Correlation of virology and clinical course of cytomegalovirus retinitis

Prevalence and causes of clinically detectable uveitic serous retinal detachment

PURPOSE

To describe the prevalence and causes of clinically detectable uveitic serous retinal detachment (SRD).

METHODS

Retrospective chart review of a large clinic-based series.

RESULTS

Serous retinal detachment was present in 78 of the 2761 (2.8%) patients. Vogt-Koyanagi-Harada (VKH) disease was the most commonly identified cause (38/78, 48.7%). Less common associated etiologies included toxoplasmic retinochoroiditis (8/78, 10.3%), sarcoidosis (5/78, 6.4%), intraocular lymphoma (4/78, 5.1%), presumed tuberculosis (3/78, 3.8%), and posterior scleritis (2/78, 2.6%). Fifteen patients (19.2%) with uveitic SRD at presentation had no identifiable etiology and were labeled idiopathic or indeterminant. Thirty of the 38 patients with VKH disease (78.9%) had positive neurological and/or integumentary findings, and therefore constituted either complete or incomplete subtypes of the disease. The remaining eight (21.1%) had presumed/ocular VKH disease limited to the eye.

CONCLUSION

While VKH disease by far is the most common cause of clinically detectable uveitic SRD, a number of other non-infectious and infectious inflammatory disorders were also associated with this distinctive clinical finding.

Transient vitreous inflammatory reactions associated with combination antiretroviral therapy in patients with AIDS and cytomegalovirus retinitis

PURPOSE

To report the observation that a transient vitreous inflammatory reaction may develop in the eyes of patients with acquired immunodeficiency syndrome (AIDS), cytomegalovirus retinitis, and an increased CD4+ T-lymphocyte count during treatment with antiretroviral therapy including a protease inhibitor.

METHODS

We reviewed the medical records of eight patients with AIDS and cytomegalovirus retinitis who developed vitreous inflammatory reactions greater than those usually seen with this disease.

RESULTS

Vitreous inflammatory reactions obscured the view of the posterior pole in all patients. No iris nodules, synechiae, glaucoma, or cystoid macular edema were observed. Six patients had unilateral cytomegalovirus retinitis, and, in each, the inflammation occurred only in the eye with cytomegalovirus retinitis. The vitreous inflammatory reactions were associated with clinically inactive cytomegalovirus retinitis in six patients, with disease reactivation in one patient, and were present at diagnosis of active disease in one patient. Cytomegalovirus retinitis has not recurred in any of these patients since their episodes of vitreous inflammation. Vitreous inflammation developed in all eight patients after a substantial increase in CD4+ T-lymphocyte counts caused by combination antiretroviral therapy. Five patients had CD4+ T-lymphocyte counts of greater than 100 cells per microl at the time the vitreous inflammatory reaction developed. No other causes of uveitis were found.

CONCLUSIONS

Patients with AIDS and cytomegalovirus retinitis may develop transient intraocular inflammation associated with combination antiretroviral therapy. We believe that this inflammation reflects an improved immune response against cytomegalovirus.

Diagnostic assays in cytomegalovirus retinitis: detection of herpesvirus by simultaneous application of the polymerase chain reaction and local antibody analysis on ocular fluid

AIM

To determine the value of the polymerase chain reaction (PCR) technique and the analysis of intraocularly produced antibodies by calculating a Goldmann-Witmer quotient (GWq) as diagnostic assays in the confirmation of a clinically diagnosed cytomegalovirus (CMV) retinitis in a group of unselected AIDS patients.

METHODS

Eleven samples of undiluted ocular fluid, obtained from nine AIDS patients with a clinically diagnosed CMV retinitis were analysed for the presence of genomic DNA from CMV, HSV-1, VZV, and EBV by PCR. Nine of these samples were analysed for the presence of locally produced IgG antibodies against these herpesviruses by calculating a GWq. Ten samples obtained from patients with various entities of clinical non-herpetic uveitis and 17 samples of aqueous humour obtained at cataract surgery were used as controls.

RESULTS

In 10 out of 11 samples from AIDS patients (91%) the presence of CMV DNA was demonstrated. In four out of nine (44%) patients this was accompanied by CMV DNA in the blood indicating a CMV viraemia. In one sample, VZV DNA was detected and in another sample both CMV and VZV DNA were detected. No HSV-1 or EBV DNA could be demonstrated in these 11 samples. In contrast, simultaneous analysis of locally produced IgG antibodies against herpesviruses could not confirm the initial diagnosis of CMV retinitis. Ocular fluid samples obtained from 10 control uveitis patients were negative for DNA from CMV, VZV, and EBV by PCR. In one of 10 uveitis control samples HSV-1 DNA was detected; antibody analysis did not confirm this. In the uveitis control group, a significant GWq was calculated in one sample for HSV-1 and in another sample for VZV. The cataract control samples were all herpesvirus DNA negative by PCR.

CONCLUSIONS

To establish the diagnosis of CMV retinitis in AIDS patients, ophthalmoscopic examination is a sensitive method. In confirming a diagnosis in indistinctive cases, application of a PCR assay detecting CMV DNA is a more sensitive method than analysis of locally produced antibodies by calculating a GWq. In clinical non-herpetic uveitis, secondary release of HSV-1 and VZV should be considered requiring additional therapeutic anticipation.

Systemic viral infections and their retinal and choroidal manifestations

Viruses are one of the most common causes of infections involving the posterior segment of the eye. Such infections can occur either on a congenital or an acquired basis, and may affect primarily the retina or the choroid. Congenital cytomegalovirus (CMV) and rubella infections may result in retinitis. CMV retinitis is also the most common cause of acquired viral retinitis, primarily because of the acquired immunodeficiency syndrome (AIDS). Other types of viral retinitis, such as those caused by herpes simplex or herpes zoster, can occur in immunocompromised or immunocompetent individuals. Retinitis or choroiditis caused by viruses such as measles, influenza, Epstein-Barr virus, and Rift Valley fever virus, typically occurs subsequent to an acute viral systemic illness. The systemic and ocular manifestations, as well as the histopathology, laboratory tests, differential diagnoses, and treatment regimens for each of the individual viruses are discussed in detail.

Epidemiological evidence is crucial as proof of causation in cytomegalovirus disease

This review analyses the methods available to establish proof of causation in cytomegalovirus (CMV) disease. The clinical spectrum of CMV disease is discussed in the light of the crucial role of longitudinal epidemiological studies in proving causation in such disease.

Treatment of retinal detachments in patients with the acquired immune deficiency syndrome

Thirty-nine eyes from 31 patients with retinal detachment due to cytomegalovirus (CMV) retinitis were treated by either laser photocoagulation (22 eyes), scleral buckle (9 eyes), pars plana vitrectomy (5 eyes), or no therapy (3 eyes). The success rates for photocoagulation (77.2%), scleral buckle (77.7%), and vitrectomy (with gas or oil, 80%) were similar. The median survival time was 95 days (range, of 7 to 280 days). The extent of detachment, the presence of active disease in either the periphery or the posterior pole, and overall health served to determine what type of therapy was best suited for each patient. Although silicone oil appears to be best for patients with a total retinal detachment and active disease, this small series suggests that conservative modes of therapy such as laser photocoagulation and scleral buckles can be used successfully to treat these patients if there is an absence of active retinitis.

Cytomegalovirus retinitis

Cytomegalovirus retinitis is a frequent and serious complication of various conditions, including diseases characterized by impaired immunity, such as the acquired immunodeficiency syndrome. Due to recent advances in the treatment of cytomegalovirus retinitis, accurate diagnosis and management have become increasingly important. In this review, the authors present the epidemiology, clinical features, diagnostic testing, treatment with complications, and prognosis of cytomegalovirus retinitis. A differential diagnosis is presented and the characteristic ocular lesions are illustrated.

Foscarnet in the treatment of cytomegalovirus retinitis in acquired immune deficiency syndrome

Cytomegalovirus (CMV) retinitis is the major cause of visual loss in acquired immune deficiency syndrome (AIDS). Thirty-one patients with active CMV retinitis were treated with the new antiviral drug, Foscarnet (trisodium phosphonoformate). After a 3-week course of induction therapy, the retinitis improved in 29 of 31 patients (93.5%). Complete resolution of the retinitis was seen in 19 cases (61.3%). Ten patients had partial resolution (32.2%) and two (6.5%) failed to respond. After induction therapy, six patients were put on a low-dose maintenance regimen. All patients without maintenance therapy relapsed within 3 weeks after discontinuation of Foscarnet. The rate of relapse on maintenance therapy was 50% (3/6) within the first 5 weeks. The three other patients of Foscarnet maintenance did not relapse after a follow-up period of 12 weeks. In contrast to ganciclovir, Foscarnet did not induce neutropenia but it produced kidney toxicity that led to reversible renal insufficiency in three cases. Thus, Foscarnet appears to be a useful alternative to ganciclovir, particularly when combined with bone marrow toxic drugs, such as zidovudine (azidothymidine).

Acute multifocal hemorrhagic retinal vasculitis

The authors present a series of seven patients with acute visual loss associated with mild anterior uveitis, multifocal retinal vasculitis, retinal capillary nonperfusion, retinal hemorrhage, disc swelling, and vitreitis. Oral prednisone was of some benefit in these patients and oral acyclovir was generally ineffective. Neovascular complications including retinal, disc, choroidal, and iris new vessels were common, requiring photocoagulation in five patients. Horseshoe tears developed in two patients in zones of uninvolved retina but retinal detachment did not occur. The etiology remains unknown, although it may represent either a localized ocular form of Behçet's disease or other systemic syndrome, infection with a herpes group virus other than zoster varicella virus, or a manifestation of an undefined infectious agent.

Treatment of cytomegalovirus retinitis with ganciclovir (9-[2-hydroxy-1-(hydroxymethyl) ethoxymethyl] guanine (BW B759U)

Six patients (11 eyes) with virologically confirmed cytomegalovirus (CMV) retinitis involving the posterior pole of the eye were treated with a new drug, ganciclovir. Treatment with intravenous ganciclovir consistently halted progression of retinitis and produced improvement in measures of visual function. However, within three weeks after cessation of therapy renewed CMV activity and worsening of visual function were observed in most cases. Maintenance therapy with ganciclovir extended the period of remission from CMV retinitis.

Prevalence, pathophysiology, and treatment of rhegmatogenous retinal detachment in treated cytomegalovirus retinitis

Seventeen patients with the acquired immune deficiency syndrome and cytomegalovirus retinitis were treated with the antiviral drug ganciclovir (9-[1,3-dihydroxy-2-propoxy-methyl]-guanine, DHPG). Eight eyes of five patients developed rhegmatogenous retinal detachment after initiation of treatment. Multiple breaks in areas of peripheral, healed, atrophic retina accounted for the detachments. All seven eyes that underwent surgery had extensive retinal detachments that were reattached with vitrectomy and silicone oil. Retinotomy and retinal tacks were necessary in two cases that were complicated by severe proliferative vitreoretinopathy. In the fellow eye of one patient, laser treatment was used prophylactically to wall off a peripheral patch of healed retinitis. Endoretinal biopsies and culture were taken in five eyes; evidence of persistent cytomegalovirus was seen in two cases despite concurrent and clinically effective antiviral therapy.

Antiviral therapy with ganciclovir for cytomegalovirus retinitis and bilateral exudative retinal detachments in an immunocompromised child

A child with bilateral cytomegalovirus (CMV) retinitis, vitritis, and exudative retinal detachments, who was in remission from stage IV neuroblastoma and status post-chemotherapy and autologous bone marrow transplantation, was treated with ganciclovir. The drug is a new acyclic nucleoside antiviral drug with potent antiCMV activity. There was bilateral retinal reattachment, clearing of vitritis and regression of retinal exudates and hemorrhages, with concomitant resolution of viral shedding in urine and blood, on ganciclovir 7.5 mg/kg per day. There was recurrence of exudative detachments, vitritis and retinitis when the dose was reduced to 2.5 mg/kg per day, and regression of these findings when the dose was again increased to 7.5 mg/kg per day. Despite continued therapy at this dose, a relapse occurred. When the dose of drug was doubled to 15 mg/kg per day, there initially was a partial therapeutic response, followed by a subsequent relapse. No further response was seen when the dose was increased to 19.5 mg/kg per day. This patient was treated with ganciclovir for a total of 192 days. No adverse reactions to ganciclovir were seen. On the last day of drug administration, there were persistent bilateral exudative retinal detachments and progressive optic nerve head involvement with optic disc pallor, despite quiescence of the retinitis.

Antiviral therapy for cytomegalovirus retinitis in AIDS with dihydroxy propoxymethyl guanine

Six patients (all male, five homosexual and one bisexual, 23 to 48 years old) with the acquired immune deficiency syndrome (AIDS) who had cytomegalovirus retinitis were treated with a new antiviral drug as a part of a prospective open-labeled trial for serious cytomegalovirus infections. The drug, 9-[2-hydroxy-1-(hydroxymethyl)ethoxymethyl] guanine (referred to as dihydroxy propoxymethyl guanine), a new acyclic nucleoside antiviral agent similar in structure to acyclovir, produced positive results. These patients treated with dihydroxy propoxymethyl guanine (2.5 mg/kg of body weight every eight hours) showed regression and often disappearance of the lesions of cytomegalovirus retinitis during and for several weeks after therapy, usually with concomitant resolution of viral shedding. The cytomegalovirus retinitis recurred in four patients (the other two were lost to follow-up), but retreatment usually led to remission. Adverse drug toxicity (reversible granulocytopenia) occurred in two patients.

The acute retinal necrosis syndrome. Possible herpes simplex retinitis

The acute retinal necrosis (ARN) syndrome is a severe necrotic peripheral retinitis with vasculitis and vitritis. It attacks healthy people and carries a poor visual prognosis. Five patients with ARN were seen. Two showed interesting clinical features. One patient developed the ARN syndrome in both eyes but with a 14-year hiatus separating the two episodes, each being preceded by an infectious illness. A second patient had a possible recurrence of the ARN syndrome in the same eye, one year after the original episode. Each episode was preceded by an upper respiratory infection and ipsilateral vesicular skin lesions on the face. Biopsy of one lesion yielded herpes simplex virus (HSV) in culture. These associations, although not definitive, do lend support to the hypothesis that HSV may be the cause of the ARN syndrome.

Bilateral acute retinal necrosis (BARN). Identification of the presumed infectious agent

We describe histopathologic features of an enucleated eye of a patient suffering bilateral acute retinal necrosis (BARN). Retinal tissue was found focally degenerated, and the choroid massively enlarged by lymphoid-like agranular cells. An association of the disease with a viral infection could be demonstrated by (a) the presence of virus particles of the herpesvirus type in retinal tissue, (b) the transmission of the infected principle to human embryo fibroblast cultures, and (c) the visualization of CMV-antigens by immunofluorescence microscopy in such infected cultures. Slow growth of the virus in vitro and the presence of CMV-antigens after infection indicate that the herpesvirus involved in BARN was of the type CMV. On the basis of these findings we propose a guideline for therapy.

Acquired immune deficiency syndrome. Ocular manifestations

The acquired immune deficiency syndrome (AIDS) is a recently described disorder of cellular immunity in homosexuals, intravenous drug abusers, and Haitians. Manifestations include Kaposi's sarcoma, Pneumocystis carinii pneumonia, and other opportunistic infections. Ophthalmic and autopsy examinations of 30 patients at UCLA revealed frequent ocular abnormalities. Findings included cotton-wool spots (16 patients), cytomegalovirus retinitis (eight patients), conjunctivitis and keratitis (four patients), conjunctival Kaposi's sarcoma (three patients), Mycobacterium avium intracellulare choroidal granulomas (one patient), and retinal periphlebitis (one patient). We feel that the presence of cotton-wool spots in patients with this syndrome indicates a poor prognosis. Immunologic and electronmicroscopic studies of cotton-wool spots revealed no infectious agents or immunoglobulin deposition. Cytomegalovirus retinitis always was associated with a fatal outcome. The retinitis was characterized by an acute inflammatory reaction in 50% of patients. Ophthalmologists should be aware of the syndrome and its ocular manifestations.

Cytomegalovirus retinitis: a manifestation of the acquired immune deficiency syndrome (AIDS)

Two homosexual males with the "gay bowel syndrome' experienced an acute unilateral loss of vision. Both patients had white intraretinal lesions, which became confluent. One of the cases had a depressed cell-mediated immunity; both patients ultimately died after a prolonged illness. In one patient cytomegalovirus was cultured from a vitreous biopsy. Autopsy revealed disseminated cytomegalovirus in both patients. Widespread retinal necrosis was evident, with typical nuclear and cytoplasmic inclusions of cytomegalovirus. Electron microscopy showed herpes virus, while immunoperoxidase techniques showed cytomegalovirus. The altered cell-mediated response present in homosexual patients may be responsible for the clinical syndromes of Kaposi's sarcoma and opportunistic infection by Pneumocystis carinii, herpes simplex, or cytomegalovirus.

Cytomegalovirus retinitis in a young homosexual male with acquired immunodeficiency

A case is reported of histopathologically documented CMV retinitis. It is part of a recently appreciated syndrome in young homosexual men, in which cellular immune deficiency has been documented and in which CMV infection may play a role. This case demonstrates that CMV retinitis is not excluded by negative CMV serology or cultures.

Ocular disorders associated with a new severe acquired cellular immunodeficiency syndrome

Among the prominent features of a newly described acquired cellular immunodeficiency syndrome that affects previously healthy male homosexuals are multiple opportunistic infections and Kaposi's sarcoma. Immunosuppression induced by cytomegalovirus infection may play a major role in the pathogenesis of this disorder. We have performed ophthalmic examinations on seven such patients and found ocular abnormalities in all cases. Six patients were examined during the course of their illness and one patient at autopsy only. Each patient had several cotton-wool spots in the affected eye. Other ocular findings included cytomegalovirus retinitis, severe retinal periphlebitis, and conjunctival Kaposi's sarcoma (one case each).

Bilateral cytomegalovirus panuveitis after high-dose corticosteroid therapy

A 30-year-old previously healthy woman who recieved immunosuppressive doses of corticosteroids developed an unusual culture-proved cytomegalovirus panuveitis bilaterally. The atypical clinical course was marked by bilateral exudative detachements with minimal evidence of retinitis. Any patient receiving blood transfusions and immunosuppressive doses of corticosteroids is potentially at risk for developing ocular cytomegalovirus infection, and the clinical presentation of the ocular infection may be atypical.

Necrotizing retinitis caused by opportunistic virus infection in a patient with Hodgkin's disease

A 33-year-old woman with Hodgkin's disease developed a painless progressive loss of vision in both eyes. Despite an ophthalmoscopic appearance of white-yellow retinal necrosis and retinal hemorrhage similar to that described with Hodgkin's disease, no sign of the disorder was found at autopsy. Instead, widespread evidence of Herpesviridae family virus infection was present in several organs, including the retinas. Opportunistic infection, including herpes simplex and cytomegalovirus, should be considered when retinitis complicates Hodgkin's disease.

Rhegmatogenous retinal detachment complicating cytomegalovirus retinitis

Six eyes in four patients with cytomegalovirus retinitis developed retinal holes and retinal detachment. Holes appeared in areas of necrosis and were typically large and round with shaggy edges. Differentiation from exudative detachment was sometimes difficult because of obscuration of the fundus by vitreous haze. Cryotherapy was successful in closing open breaks without detachment; cryotherapy and exoplant surgery were used effectively to treat the initial detachments. The occurrence of massive periretinal proliferation and late development of new areas of hole formation or retinitis complicated therapy for these detachments.

Retinal aneurysms in adult cytomegalovirus retinitis

We observed aneurysms of the retinal arteries, capillaries, and venules occurring in a patient with cytomegalovirus retinitis. These aneurysms were caused by involvement of the retinal vascular endothelium resulting in focal weaknesses in the vascular walls. The clinical appearance of this retinitis superficially resembled retinal branch vein occlusion.

Cytomegalovirus in juvenile iridocyclitis

We cultured cytomegalovirus from lens material aspirated from the eye of a 4-year-old boy who had a severe bilateral iridocyclitis and secondary cataracts. There were neither systemic manifestations of congenital disease nor chorioretinitis.

Cytomegalovirus retinitis in adults. A manifestation of disseminated viral infection

Retinitis caused by cytomegalovirus (CMV) infection is unusual in adults. Sixteen of the 17 cases reported have occurred in immunologically compromised patients, most frequently renal transplant recipients. CMV retinitis is associated with a distinctive ophthalmoscopic appearance and, in the majority of cases, was the first clinical manifestation of systemic viral infection. Severe and permanent visual deficits are characteristic. Since retinitis is a reliable sign of disseminated disease and ophthalmoscopic examination a rapid method of establishing its presence, recognition of this manifestation should allow earlier diagnosis of serious CMV infection.

Cytomegalovirus retinitis secondary to chronic viremia in phagocytic leukocytes

We studied the relationship between the duration and intensity of cytomegalovirus viremia, cytomegalovirus complement fixing antibody, and cytomegalovirus retinitis in 61 renal transplant recipients. Five (8%) patients had chronic viremia which lasted more than six months. Two of the five developed typical cytomegalovirus retinitis and a severe fungal infection after intensive viremia of more than 11 months' duration. Retinitis did not develop in 22 patients with short-term viremia. Infectious cytomegalovirus was largely associated with polymorphonuclear leukocytes, but the virus was associated with monocytes during the immature granulocytic response accompanying one patient's terminal illness.

Necrotizing vaso-occlusive retinitis

We studied two adult patients with fulminating, necrotizing vaso-occlusive retinitis, and documented the progressive course of retinal necrosis, vitreoretinal interface contraction, and consequent retinal detachment. The systemic criteria for Behçet's disease were present in one patient, and partially fulfilled in the second.

Cytomegalovirus infection and immunity in renal allograft recipients: assessment of the competence of humoral immunity

Cytomegalovirus (CMV) infections are prevalent in renal allograft recipients. The purpose of this ongoing study is to attempt to elucidate the mechanism(s) responsible for the enhanced susceptibility to CMV infections on the part of transplant patients and for their apparent inability to eradicate the infection once it starts. The present report assesses the competence of humoral immunity to CMV in renal allograft recipients. The total study population was comprised of 41 renal allograft recipients (10 followed prospectively) and 38 age-matched control subjects. The overall CMV infection rate in renal allograft recipients was 90.2%, and in 11 cohort control subjects it was 45.5%. Active infection was present in 61.0% of transplant patients (24.0% of these had CMV disease) and in 18.2% of the cohorts. THESE DIFFERENCES ARE SIGNIFICANT. CMV complement fixation and neutralization antibody prevalence was similar in 10 patients with renal failure undergoing hemodialysis before transplantation and in 23 control subjects. There was similarly no difference in antibody response between allograft recipients in whom the infection was primary (eight subjects) or secondary (17 subjects). We conclude that despite immunosuppressant therapy (with azathioprine and corticosteroids), humoral immunity to CMV is not impaired in transplant patients with either a primary or secondary infection.

Adult cytomegalovirus inclusion retino-uveitis

A 27-year-old male renal transplant recipient acquired cytomegalovirus (CMV) infection of both eyes. This was characterized early by a distinctive necrotic retinitis with discrete advancing edges. A large exudative retinal detachment and hypopyon developed in one eye, and cultures from the anterior chamber aspirate grew CMV. Cytomegalovirus was also isolated from the urine and throat; after serial negative base-line titers, CMV antibody titer became positive. At autopsy CMV was isolated from lung, esophagus, and kidney tissue. Light and electron microscopic studies demonstrated extensive necrosis and disruption of the sensory retina and retinal pigment epithelium with exudative retinal detachments. The diseased retinal cells contained a multiplicity of viral particles in various stages of maturity. Cytomegalic inclusion-bearing cells were demonstrated in the choroid of the more severely affected eye.

Cytomegalovirus in tears from patients with normal eyes and with acute cytomegalovirus chorioretinitis

Cytomegalovirus (CMV) was recovered from the tears in eight of 41 (19.5%) children excreting CMV in their urine or saliva. Tear excretors were all immunosuppressed children with acute lymphocytic leukemia. Three had active CMV chorioretinitis and five did not develop retinal disease in nine to 15 months of observation. To our knowledge this was the first report of the recovery of CMV from tears and of acquired CMV chorioretinitis in children. One patient with active chorioretinitis presented with a disciform elevation of the macula. Therapy with adenine arabinoside (ara-A) or idoxuridine was ineffective in two patients while a third patient treated with ara-Apossibly had a more rapid recovery. However, the significance is uncertain due to the unusual disease presentation and lack of data regarding the nature of cytomegalic inclusion disease chorioretinitis. Areas of retinal calcification were present at autopsy in one patient.