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Kumar A, Ausayakhun S, Ausayakhun S, Apivatthakakul A, Liu Y, Snyder BM, Margolis TP, Keenan JD. Quality of Life Outcomes Among Patients Being Screened for Cytomegalovirus Retinitis in Thailand. Ocul Immunol Inflamm 2024; 32:520-524. [PMID: 37801648 DOI: 10.1080/09273948.2023.2263091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023]
Abstract
PURPOSE Cytomegalovirus (CMV) retinitis can have debilitating impacts on quality of life (QOL), but few contemporary studies have characterized these ramifications. This study assessed the impact of CMV retinitis on vision-related QOL for those living with HIV/AIDS in Thailand. METHODS QOL was assessed as part of a prospective interventional cohort study of patients referred to a tertiary hospital in Thailand for CMV retinitis screening. A validated vision-related QOL questionnaire was administered at the baseline screening visit and at the 6-month study visit. Multivariable linear regression models were performed to determine the effect of CMV retinitis diagnosis on QOL score. RESULTS A total of 152 participants completed the QOL questionnaire at their initial clinic visit. At baseline, a diagnosis of CMV retinitis diagnosis was significantly associated with decreased QOL score: unilateral retinitis was associated with a 0.11 (95% CI: -0.26-0.03) decrement in QOL, and bilateral retinitis was associated with a 0.33 (95% CI: -0.51-0.16) decrement (joint P-value = 0.0009). For the 78 participants with a 6-month visit, changes in QOL from baseline were small and not significant. A diagnosis of CMV retinitis was still associated with decreased QOL score at 6 months (joint P-value = 0.03). CONCLUSIONS This study found that vision-related QOL was lower in those with CMV retinitis, especially with bilateral involvement, and did not improve after treatment among those with follow-up. These findings reinforce the debilitating clinical manifestations of this disease, and support efforts for earlier screening to detect CMV retinitis before impacts on QOL have occurred.
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Affiliation(s)
- Anika Kumar
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Somsanguan Ausayakhun
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sakarin Ausayakhun
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Atitaya Apivatthakakul
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Yingna Liu
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Blake M Snyder
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Todd P Margolis
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jeremy D Keenan
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
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Cytomegalovirus-Specific T Cells from Third-Party Donors Successfully Treated Refractory Cytomegalovirus Retinitis after Unrelated Umbilical Cord Blood Transplantation. J Immunol Res 2022; 2022:6285510. [DOI: 10.1155/2022/6285510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/19/2022] [Accepted: 07/23/2022] [Indexed: 11/17/2022] Open
Abstract
Umbilical cord blood (UCB) transplants (UCBTs) are becoming increasingly common in the treatment of a variety of hematologic and nonhematologic conditions. The T cells from UCB are naïve T cells, which have not yet been exposed to antigens and therefore do not contain T cells with specific immune functions against viruses. Cytomegalovirus (CMV) infections occur in more than 80% of patients after UCBT compared to other types of transplantation. Anti-CMV medications are currently restricted, with ganciclovir, foscarnet, and valganciclovir being the most common in China; however, with limited efficacy and considerable side effects, all these drugs are susceptible to viral resistance. In recent years, cytomegalovirus-specific T cells (CMVST) have advanced the treatment of viral infections in immunodeficient patients. CMVST usually uses the same donor as hematopoietic stem cell transplantation. CMVST should be administered to UCBT patients because of the absence of donors after UCBT. In China, there is no report on the use of CMVST to treat CMV infection after UCBT, and foreign reports are also limited. This paper reported a 20-year-old male patient with acute myeloid leukemia who developed cytomegalovirus retinitis (CMVR) after umbilical cord blood transplantation. After ineffective viral treatment, he was treated with a third-party donor CMVST and was successfully transformed into CMV nucleic acid negative.
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Lee JH, Agarwal A, Mahendradas P, Lee CS, Gupta V, Pavesio CE, Agrawal R. Viral posterior uveitis. Surv Ophthalmol 2017; 62:404-445. [PMID: 28012878 PMCID: PMC5654632 DOI: 10.1016/j.survophthal.2016.12.008] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 12/12/2016] [Accepted: 12/13/2016] [Indexed: 12/28/2022]
Abstract
The causes of posterior uveitis can be divided into infectious, autoimmune, or masquerade syndromes. Viral infections, a significant cause of sight-threatening ocular diseases in the posterior segment, include human herpesviruses, measles, rubella, and arboviruses such as dengue, West Nile, and chikungunya virus. Viral posterior uveitis may occur as an isolated ocular disease in congenital or acquired infections or as part of a systemic viral illness. Many viruses remain latent in the infected host with a risk of reactivation that depends on various factors, including virulence and host immunity, age, and comorbidities. Although some viral illnesses are self-limiting and have a good visual prognosis, others, such as cytomegalovirus retinitis or acute retinal necrosis, may result in serious complications and profound vision loss. Since some of these infections may respond well to antiviral therapy, it is important to work up all cases of posterior uveitis to rule out an infectious etiology. We review the clinical features, diagnostic tools, treatment regimens, and long-term outcomes for each of these viral posterior uveitides.
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Affiliation(s)
- Joanne H Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Aniruddha Agarwal
- Department of Vitreoretina and Uveitis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Cecilia S Lee
- Department of Uveitis, University of Washington, Seattle, Washington, USA
| | - Vishali Gupta
- Department of Vitreoretina and Uveitis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Carlos E Pavesio
- Department of Medical Retina, Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom
| | - Rupesh Agrawal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Department of Medical Retina, Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom; Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore.
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Jeon S, Lee WK. Cytomegalovirus Retinitis in a Human Immunodeficiency Virus-negative Cohort: Long-term Management and Complications. Ocul Immunol Inflamm 2016; 23:392-9. [PMID: 25760914 DOI: 10.3109/09273948.2014.985385] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To examine the clinical outcomes achieved by using intravitreal ganciclovir injections combined with systemic anti-viral therapy in treating cytomegalovirus (CMV) retinitis in patients without human immunodeficiency virus (HIV) infection. METHODS Twenty-three eyes of 15 HIV-negative patients diagnosed with CMV retinitis were included in this retrospective study. RESULTS The median follow-up was 68 weeks (range, 12-156), and median number of injections was 10 (range, 2-22). The retinal lesions stopped progressing within 1-2 weeks following treatment. All of the eyes showed either unchanged or ≥2 line improvements of BCVA at last visit. There was no development of CMV retinitis in a fellow eye, or recurrence in a studied eye. Systemic complications such as neutropenia were not detected. CONCLUSIONS Intravitreal ganciclovir injections combined with systemic anti-viral treatment is a good therapeutic option for treating CMV retinitis without HIV infection. Such treatment provided favorable visual outcomes, with minimal ocular and systemic complications.
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Affiliation(s)
- Sohee Jeon
- a Department of Ophthalmology , Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine , Seoul , South Korea
| | - Won Ki Lee
- a Department of Ophthalmology , Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine , Seoul , South Korea
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Hamouda M, Kahloun R, Jaballah L, Aloui S, Skhiri H, Jelliti B, Khairallah M, Elmay M. Cytomegalovirus Ocular Involvement in a Kidney Transplant Recipient. EXP CLIN TRANSPLANT 2016; 16:495-498. [PMID: 27363821 DOI: 10.6002/ect.2016.0022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cytomegalovirus remains the most common infection after kidney transplant. We report cytomegalovirus retinitis and anterior uveitis, which developed consecutively within 1 year in a kidney transplant recipient. A 25-year-old man presented 5 months after transplant with decreased visual acuity in his left eye. Fundus examination revealed bilateral areas of necrotizing retinitis with intraretinal hemorrhages. The confirmation of cytomegalovirus disease was based on clinical findings and positive polymerase chain reaction for cytomegalovirus in plasma and in aqueous humor. The patient was treated with intravenous ganciclovir for 21 days and then with valacyclovir for 3 months. The patient's symptoms improved, and fundus examination revealed resolution of retinitis with appearance of retinal scarring. One year later, the patient presented with cytomegalovirus anterior uveitis associated with increased intraocular pressure, which was treated with antiviral agents, antiglaucomatous eye drops, and trabeculectomy. Cytomegalovirus ocular involvement for our immunocompromised patient presented in 2 consecutive forms: bilateral retinitis and anterior uveitis. Early diagnosis and treatment of active cytomegalovirus retinitis and uveitis remain crucial to prevent their progression to irreversible visual impairment.
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Affiliation(s)
- Mouna Hamouda
- From the Department of Nephrology, Fattouma Bourguiba Hospital, and the University Faculty of Medicine, Monastir, Tunisia
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Leenasirimakul P, Liu Y, Jirawison C, Khienprasit N, Kamphaengkham S, Ausayakhun S, Chen J, Yen M, Heiden D, Holland GN, Margolis TP, Keenan JD. Risk factors for CMV retinitis among individuals with HIV and low CD4 count in northern Thailand: importance of access to healthcare. Br J Ophthalmol 2016; 100:1017-21. [PMID: 27297217 DOI: 10.1136/bjophthalmol-2016-308556] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/12/2016] [Indexed: 11/03/2022]
Abstract
AIM To determine if poor access to healthcare is associated with increased cytomegalovirus (CMV) retinitis risk among patients with HIV with CD4 counts of <100 cells/μL screened in a resource-limited setting. METHODS This is a prospective cross-sectional study. Patients with known HIV and a CD4 count of <100 cells/μL attending an HIV clinic in Chiang Mai, Thailand, completed a standardised questionnaire and underwent dilated fundus examination. Participants without CMV retinitis were invited for repeated examinations every 3 months until their CD4 count exceeded 100 cells/μL. The relationship between various potential risk factors and CMV retinitis was assessed with logistic regression. RESULTS 103 study participants were enrolled. At enrolment, the mean age was 37.5 (95% CI 35.7 to 39.2) years, 61.2% (95% CI 51.6% to 70.7%) were male and the mean CD4 count was 29.5 (95% CI 25.9 to 33.1) cells/μL. 21 eyes from 16 (15.5%) participants were diagnosed with CMV retinitis. In multivariate analyses, CMV retinitis was significantly associated with lower CD4 count (OR 1.42 per 10-cell decrement, 95%CI 1.05 to 1.93), longer travel time to clinic (OR 3.85 for those with >30-min travel time, 95% CI 1.08 to 13.8) and lower income (OR 1.22 per US$50 less income, 95% CI 1.02 to 1.47). CONCLUSIONS CD4 count, low income and longer travel time to clinic were significant risk factors for CMV retinitis among patients with HIV in a resource-limited setting. These results suggest that reducing blindness from CMV retinitis should focus on increasing accessibility of screening examinations to poor and hard-to-reach patients.
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Affiliation(s)
| | - Yingna Liu
- Francis I. Proctor Foundation, University of California, San Francisco, California Harvard Medical School, Boston, Massachusetts, USA
| | - Choeng Jirawison
- Department of Ophthalmology, Nakornping Hospital, Chiang Mai, Thailand
| | - Nitta Khienprasit
- Department of Internal Medicine, Nakornping Hospital, Chiang Mai, Thailand
| | | | - Somsanguan Ausayakhun
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Jenny Chen
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Michael Yen
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | - David Heiden
- Department of Ophthalmology and Pacific Vision Foundation, California Pacific Medical Center, San Francisco, California, USA
| | - Gary N Holland
- Department of Ophthalmology, Ocular Inflammatory Disease Center, Jules Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Todd P Margolis
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, California Department of Ophthalmology, University of California, San Francisco, California, USA
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Sittivarakul W, Benjhawaleemas T, Aui-Aree N, Jirarattanasopa P, Liabsuetrakul T. Incidence Rate and Risk Factors for Contralateral Eye Involvement among Patients with AIDS and Cytomegalovirus Retinitis Treated with Local Therapy. Ocul Immunol Inflamm 2015; 24:530-6. [PMID: 26327465 DOI: 10.3109/09273948.2015.1032307] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To calculate the incidence of, and to identify the risk factors for developing contralateral eye involvement among patients with AIDS and unilateral cytomegalovirus retinitis (CMV retinitis), who were treated, in the era of highly-active antiretroviral therapy (HAART), with repetitive intravitreal ganciclovir injections. MATERIALS AND METHODS The clinical records of 119 patients were included. The main outcome measurement was the occurrence of contralateral eye involvement. RESULTS Over a mean follow-up period of 1.6 years, the overall incidence rate of contralateral involvement was 0.17/person-year. The cumulative incidence of contralateral involvement at 6 months and 1 year was 23.8% and 28.4%, respectively. Receiving HAART at the visit before the event was associated with a decreased risk of developing contralateral retinitis (hazard ratio [HR] = 0.26, P = 0.002). CONCLUSIONS The use of HAART, associated with subsequent immune recovery, significantly reduced the incidence of contralateral eye involvement by approximately 75% among patients in our setting.
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Affiliation(s)
- Wantanee Sittivarakul
- a Department of Ophthalmology, Faculty of Medicine , Prince of Songkla University , Hat Yai , Thailand and
| | - Thanyapat Benjhawaleemas
- a Department of Ophthalmology, Faculty of Medicine , Prince of Songkla University , Hat Yai , Thailand and
| | - Nipat Aui-Aree
- a Department of Ophthalmology, Faculty of Medicine , Prince of Songkla University , Hat Yai , Thailand and
| | - Pichai Jirarattanasopa
- a Department of Ophthalmology, Faculty of Medicine , Prince of Songkla University , Hat Yai , Thailand and
| | - Tippawan Liabsuetrakul
- b Epidemiology Unit, Faculty of Medicine , Prince of Songkla University , Hat Yai , Thailand
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Kempen JH, Sugar EA, Lyon AT, Lewis RA, Jabs DA, Heinemann MH, Dunn JP. Risk of cataract in persons with cytomegalovirus retinitis and the acquired immune deficiency syndrome. Ophthalmology 2012; 119:2343-50. [PMID: 22853972 DOI: 10.1016/j.ophtha.2012.05.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 05/24/2012] [Accepted: 05/24/2012] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate cataract risk in eyes of patients with AIDS and cytomegalovirus (CMV) retinitis and to identify risk factors. DESIGN Prospective cohort study. PARTICIPANTS Patients with AIDS and CMV retinitis. METHODS Patients 13 years of age and older were enrolled between 1998 and 2008. Demographic and clinical characteristics, slit-lamp biomicroscopy findings, and dilated ophthalmoscopy results were documented at quarterly visits. Cataract status was determined at the initial visit (prevalence) and at follow-up visits (incidence). MAIN OUTCOME MEASURES For cataract, a high grade of lens opacity by biomicroscopy to which best-corrected visual acuity worse than 20/40 was attributed. Eyes that had undergone cataract surgery before enrollment or between visits also were counted as having cataract. RESULTS Seven hundred twenty-nine eyes of 489 patients diagnosed with CMV retinitis were evaluated. Higher prevalence was observed for patients with bilateral versus unilateral CMV retinitis (adjusted odds ratio [aOR], 2.74; 95% confidence interval [CI], 1.76-4.26) and, among unilateral CMV retinitis cases, for eyes with retinitis versus without retinitis (15% vs. 1.4%; P<0.0001). The age-adjusted prevalence of cataract among CMV retinitis cases was higher than that in a population-based sample (P<0.0001). Cataract prevalence increased with age (aOR, 11.77; 95% CI, 2.28-60.65 for age ≥ 60 years vs. younger than 40 years) and longer duration of retinitis (aOR, 1.36; 95% CI, 1.20-1.54 per year). Among eyes with CMV retinitis initially free of cataract, the cataract incidence was 8.1%/eye-year (95% CI, 6.7%-10.0%). Prior retinal detachment was associated with higher cataract risk (if repaired with silicone oil: adjusted hazard ratio [aHR], 10.37; 95% CI, 6.51-16.52; otherwise: aHR, 2.90; 95% CI, 1.73-4.87). Large CMV retinitis lesions also were associated with higher risk of cataract (for involvement of 25-49% retinal area: aHR, 2.30; 95% CI, 1.51-3.50; for ≥ 50% involvement: aHR, 3.63; 95% CI, 2.18-6.04), each with respect to ≤ 24% involvement, as were anterior segment inflammation (aHR, 2.27; 95% CI, 1.59-3.25) and contralateral cataract (aHR, 2.52; 95% CI, 1.74-3.66). CONCLUSIONS Cytomegalovirus retinitis is associated with a high absolute and relative risk of cataract. Among several risk factors, large retinal lesion size and use of silicone oil in retinal detachment repair are potentially modifiable, albeit not in all cases. Cataract is likely to be an increasingly important cause of visual morbidity in this population.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, and the Center for Clinical Epidemiology and Biostatistics, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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Sugar EA, Jabs DA, Ahuja A, Thorne JE, Danis RP, Meinert CL. Incidence of cytomegalovirus retinitis in the era of highly active antiretroviral therapy. Am J Ophthalmol 2012; 153:1016-24.e5. [PMID: 22310076 DOI: 10.1016/j.ajo.2011.11.014] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 11/14/2011] [Accepted: 11/14/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE To estimate the incidence of cytomegalovirus (CMV) retinitis in the era of highly active antiretroviral therapy (HAART) and to characterize the factors associated with increased risk of CMV retinitis. DESIGN Prospective cohort study. METHODS A total of 1600 participants with acquired immunodeficiency syndrome (AIDS) but without CMV retinitis at enrollment who completed at least 1 follow-up visit in the Longitudinal Study of the Ocular Complications of AIDS (LSOCA) were seen every 6 months to obtain disease and treatment history, ophthalmic examination, and laboratory testing. Incidence of CMV retinitis and risk factors for incident CMV retinitis were assessed. RESULTS The incidence rate of CMV retinitis in individuals with AIDS was 0.36/100 person-years (PY) based upon 29 incident cases during 8134 PY of follow-up. The rate was higher for those with a CD4+ T cell count at the immediately prior visit below 50 cells/μL (3.89/100 PY, P < .01), whereas only 1 individual with a CD4+ T cell count of 50 to 99 cells/μL and 2 individuals with a CD4+ T cell count >100 cells/μL developed CMV retinitis. Having a CD4+ T cell count below 50 cells/μL at the clinical visit prior to CMV retinitis evaluation was the single most important risk factor (HR: 136, 95% CI: 30 to 605, P < .0001) for developing retinitis. CONCLUSIONS Patients with AIDS, especially those with severely compromised immune systems, remain at risk for developing CMV retinitis in the HAART era, although the incidence rate is reduced from that observed in the pre-HAART era.
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Teoh SC, Ou X, Lim TH. Intravitreal ganciclovir maintenance injection for cytomegalovirus retinitis: efficacy of a low-volume, intermediate-dose regimen. Ophthalmology 2011; 119:588-95. [PMID: 22137552 DOI: 10.1016/j.ophtha.2011.09.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Revised: 08/27/2011] [Accepted: 09/02/2011] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To report the clinical outcomes of highly active antiretroviral therapy (HAART)-naïve, human immunodeficiency virus (HIV)-positive patients with newly diagnosed cytomegalovirus (CMV) retinitis receiving intravitreal injections of a low-volume intermediate maintenance dose (1.0 mg/0.02 ml) of ganciclovir. DESIGN Nonrandomized, retrospective, interventional series. PARTICIPANTS A consecutive cohort of 34 eyes from 24 HAART-naïve patients with AIDS and diagnosed with CMV retinitis by retinal specialists at the Singapore Communicable Disease Centre. INTERVENTION Patients received a maintenance dose of 1.0 mg/0.02 ml of intravitreal ganciclovir once weekly after standard induction therapy with 2.0 mg/0.04 ml of twice weekly intravitreal ganciclovir. MAIN OUTCOME MEASURES Time to progression, visual acuity, and complications. Progression was observed using photographic documentation. RESULTS The median time to progression was 152 days (mean, 380.1 days, 95% confidence interval, 240.8-519.4). The median follow-up was 95 days (mean, 207.9 days). Three eyes developed rhegmatogenous detachments, but there was no endophthalmitis after 1858 injections. Contralateral involvement of CMV retinitis occurred in 17.6% of the patients. The cost estimate for intravitreal injections over a 6-month period was 11.7% that of sustained-release implants for unilateral treatment and 11.1% that of daily continuous intravenous infusions and oral valganciclovir compared with bilateral treatments. CONCLUSIONS Weekly low-volume, intermediate-dose (1.0 mg/0.02 ml) ganciclovir is an efficacious option in developing countries where newer options of sustained-release implants and oral valganciclovir are unavailable or prohibitively expensive. The regimen maintains a long time to progression, preserving vision while minimizing retinal toxicity complications.
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Affiliation(s)
- Stephen C Teoh
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Republic of Singapore
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Tan S, Liu S, Jiang S. Pathogenesis and treatment of human immunodeficiency virus-associated cytomegalovirus retinitis. Future Virol 2011. [DOI: 10.2217/fvl.11.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In the era of HAART, human cytomegalovirus (HCMV) retinitis remains the leading opportunistic ocular infection and the major cause of blindness in patients with AIDS. The virus has been subjected to selection and presented with the opportunity to occupy a niche to which it is highly adapted in order to escape from host immune recognition and establish persistent infection in the retina. The imbalance between host immune protection and viral immune evasion results in retinitis progression. Moreover, a synergistic interaction between HCMV and HIV in the pathogenesis of retinitis has been proposed. HAART has had a major beneficial impact on the prognosis for HIV-infected individuals. Both HAART and specific anti-HCMV treatment contribute to therapeutic success against HCMV retinitis in AIDS patients. The improved prognosis for AIDS patients with respect to the development of HCMV retinitis has been welcomed; however, we should bear in mind the occurrence of HIV drug resistance, relapse of retinitis and immune recovery uveitis after treatment, which mean that this complication of HIV infection remains a threat.
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Affiliation(s)
- Suiyi Tan
- School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
- Viral Immunology Laboratory, Lindsley F Kimball Research Institute, New York Blood Center, New York, NY 10065, USA
| | - Shuwen Liu
- School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Shibo Jiang
- School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
- Viral Immunology Laboratory, Lindsley F Kimball Research Institute, New York Blood Center, New York, NY 10065, USA
- Key Laboratory of Medical Molecular Virology of MOE/MOH & Institute of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai 200032, China
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Abstract
Cytomegalovirus (CMV) retinitis is the most common cause of vision loss in patients with acquired immunodeficiency syndrome (AIDS). CMV retinitis afflicted 25% to 42% of AIDS patients in the pre-highly active antiretroviral therapy (HAART) era, with most vision loss due to macula-involving retinitis or retinal detachment. The introduction of HAART significantly decreased the incidence and severity of CMV retinitis. Optimal treatment of CMV retinitis requires a thorough evaluation of the patient's immune status and an accurate classification of the retinal lesions. When retinitis is diagnosed, HAART therapy should be started or improved, and anti-CMV therapy with oral valganciclovir, intravenous ganciclovir, foscarnet, or cidofovir should be administered. Selected patients, especially those with zone 1 retinitis, may receive intravitreal drug injections or surgical implantation of a sustained-release ganciclovir reservoir. Effective anti-CMV therapy coupled with HAART significantly decreases the incidence of vision loss and improves patient survival. Immune recovery uveitis and retinal detachments are important causes of moderate to severe loss of vision. Compared with the early years of the AIDS epidemic, the treatment emphasis in the post- HAART era has changed from short-term control of retinitis to long-term preservation of vision. Developing countries face shortages of health care professionals and inadequate supplies of anti-CMV and anti-HIV medications. Intravitreal ganciclovir injections may be the most cost effective strategy to treat CMV retinitis in these areas.
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Affiliation(s)
- Michael W Stewart
- Department of Ophthalmology, Mayo School of Medicine, Jacksonville, FL, USA.
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Affiliation(s)
- Aliza Jap
- Division of Ophthalmology, Changi General Hospital, 2 Simei Street 3, Singapore
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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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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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Affiliation(s)
- Lucia Sobrin
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Boston, MA 02114, USA
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Zemnick C, Asher ES, Wood N, Piro JD. Immediate nasal prosthetic rehabilitation following cytomegalovirus erosion: a clinical report. J Prosthet Dent 2006; 95:349-53. [PMID: 16679129 DOI: 10.1016/j.prosdent.2006.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The immediate prosthetic rehabilitation of a patient with erosive cutaneous cytomegalovirus (CMV) is presented. Although CMV is a major cause of morbidity and mortality in immunocompromised patients, skin lesions are rarely discussed in the literature. Recognition of the susceptibility of medically compromised patients to infections that can cause extraoral and intraoral deformity is essential to prevention, early diagnosis, and prompt intervention of a life-threatening destructive debilitation. A method for rapidly fabricating a nasal prosthesis is described, and the importance of prompt esthetic and psychological rehabilitation is reviewed.
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