONS Rates of resistance have decreased from the high levels seen in the pre-HAART era. Better control of CMV replication may have contributed to this decrease.
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Affiliation(s)
- Barbara K Martin
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
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Riedel DJ, Pardo CA, McArthur J, Nath A. Therapy Insight: CNS manifestations of HIV-associated immune reconstitution inflammatory syndrome. ACTA ACUST UNITED AC 2006; 2:557-65. [PMID: 16990829 DOI: 10.1038/ncpneuro0303] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Accepted: 08/03/2006] [Indexed: 11/09/2022]
Abstract
The introduction of combination antiretroviral therapy for HIV infection has prolonged the lives of patients with AIDS. It is increasingly being recognized, however, that following initiation of this therapy some patients can develop a paradoxical neurological deterioration, despite dramatic improvements in HIV viral load and CD4+ T-cell counts. This immune reconstitution inflammatory syndrome (IRIS) in the CNS is emerging as an important neurological complication, particularly as antiretroviral therapy is now becoming readily available worldwide. Currently, there are no guidelines for prevention, diagnosis or treatment of the CNS manifestations of IRIS. Even in patients with an acute presentation, the diagnosis can be challenging. Furthermore, it is possible that more-chronic forms of the syndrome exist but remain unrecognized. Here, we review the various clinical presentations of CNS IRIS, and discuss options for their management.
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Thorne JE, Jabs DA, Kempen JH, Holbrook JT, Nichols C, Meinert CL. Incidence of and Risk Factors for Visual Acuity Loss among Patients with AIDS and Cytomegalovirus Retinitis in the Era of Highly Active Antiretroviral Therapy. Ophthalmology 2006; 113:1432-40. [PMID: 16766032 DOI: 10.1016/j.ophtha.2006.03.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Revised: 03/21/2006] [Accepted: 03/21/2006] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To describe the incidence of and risk factors for visual acuity loss among patients with AIDS and cytomegalovirus (CMV) retinitis in the era of highly active antiretroviral therapy (HAART). DESIGN Multicenter prospective observational study. PARTICIPANTS Three hundred seventy-nine patients with AIDS and CMV retinitis (494 eyes). METHODS Follow-up every 3 months with medical history, ophthalmologic examination, and laboratory testing. MAIN OUTCOME MEASURES Incidence of visual acuity loss to 20/50 or worse, to 20/200 or worse, and of doubling of the visual angle in eyes affected with CMV retinitis. RESULTS Among the 494 eyes with CMV retinitis, the baseline frequencies of visual acuity loss to 20/50 or worse and to 20/200 or worse were 29% and 15%, respectively. Over a median follow-up period of 3.1 years, the incidences of visual acuity loss to 20/50 or worse, to 20/200 or worse, and of doubling of the visual angle were 0.10/eye-year (EY), 0.06/EY, and 0.13/EY, respectively. Immune recovery was associated with a 42% reduction in vision loss to 20/50 or worse and with a 61% reduction in vision loss to 20/200 or worse after adjusting for confounding. Of the patients with immune recovery at baseline, 17% had immune recovery uveitis (IRU). In these patients, the incidence rate of 20/50 or worse vision was similar to that observed in patients without immune recovery (0.17/EY vs. 0.16/EY), but the incidence of 20/200 or worse vision was similar to that observed among patients with immune recovery (0.04/EY vs. 0.04/EY). CONCLUSIONS Cytomegalovirus retinitis is associated with a substantial risk of incident vision loss in the era of HAART. Those who have HAART-induced immune recovery have approximately 50% lower risk of visual acuity loss. Presence of IRU at baseline attenuated the protective effect of immune recovery for moderate vision loss but not for blindness.
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Affiliation(s)
- Jennifer E Thorne
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Thorne JE, Jabs DA, Kempen JH, Holbrook JT, Nichols C, Meinert CL. Causes of Visual Acuity Loss among Patients with AIDS and Cytomegalovirus Retinitis in the Era of Highly Active Antiretroviral Therapy. Ophthalmology 2006; 113:1441-5. [PMID: 16781775 DOI: 10.1016/j.ophtha.2006.03.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Revised: 03/20/2006] [Accepted: 03/20/2006] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To quantitate the frequencies of the common causes of visual acuity loss for patients with AIDS and cytomegalovirus (CMV) retinitis in the era of highly active antiretroviral therapy (HAART). DESIGN Multicenter prospective observational study. PARTICIPANTS Three hundred seventy-nine patients (494 eyes) with CMV retinitis. METHODS Follow-up every 3 months with medical history, ophthalmologic examination, and laboratory testing. MAIN OUTCOME MEASURES Loss of visual acuity across the 20/50 or worse and 20/200 or worse thresholds and doubling of the visual angle; frequencies of causes of such vision loss. RESULTS Overall, involvement of the posterior pole with CMV retinitis (zone 1 retinitis) accounted for approximately one half of incident visual acuity loss of 20/50 or worse, 20/200 or worse, and of doubling of the visual angle. Cataract and retinitis-related retinal detachment were the second and third most common causes of vision loss, accounting for 22% to 33% and 13% to 20% of vision loss for the 3 outcomes, respectively. In subset analysis, cataract and cystoid macular edema (CME) accounted for approximately 50% of incident vision loss in eyes of patients with longstanding CMV retinitis and immune recovery at baseline, but these complications accounted for <10% of incident vision loss in eyes of patients with newly diagnosed CMV retinitis at baseline. Of eyes that had a vision-threatening complication of CMV retinitis, eyes that developed retinal detachment had the highest risk of vision loss, with 100% of eyes developing visual impairment (20/50 or worse vision) and 42% of eyes developing legal blindness (20/200 or worse vision) at 12 months after diagnosis of the retinal detachment. CONCLUSIONS In the HAART era, zone 1 involvement and retinal detachment remain the most common causes of visual acuity loss among patients with CMV retinitis. Cataract and CME also are common causes of loss of visual acuity, primarily in those patients with HAART-induced immune recovery.
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Affiliation(s)
- Jennifer E Thorne
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Affiliation(s)
- Torsten W Wiegand
- Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA
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Kempen JH, Min YI, Freeman WR, Holland GN, Friedberg DN, Dieterich DT, Jabs DA. Risk of Immune Recovery Uveitis in Patients with AIDS and Cytomegalovirus Retinitis. Ophthalmology 2006; 113:684-94. [PMID: 16581429 DOI: 10.1016/j.ophtha.2005.10.067] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Revised: 10/29/2005] [Accepted: 10/31/2005] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To evaluate the prevalence of and risk factors for immune recovery uveitis (IRU) in eyes of patients with AIDS and cytomegalovirus (CMV) retinitis. DESIGN Enrollment data from a 19-clinical center cohort study. PARTICIPANTS Three hundred seventy-four patients with AIDS and CMV retinitis affecting 539 eyes. METHODS Patients with AIDS were enrolled at 19 United States AIDS ophthalmology clinics. Data were collected by interview, review of medical records, ophthalmic examination, and phlebotomy. MAIN OUTCOME MEASURE Immune recovery uveitis. RESULTS Thirty-six patients (9.6%) were diagnosed with IRU involving 50 eyes. The CD4+ T-cell count of 31 of these had risen by > or =50 cells per microliter above nadir to a level > or = 100 cells per microliter (immune recovery), making up 17.6% of the patients known to have immune recovery after diagnosis of CMV retinitis (95% confidence interval, 12.3%-24.1%). No patients with IRU were observed to have active retinitis or detectable CMV DNA in peripheral blood (P<0.001 and P<0.001 with respect to patients without IRU). Other factors associated with IRU were > or =25% retinal area (odds ratio [OR], 2.72; P = 0.014) or posterior pole involvement with CMV retinitis (odds ratio, 0.43; P = 0.039), treatment with intravitreous injection of cidofovir (OR, 10.6 with respect to eyes never exposed to intravitreous or IV cidofovir; P<0.001), and male gender (OR, 0.26; P = 0.012). More eyes with IRU had visual acuity (VA) of 20/50 or worse (38.0% vs. 26.3%, P = 0.077) relative to eyes without IRU, but the proportions with VA of 20/200 or worse were similar (14.0% vs. 13.8%, P = 0.96). Eyes with IRU more commonly had cystoid macular edema (CME) (45.5% vs. 3.7%, P<0.001) and epiretinal membrane (48.9% vs. 13.3%, P<0.001) than eyes without IRU. CONCLUSIONS Among eyes of patients with immune recovery, the prevalence of IRU is substantial. Eyes with IRU have a high risk of additional morbidity over and above that seen with CMV retinitis, with several-fold higher risk of CME and epiretinal membrane. Large CMV lesions and use of intravitreous cidofovir are risk factors for IRU.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Lee CH, Bright DC, Ferrucci S. Treatment of cytomegalovirus retinitis with oral valganciclovir in an acquired immunodeficiency syndrome patient unresponsive to combination antiretroviral therapy. ACTA ACUST UNITED AC 2006; 77:167-76. [PMID: 16567278 DOI: 10.1016/j.optm.2006.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) retinitis was a much-feared visual complication of late-stage acquired immunodeficiency syndrome (AIDS) in the past. Its incidence has waned significantly owing to the benefits of potent antiretroviral combination therapy, which for many individuals has provided some degree of immune reconstitution and avoidance of opportunistic infections, particularly this blinding disease. CASE REPORT A 45-year-old white man with long-standing, multidrug-resistant human immunodeficiency virus (HIV) infection and severe immunodeficiency despite multiple antiretroviral drug regimens, presented to the eye clinic reporting decreased vision and spider web patterns in his left eye for the past week. Best-corrected visual acuity was 20/20 in the right (O.D.) and 20/25 in the left eye (O.S.). Dilated funduscopic examination of the left eye found vasculitis of the midperipheral inferonasal arcade in the midperiphery, with surrounding intraretinal hemorrhage and granular retinal necrosis. Diagnosis of cytomegalovirus retinitis was made, and the patient began induction therapy with oral valganciclovir 900 mg twice a day for 3 weeks. Maintenance therapy after retinitis stabilization was 900 mg every day until any observed recurrence of infection. Three months after complete resolution of the active retinitis, the patient returned to the clinic reporting new floaters of recent onset. A reactivation of the CMV retinitis warranted a reinduction with valganciclovir 900 mg orally twice a day for 3 weeks. CONCLUSION This case is illustrative of the efficacy and relative ease of administration of valganciclovir, the newest medication approved for treatment and maintenance of CMV retinitis. Despite his severe immunodeficiency, our patient tolerated the induction and maintenance therapy of oral valganciclovir well, and the CMV retinitis was stabilized and resolved with full recovery of visual acuity.
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Affiliation(s)
- Carol H Lee
- Sepulveda Ambulatory Care Center and Nursing Home, Sepulveda, California, USA
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Kozak I, LaBree L, Azen SP, Cheng L, Reagan NL, Freeman WR. Long-term Study of Intraocular Pressure Changes in Patients with Human Immunodeficiency Virus Treated with Highly Active Antiretroviral Therapy. Ophthalmology 2006; 113:451-5. [PMID: 16513459 DOI: 10.1016/j.ophtha.2005.10.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2005] [Revised: 10/20/2005] [Accepted: 10/24/2005] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To characterize a longitudinal relationship between highly active antiretroviral therapy immune recovery as defined by an increase in CD4 cell counts and any associated changes in intraocular pressure (IOP) in both patients with and patients without a history of cytomegalovirus (CMV) retinitis and to determine if human immunodeficiency (HIV)-induced reduction in IOP is reversible. DESIGN Retrospective analysis of patient data collected from 1997 through 2004. PARTICIPANTS Cohort of patients from one eye center, including patients from the Longitudinal Study of Ocular Complications of Acquired Immunodeficiency Syndrome. METHODS Linear regression analyses were conducted within the CMV and non-CMV groups to determine the change in IOP per 100-unit change in CD4 count. Average changes in IOP per change in CD4 count were compared between the CMV and the non-CMV groups using a Wilcoxon rank-sum test. Linear regression analyses were conducted within the CMV and non-CMV groups to determine the linear relationship between the 12-month change in IOP per 12-month 100-unit change in CD4 count. MAIN OUTCOME MEASURE Intraocular pressure in relation to changes in CD4 cell counts. RESULTS Compared with the non-CMV group, the median IOP change per change in CD4 count was not statistically different from the CMV group (0.9 vs. 1.7 mmHg/100 CD4 cells, respectively; P = 0.20). Analysis of the linear relationship between the 12-month change in IOP and the 12-month change in CD4 count within both the CMV and non-CMV groups showed a strong linear relationship: 67% of the variability in a 12-month IOP change for the CMV group (P<0.0001) and 36% of the variability in a 12-month IOP change for the non-CMV group (P<0.001). CONCLUSIONS Reduction in T-lymphocyte count in HIV infection is accompanied by a decrease in IOP in both CMV-infected and non-CMV-infected eyes, and immune recovery is associated with an increase in IOP.
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Affiliation(s)
- Igor Kozak
- Jacobs Retina Center, University of California San Diego, Shiley Eye Center, La Jolla, California 92037, USA
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76
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77
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Kosobucki BR, Freeman WR. Retinal Disease in HIV-infected Patients. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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78
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Kreiger AE, Gonzales CR. Management of Combined Inflammatory and Rhegmatogenous Retinal Detachments (AIDS and ARN). Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50152-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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79
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Goldberg DE, Smithen LM, Angelilli A, Freeman WR. HIV-associated retinopathy in the HAART era. Retina 2005; 25:633-49; quiz 682-3. [PMID: 16077362 DOI: 10.1097/00006982-200507000-00015] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The effectiveness of highly active antiretroviral therapy (HAART) in restoring immune function in patients with acquired immunodeficiency syndrome (AIDS) has led to changes in the incidence, natural history, management, and sequelae of human immunodeficiency virus (HIV)-associated retinopathies, especially cytomegalovirus (CMV) retinitis. METHODS The medical literature pertaining to HIV-associated retinopathies was reviewed with special attention to the differences in incidence, management strategies, and complications of these conditions in the eras both before and after the widespread use of HAART. RESULTS In the pre-HAART era, CMV retinitis was the most common HIV-associated retinopathy, occurring in 20%-40% of patients. Median time to progression was 47 to 104 days, mean survival after diagnosis was 6 to 10 months, and indefinite intravenous maintenance therapy was mandatory. Retinal detachment occurred in 24%-50% of patients annually. Herpetic retinopathy and toxoplasmosis retinochoroiditis occurred in 1%-3% of patients and Pneumocystis carinii choroiditis, syphilitic retinitis, tuberculous choroiditis, cryptococcal choroiditis, and intraocular lymphoma occurred infrequently. In the HAART era the incidence of CMV retinitis has declined 80% and survival after diagnosis has increased to over 1 year. Immune recovery in patients on HAART has allowed safe discontinuation of maintenance therapy in patients with regressed CMV retinitis and other HIV-associated retinopathies. Immune recovery uveitis (IRU) is a HAART dependent inflammatory response that may occur in up to 63% of patients with regressed CMV retinitis and elevated CD4 counts and is associated with vision loss from epiretinal membrane, cataract, and cystoid macular edema. CONCLUSIONS The incidence, visual morbidity, and mortality of CMV retinitis and other HIV-associated retinopathies have decreased in the era of HAART and lifelong maintenance therapy may safely be discontinued in patients with restored immune function. Patients with regressed CMV retinitis, however, may still lose vision from epiretinal membrane, cystoid macular edema, and cataract secondary to IRU.
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Affiliation(s)
- Daniel E Goldberg
- Vitreous, Retina, Macula Consultants of New York, LuEsther T. Mertz Retinal Research Laboratory, Manhattan Eye, Ear and Throat Hospital, New York, New York 10022, USA.
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80
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Kempen JH, Jabs DA, Wilson LA, Dunn JP, West SK. Incidence of cytomegalovirus (CMV) retinitis in second eyes of patients with the acquired immune deficiency syndrome and unilateral CMV retinitis. Am J Ophthalmol 2005; 139:1028-34. [PMID: 15953432 DOI: 10.1016/j.ajo.2005.01.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2004] [Accepted: 01/04/2005] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the risk and risk factors for developing cytomegalovirus (CMV) retinitis in previously uninvolved second eyes among patients with unilateral CMV retinitis. DESIGN Cohort study. METHODS SETTINGS Single-center academic AIDS ophthalmology practice. PATIENT POPULATION Three hundred seventy-six consecutive patients with AIDS and unilateral CMV retinitis were followed from the time of CMV retinitis diagnosis for the development of second-eye retinitis. EXPERIMENTAL PROCEDURES Demographic and clinical characteristics were noted at baseline. Use of highly active antiretroviral therapy (HAART) and immune recovery in response to HAART were noted prospectively. MAIN OUTCOME MEASURE Development of CMV retinitis in a previously uninvolved eye. RESULTS Ninety-one percent of subjects received systemic anti-CMV treatment. Second-eye retinitis occurred in 26.1%/person-year (19.6% within the first 6 months), less than half the rate previously reported in untreated groups. Initial CD4+ T cell count >12 cells/microl, use of HAART, and initial posterior pole involvement were associated with 64%, 46%, and 41% reductions in incidence vis-à-vis comparison groups. Benefit from HAART was limited to that subset who developed immune recovery of a degree expected to restore innate control of CMV (a rise in the CD4+ T cell count by >50 cells/microl to a level >100 cells/microl). CONCLUSIONS The risk of second-eye retinitis is substantial in patients with unilateral CMV retinitis but appears to be reduced by anti-CMV therapy and by HAART-induced immune recovery. Patients are at highest risk when CD4+ T cell counts are very low and in the months immediately after CMV retinitis diagnosis.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, 550 North Broadway, Suite 700, Baltimore, MD 21205, USA.
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81
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Benson CA, Kaplan JE, Masur H, Pau A, Holmes KK. Treating Opportunistic Infections among HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. Clin Infect Dis 2005. [DOI: 10.1086/427906] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Scott GM, Isaacs MA, Zeng F, Kesson AM, Rawlinson WD. Cytomegalovirus antiviral resistance associated with treatment induced UL97 (protein kinase) and UL54 (DNA polymerase) mutations. J Med Virol 2005; 74:85-93. [PMID: 15258973 DOI: 10.1002/jmv.20150] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
HCMV-related illness due to infections with antiviral resistant virus was verified by phenotypic and genotypic assays in 17% (8/47) of high-risk immunocompromised Australian patients. Selective PCR-sequencing of UL97 (protein kinase; PK) and UL54 (DNA polymerase; DNApol) regions important for antiviral sensitivity, identified the majority (6/8) of resistant strains through detection of mutations known to confer antiviral resistance. Additionally, eight UL54 (DNApol) mutations (N408K, T691S, A692V, S695T, L737M, A834P, V955I, and A972V) of unknown phenotype were identified in six specimens from patients with clinical evidence of antiviral resistant infections. One isolate was resistant to ganciclovir (GCV) and another resistant to PFA on phenotypic testing where mutations in UL97 (PK) or UL54 (DNApol) were not detected, suggesting a loss of correlation between phenotype and genotype. Selective PCR-sequencing of UL97 (PK) and UL54 (DNApol) provided rapid and comprehensive results, but missed some resistance detected by phenotypic assays. A combination of phenotypic and genotypic assays is recommended for complete analysis of CMV antiviral resistance, as well as further definition of the clinical relationship between novel UL54 (DNApol) mutations and antiviral resistance.
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Affiliation(s)
- G M Scott
- Virology Division, Department of Microbiology, SEALS, Prince of Wales Hospital, Randwick, and School of Medicial Sciences, University of New South Wales, Kensington, Australia
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83
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Kozak I, Bartsch DU, Cheng L, Kosobucki BR, Freeman WR. Objective analysis of retinal damage in HIV-positive patients in the HAART era using OCT. Am J Ophthalmol 2005; 139:295-301. [PMID: 15733991 PMCID: PMC3757251 DOI: 10.1016/j.ajo.2004.09.039] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2004] [Indexed: 12/13/2022]
Abstract
PURPOSE To assess retinal nerve fiber layer (RNFL) thickness in patients with human immunodeficiency virus (HIV) disease without cytomegalovirus retinitis (CMV). DESIGN A case-control study. METHODS The study included 113 eyes of 65 patients in one center. Thickness of RNFL along a 3.4-mm-diameter circle centered on the optic nerve head was evaluated using third-generation optical coherence tomography. Patients in group A (39 eyes of 22 patients) were human immunodeficiency virus-negative control subjects. Group B (36 eyes of 18 patients) was composed of HIV patients with no history of CMV retinitis and CD4 counts consistently above 100. Group C (38 eyes of 25 patients) comprised HIV patients with no history of CMV retinitis but a history of CD4 count less than 100 at some point lasting for at least 6 months. RESULTS The average RNFL thicknesses in groups A, B, and C were 103.33 +/- 8.50 microm, 103.30 +/- 9.28 microm, and 90.10 +/- 12.50 microm, respectively. Group C had significantly thinner overall RNFL than either of the groups A and B (Tukey-Kramer). This difference was most prominent in temporal, superior, and inferior retinal areas. No difference was in nasal retinal area, nor between groups A and B in any of the areas. CONCLUSIONS Significant RNFL thinning occurs in HIV patients without CMV retinitis and with low CD4 counts compared with the same subgroup of patients with CD4 count increased to above 100 and HIV-negative control subjects. Third-generation OCT may be useful in diagnosis of early subclinical HIV-associated visual functional loss.
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Affiliation(s)
- Igor Kozak
- Jacobs Retina Center, Department of Ophthalmology, University of California, San Diego, La Jolla, California 92037, USA
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Vogel JU, Fleckenstein C, Wagner M, Gümbel HOC, Theegarten D, Cinatl J, Doerr HW. The human eye (retina): a site of persistent HCMV infection? Graefes Arch Clin Exp Ophthalmol 2005; 243:671-6. [PMID: 15672249 DOI: 10.1007/s00417-004-0965-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2004] [Revised: 05/10/2004] [Accepted: 06/16/2004] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Human cytomegalovirus (HCMV) retinitis frequently occurs in severely naturally and iatrogenically immunocompromised patients. It has been shown that the immune-privileged retina is a major site of HCMV infection in AIDS patients. It is conceivable either that during the immunosuppression HCMV infection reactivates in various other organs viremically affecting the retina or that HCMV persisting in the retina may locally reactivate and result in HCMV retinitis. METHODS As there is still controversy about the sites of HCMV latency and persistence we investigated 75 eyes of HIV-seronegative patients undergoing enucleation due to a variety of malignant and non-viral benign ophthalmic disorders for the retinal presence of HCMV antigen and DNA. RESULTS None of the analyzed patients had symptoms of HCMV retinitis. Immunohistologic staining as well as Taq Man DNA PCR analysis showed all samples to be free of HCMV. CONCLUSIONS Our data suggest that the human eye is rather unlikely to be a site of productive or latent HCMV persistence.
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Affiliation(s)
- Jens-Uwe Vogel
- Institute of Medical Virology, Center of Hygiene, University Hospital, Johann Wolfgang Goethe University, Paul-Ehrlich Strasse 40, 60596 Frankfurt am Main, Germany.
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Jabs DA, Van Natta ML, Thorne JE, Weinberg DV, Meredith TA, Kuppermann BD, Sepkowitz K, Li HK. Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: 2. Second eye involvement and retinal detachment. Ophthalmology 2004; 111:2232-9. [PMID: 15582079 DOI: 10.1016/j.ophtha.2004.05.028] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2004] [Accepted: 05/18/2004] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To describe the course of cytomegalovirus (CMV) retinitis in patients with AIDS in the era of highly active antiretroviral therapy (HAART). DESIGN Multicenter, prospective, observational study. PARTICIPANTS Two hundred seventy-one patients with AIDS and CMV retinitis. METHODS Follow-up every 3 months with medical history, ophthalmologic examination, laboratory testing, and fundus photographs. MAIN OUTCOME MEASURE Second (contralateral) eye involvement among patients with unilateral disease and retinal detachment (RD). RESULTS The overall rate of second eye involvement among patients with unilateral CMV retinitis was 0.07 per person-year (PY); among those with CD4+ T-cell counts of <50/microl it was 0.34/PY, compared with 0.02/PY among those with CD4+ T-cell counts of > or =200/microl (P<0.0001). Risk factors for contralateral eye involvement included low CD4+ T-cell count and detectable CMV load. The overall rate of RD was 0.06/PY; among those with CD4+ T-cell counts of <50/microl it was 0.30/PY, compared with 0.02/PY among those with CD4+ T-cell counts of > or =200/microl (P<0.0001). Risk factors for RD included a low CD4+ T-cell count and larger area of CMV retinitis. CONCLUSIONS Compared with the rates reported in the pre-HAART era of second eye involvement (approximately 0.40/PY) and RD (approximately 0.50/PY), the rates of these events were reduced among patients in the HAART era. However, among patients with CD4+ T-cell counts of <50/microl, the rates were more similar to those from the pre-HAART era.
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Affiliation(s)
- Douglas A Jabs
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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86
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Jabs DA, Van Natta ML, Thorne JE, Weinberg DV, Meredith TA, Kuppermann BD, Sepkowitz K, Li HK. Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: 1. Retinitis progression. Ophthalmology 2004; 111:2224-31. [PMID: 15582078 DOI: 10.1016/j.ophtha.2004.05.031] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2003] [Accepted: 05/11/2004] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To describe the course of cytomegalovirus (CMV) retinitis in patients with AIDS in the era of highly active antiretroviral therapy (HAART). DESIGN Multicenter, prospective, observational study. PARTICIPANTS Two hundred seventy-one patients with AIDS and CMV retinitis. METHODS Follow-up every 3 months with medical history, ophthalmologic examination, laboratory testing, and fundus photographs. Photographs were evaluated for relapse of the retinitis (progression) by graders at a centralized reading center. MAIN OUTCOME MEASURE Retinitis progression (movement of the border of a CMV lesion > or =750 microm over a > or =750-microm front or occurrence of a new lesion one-quarter disc area or more in size). RESULTS The overall rate of retinitis progression was 0.10/person-year (PY); among those with CD4+ T-cell counts of <50/microl, it was 0.58/PY, compared to 0.02/PY among those with CD4+ T-cell counts of > or =200/microl (P<0.0001). In the multivariate analysis, significant risk factors for retinitis progression included a low CD4+ T-cell count, positive CMV load, longer time from AIDS diagnosis, and low Karnofsky score. CONCLUSIONS Compared with the rate of retinitis progression (approximately 3.0/PY) reported in the pre-HAART era, the rate of retinitis progression was reduced among patients in the HAART era, even among those with low CD4+ T-cell counts, who might be expected to behave most like patients from the pre-HAART era. However, these events also occurred among patients with high CD4+ T-cell counts and presumed immune recovery. Continued ophthalmologic follow-up of patients with immune recovery is recommended to detect early retinitis progression.
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Affiliation(s)
- Douglas A Jabs
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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87
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Lalonde RG, Boivin G, Deschênes J, Hodge WG, Hopkins JJ, Klein AH, Lindley JI, Phillips P, Shafran SD, Walmsley S. Canadian consensus guidelines for the management of cytomegalovirus disease in HIV/AIDS. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2004; 15:327-35. [PMID: 18159510 PMCID: PMC2094992 DOI: 10.1155/2004/369390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2004] [Accepted: 06/01/2004] [Indexed: 01/11/2023]
Abstract
BACKGROUND The management of HIV-infected patients with cytomegalovirus (CMV) disease has changed significantly with the availability of highly active antiretroviral therapy (HAART). OBJECTIVES These updated guidelines are intended to provide practical help to physicians managing HIV-positive patients with or at risk for CMV disease. METHODS The 10 members of the Canadian CMV Disease in HIV/AIDS Consensus Group were infectious disease specialists, a primary care physician and ophthalmologists with expertise in HIV and CMV infection. Financial support by Hoffmann-La Roche Canada Ltd was unrestricted, and was limited to travel expenses and honoraria. The consensus group met in June and October 2002. Key areas to be considered were identified, and group members selected, reviewed and presented relevant recent literature for their assigned section for the group's consideration. Evidence was assessed based on established criteria, which were expert opinions of the members. Draft documents were circulated to the entire group and modified until consensus was reached. The final guidelines represent the group's consensus agreement. The guidelines were approved by the Canadian Infectious Disease Society. RESULTS AND CONCLUSIONS The guidelines address symptom monitoring, screening for early detection and prevention, and treatment using oral, intravenous and intraocular anti-CMV therapies in conjunction with HAART.
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Affiliation(s)
- Richard G Lalonde
- Division of Infectious Diseases, McGill University Health Centre, Montréal, Quebec
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88
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Springer KL, Weinberg A. Cytomegalovirus infection in the era of HAART: fewer reactivations and more immunity. J Antimicrob Chemother 2004; 54:582-6. [PMID: 15282241 DOI: 10.1093/jac/dkh396] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The incidence of cytomegalovirus (CMV) disease, once the most common and highly feared viral complication of AIDS, has dramatically decreased with the advent of highly active antiretroviral therapy (HAART). HAART-associated changes in the epidemiology of CMV disease resulted from the increase in CMV-specific immune responses coupled with the decrease in CMV reactivation. However, CMV disease continues to afflict HIV-infected patients on HAART when CD4+ cell counts fail to rise above 100 cells/mm(3) and when reconstitution of normal CMV-specific immune responses does not occur. The latter scenario may lead to recurrent or de novo CMV end-organ disease, or to the recently described CMV immune recovery vitritis. HAART-associated immune reconstitution offers unique opportunities to investigate the virological and immunological correlates of protection against CMV disease. Although the full extent of CMV-specific immune reconstitution has not been defined thus far, CMV-specific interferon-gamma production has been shown to be significantly associated with protection against CMV reactivation and recurrent disease.
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Affiliation(s)
- Kathryn L Springer
- Departments of Medicine and Pediatrics, University of Colorado School of Medicine, Denver, Colorado, USA
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89
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Kuo IC, Kempen JH, Dunn JP, Vogelsang G, Jabs DA. Clinical characteristics and outcomes of cytomegalovirus retinitis in persons without human immunodeficiency virus infection. Am J Ophthalmol 2004; 138:338-46. [PMID: 15364214 DOI: 10.1016/j.ajo.2004.04.015] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2004] [Accepted: 04/12/2004] [Indexed: 11/23/2022]
Abstract
PURPOSE To describe the characteristics and outcomes of patients with cytomegalovirus (CMV) retinitis in the absence of human immunodeficiency virus (HIV) infection. DESIGN Retrospective cohort study. METHODS Consecutive patients with CMV retinitis in the absence of HIV infection were identified at a university hospital. Demographic and clinical characteristics were noted at the time of CMV retinitis. Outcomes were determined retrospectively. Main outcome measures were rates of second eye involvement, vision loss, rhegmatogenous retinal detachment (RD), immune recovery uveitis, progression of retinitis, and mortality. RESULTS The clinical characteristics of CMV retinitis in 18 patients (30 eyes) without HIV infection diagnosed between January 1, 1984, and April 13, 2003, were similar to those of patients with HIV infection. The incidences of visual loss to the levels of 20/50 or worse and of 20/200 or worse were 17% per eye-year and 14% per eye-year, respectively. The observed incidence of RD was 3.7% per eye-year, and the mortality rate was 23% per person-year. Following reduction of immunosuppression, 10 patients (56%) who discontinued anti-CMV therapy remained free of retinitis progression. The incidence of immune recovery uveitis was 13% per person-year. CONCLUSIONS In our series, CMV retinitis in patients without HIV infection had a clinical course similar to that in patients with AIDS treated with highly active antiretroviral therapy (HAART), except the incidence of RD was lower for patients without AIDS. A substantial number of patients no longer required long-term anti-CMV therapy after adjustment of immunomodulatory therapy.
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Affiliation(s)
- Irene C Kuo
- Department of Ophthalmology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
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90
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El-Bradey MH, Cheng L, Song MK, Torriani FJ, Freeman WR. LONG-TERM RESULTS OF TREATMENT OF MACULAR COMPLICATIONS IN EYES WITH IMMUNE RECOVERY UVEITIS USING A GRADED TREATMENT APPROACH. Retina 2004; 24:376-82. [PMID: 15187659 PMCID: PMC1378115 DOI: 10.1097/00006982-200406000-00007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the results of a graded treatment approach in a cohort of eyes with macular complications of immune recovery uveitis. METHODS A cohort of 18 eyes of 13 patients representing all eyes with these complications at the University of California, San Diego AIDS Ocular Treatment Unit was studied. Eyes were classified into three groups and treated according to a graded protocol. RESULTS Eyes with mild disease (macular edema and vision of 20/30 or better) were observed. These six eyes maintained good vision with only one dropping to 20/40. In eyes with worse macular edema and vision of 20/30 or worse (10 eyes of 9 patients), repository sub-Tenon steroid injections were used repeatedly. There were no complications of steroid use but visual improvement occurred in only 40% of eyes. Macular edema persisted. In eyes with structural macular changes, such as epiretinal membrane, vitrectomy resulted in vision improvement in three of four eyes. The cystoid macular edema persisted despite surgery. CONCLUSION Mild cases of immune recovery uveitis and macular edema may be observed. In eyes with reduction of vision due to cystoid macular edema, there was only a modest treatment effect using repository corticosteroids. Eyes with immune recovery uveitis that develop epiretinal membrane undergo some visual improvement after removal of the membrane. The macular edema of immune recovery uveitis is resistant to corticosteroid treatment.
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91
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Abstract
The ocular posterior segment manifestations of AIDS may be divided into four categories: retinal vasculopathy, unusual malignancies, neuro-ophthalmologic abnormalities, and opportunistic infections. Microvasculopathy is the most common manifestation. Opportunistic infections, particularly cytomegalovirus retinitis and progressive outer retinal necrosis, are the most likely to result in visual loss due to infection or subsequent retinal detachment. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.
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Affiliation(s)
- Tamara R Vrabec
- Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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92
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Siqueira RC, Cunha A, Oréfice F, Campos WR, Figueiredo LTM. PCR with the aqueous humor, blood leukocytes and vitreous of patients affected by cytomegalovirus retinitis and immune recovery uveitis. Ophthalmologica 2004; 218:43-8. [PMID: 14688435 DOI: 10.1159/000074566] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2002] [Accepted: 06/26/2003] [Indexed: 11/19/2022]
Abstract
PURPOSE To detect the cytomegalovirus (CMV) genome by PCR in the aqueous humor, blood leukocytes and vitreous of patients affected by retinitis and immune recovery uveitis (IRU). METHODS A PCR for CMV genome detection was carried out with the aqueous humor, vitreous and blood leukocytes of 54 patients with retinitis, including 25 HIV-infected patients presenting CMV retinitis in different stages (active lesion 6 cases, healed lesion 14 cases and IRU 5 cases), and 29 non-HIV-infected patients (retinitis unrelated to CMV) as negative controls. RESULTS The CMV genome was detected in the vitreous, aqueous humor and blood leukocytes of 3 out of 6 HIV-infected patients, presenting active lesions in the retina. No CMV genome was detected in the vitreous, aqueous humor and blood leukocytes of the 5 HIV-infected patients presenting IRU. CONCLUSIONS CMV genome detection by PCR in aqueous humor could be used as a specific and highly predictive technique for confirmation of this infection in the retina. The absence of CMV, based on the results of PCR done in clinical samples of the 5 IRU cases, does not confirm the hypothesis of a viral replication in the vitreous body and aqueous humor of these patients.
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93
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Robinson MR, Csaky KG, Lee SS, Masur H, Polis MA. Fibrovascular Changes Misdiagnosed as Cytomegalovirus Retinitis Reactivation in a Patient with Immune Recovery. Clin Infect Dis 2004; 38:139-41. [PMID: 14679460 DOI: 10.1086/380127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2003] [Accepted: 08/27/2003] [Indexed: 11/03/2022] Open
Abstract
A patient with human immunodeficiency virus infection and cytomegalovirus (CMV) retinitis developed immune recovery uveitis as a result of receipt of highly active antiretroviral therapy. Fibrovascular changes occurred in the CMV retinitis scar, were misdiagnosed as CMV retinitis reactivation, and were treated with anti-CMV medication. Fibrovascular membranes can be misdiagnosed as reactivated CMV retinitis, and a proper diagnosis is essential to avoid unnecessary therapy with potentially toxic antiviral medications.
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Affiliation(s)
- Michael R Robinson
- National Eye Institute, National Institutes of Health, Bethesda, Maryland 20892-1863, USA.
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94
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Tanna AP, Kempen JH, Dunn JP, Haller JA, Jabs DA. Incidence and management of cataract after retinal detachment repair with silicone oil in immune compromised patients with cytomegalovirus retinitis. Am J Ophthalmol 2003; 136:1009-15. [PMID: 14644210 DOI: 10.1016/s0002-9394(03)00724-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine the incidence of and risk factors for cataract and to describe the visual outcomes of cataract surgery in eyes with cytomegalovirus-related retinal detachments repaired with silicone oil. STUDY DESIGN Retrospective cohort study. METHODS A prospectively generated database of all patients with cytomegalovirus retinitis examined at a single tertiary care institution was used to identify all cases of retinal detachment between October 1983 and August 1997. Data on retinal detachment repair, development of cataract, and outcomes of cataract surgery were obtained retrospectively. RESULTS Among 904 eyes of 587 immune-compromised patients diagnosed with cytomegalovirus retinitis, 198 eyes of 155 patients developed retinal detachment. Among these, 106 eyes of 90 patients underwent retinal detachment repair with silicone oil. The Kaplan-Meier estimated median time to cataract was 1.8 months after surgery with silicone oil. The adjusted relative risk of cataract in eyes that underwent retinal detachment repair with silicone oil compared with eyes that did not was 6.74 (P <.0001). Eight of the eyes that developed cataract underwent uncomplicated cataract surgery by phacoemulsification and posterior chamber intraocular lens implantation. Among these, six eyes experienced >or=2 lines of improvement in visual acuity. All developed posterior capsule opacification a median of 7 days after cataract surgery. Four of five eyes that that underwent neodymium:yttrium-aluminum-garnet laser capsulotomy experienced >or=2 lines improvement in visual acuity. CONCLUSIONS There is a high incidence of cataract after surgery with silicone oil tamponade for cytomegalovirus-related retinal detachment. Posterior capsule opacification occurs rapidly after cataract surgery in these patients.
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Affiliation(s)
- Angelo P Tanna
- Department of Ophthalmology, Northwestern University Medical School, Chicago, Illinois, USA.
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95
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Erakgun T, Afrashi F, Nalbantgil S, Ozbaran M, Mentes J. Asymptomatic Cytomegalovirus Retinitis after Cardiac Transplantation. Ophthalmologica 2003; 217:446-50. [PMID: 14573981 DOI: 10.1159/000073078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2002] [Accepted: 05/26/2003] [Indexed: 11/19/2022]
Abstract
PURPOSE To determine the prevalence and the risk factors of cytomegalovirus (CMV) retinitis after cardiac transplantation in visually asymptomatic patients. METHODS Ophthalmoscopic examinations including fundus fluorescein angiography were performed in asymptomatic patients who had cardiac transplantation at Ege University Hospital between April 1998 and June 2002 to screen for evidence of diagnostic CMV retinitis lesions to determine the prevalence in this population. RESULTS Thirteen patients (aged 40 +/- 12.6) who had cardiac transplantation underwent ophthalmoscopic examination 2-50 months (23.5 +/- 16.2 months; mean +/- SD) after transplantation. All recipients had positive serology to CMV before transplantation. During the study period, 3 patients developed asymptomatic CMV reactivation. One patient developed CMV disease (pneumonia). All of the patients were visually asymptomatic during the study period. Two patients (15%) had a history of diabetes mellitus and chronic severe arterial hypertension. Seven recipients (53%) had been heavy cigarette smokers and 3 patients (23%) had hyperlipidemia. Two (15%) of 13 patients with arterial hypertension and diabetes had evidence of asymptomatic active CMV retinitis. These patients were treated with intravenous ganciclovir. CONCLUSIONS Active cytomegalovirus retinitis lesions were found in 2 (15%) of 13 cardiac transplantation patients who had no visual symptoms. We think that the patients with systemic microvascular risk factors such as diabetes, hypertension and smoking should be screened closely for the development of CMV retinitis after cardiac transplantation even if the patients have no visual symptoms.
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Affiliation(s)
- Tansu Erakgun
- Department of Ophthalmology, Ege University Hospital, Izmir, Turkey.
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96
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Kempen JH, Jabs DA, Wilson LA, Dunn JP, West SK, Tonascia J. Mortality risk for patients with cytomegalovirus retinitis and acquired immune deficiency syndrome. Clin Infect Dis 2003; 37:1365-73. [PMID: 14583871 DOI: 10.1086/379077] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2003] [Accepted: 07/10/2003] [Indexed: 12/17/2022] Open
Abstract
We prospectively followed up 589 patients to evaluate the relationship of anti-cytomegalovirus (CMV) treatment and immune reconstitution in response to highly active antiretroviral therapy (HAART) on the mortality risk of patients with CMV retinitis and acquired immune deficiency syndrome. The use of HAART was associated with an 81% lower mortality rate (95% confidence interval [CI], 74%-86%); it was 96% lower (95% CI, 92%-98%) for those who developed immune recovery and 49% lower (95% CI, 30-63%) for those who did not. Using time-updated multivariate analysis, current systemic anti-CMV treatment was independently associated with a 28% lower mortality rate (95% CI, 8%-43%). On the basis of these results, for patients who continue to have profound immunodeficiency despite HAART, the continued use of HAART and systemic anti-CMV therapy is predicted to reduce the risk of mortality by 65%, over and above the benefits of Pneumocystis carinii and Mycobacterium avium prophylaxis.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
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97
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Abstract
The type of ocular involvement in the patient with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) depends on the level of immune function and systemic diseases present. Although the prognosis for patients with HIV/AIDS has changed dramatically with the introduction of antiretroviral therapy, infections involving the retina, such as toxoplasmosis, herpes simplex and herpes zoster (HZV), still occur although opportunistic infections such as cytomegalovirus (CMV) retinitis are much less common except in patients who present late in the course of the disease (Jabs and Bartlett, 1997; Jabs et al, 2002).
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Affiliation(s)
- Michal Kramer
- Department of Ophthalmology, Rabin Medical Center, Petah Tikva, Israel
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98
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Kempen JH, Martin BK, Wu AW, Barron B, Thorne JE, Jabs DA. The effect of cytomegalovirus retinitis on the quality of life of patients with AIDS in the era of highly active antiretroviral therapy. Ophthalmology 2003; 110:987-95. [PMID: 12750102 DOI: 10.1016/s0161-6420(03)00089-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To evaluate the effect of cytomegalovirus (CMV) retinitis on quality of life (QOL) in patients with the acquired immune deficiency syndrome (AIDS). DESIGN Enrollment data from a multicenter, prospective cohort study. PARTICIPANTS Patients >/=13 years of age with AIDS in three groups: no CMV retinitis, 709 patients; long-standing CMV retinitis (diagnosed a median of 34.5 months previously), 212 patients; and newly diagnosed CMV retinitis (diagnosed </=45 days previously), 50 patients. METHODS Patients were enrolled at 19 centers throughout the United States. CMV retinitis status was determined by ophthalmoscopy. Vision-related QOL was assessed with a questionnaire designed for patients with CMV retinitis. General health-related QOL was evaluated with a modified version of the Medical Outcomes Survey-HIV instrument. Health utility was measured with the EuroQol instrument. MAIN OUTCOME MEASURES Patient-reported vision-related QOL, general health-related QOL, and health utility. RESULTS All domains of vision-related QOL were substantially lower in both the long-standing and newly diagnosed CMV retinitis groups than in the group with no CMV retinitis. The long-standing CMV retinitis group was similar to the no CMV retinitis group in most general health-related QOL domains and in health utility measures. The newly diagnosed CMV retinitis group scored substantially worse than the other groups in many of the general health-related QOL domains and in visual analog scale-measured health utility. Adjustment of selected scale scores for demographic characteristics and for CD4(+) T-cell count, human immunodeficiency virus viral load, and use of highly active antiretroviral therapy (HAART) attenuated most of the differences in general health-related QOL, except that physical function scores remained significantly lower in the newly diagnosed CMV retinitis group. Adjustment did not alter the pattern of vision-related QOL results. CONCLUSIONS These results suggest that in the HAART era, CMV retinitis is associated with reduced vision-related QOL in patients both with newly diagnosed and with long-standing disease, even though patients with long-standing CMV retinitis seem to have general health-related QOL and health utility similar to that of patients with AIDS who do not have CMV retinitis. Newly diagnosed CMV retinitis also is associated with lower general health-related QOL in most domains and with lower health utility.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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99
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Wright ME, Suzman DL, Csaky KG, Masur H, Polis MA, Robinson MR. Extensive retinal neovascularization as a late finding in human immunodeficiency virus-infected patients with immune recovery uveitis. Clin Infect Dis 2003; 36:1063-6. [PMID: 12684920 DOI: 10.1086/374050] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2002] [Accepted: 12/19/2002] [Indexed: 11/03/2022] Open
Abstract
Sixteen human immunodeficiency virus (HIV)-infected patients with inactive cytomegalovirus (CMV) retinitis who had discontinued systemic anti-CMV therapy while receiving highly active antiretroviral therapy (HAART) were prospectively observed. Fifteen patients developed immune recovery uveitis (IRU); 3 of the patients developed extensive retinal neovascularization, 1 of whom required vitrectomy for recurrent vitreous hemorrhages. These late complications indicate a need for continued ophthalmologic follow-up of HIV-infected patients who have a history of CMV retinitis, even for individuals who have not required anti-CMV therapy for >4 years.
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Affiliation(s)
- Mary E Wright
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland 20892, USA
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100
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Scholz M, Doerr HW, Cinatl J. Human cytomegalovirus retinitis: pathogenicity, immune evasion and persistence. Trends Microbiol 2003; 11:171-8. [PMID: 12706995 DOI: 10.1016/s0966-842x(03)00066-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Human cytomegalovirus (HCMV) retinitis frequently occurs in severely naturally and iatrogenically immunocompromised patients. It has been shown that the immune-privileged retinal pigment epithelium (RPE) is a major site of persistent HCMV. Recently, evidence has accumulated to show that HCMV immediate early (IE) gene expression in RPE cells deviates ocular antiviral inflammation via FasL. Moreover, unlike in other cell types, the HCMV major IE1/2 enhancer promoter (MIEP) resists activation by proinflammatory stimuli mediated by the transcription factor NF-kappaB. However, tumor necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma) found at elevated levels in transplant recipients and AIDS patients with retinitis sensitize RPE cells and other retinal cells to FasL-mediated apoptosis, thus contributing to retina destruction and necrosis rather than inflammation. These specific features of RPE cells in conjunction with deregulated immune responses of immunocompromised patients seem to contribute to virus persistence and pathogenesis within the immune-privileged ocular retina.
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Affiliation(s)
- Martin Scholz
- Zentrum der Hygiene, Institut für Medizinische Virologie, Klinikum der Johann Wolfgang Goethe-Universität, Paul-Ehrlich-Strasse 40, D-60596 Frankfurt am Main, Germany
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