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Wang I, Yang BCL, Li KH, Wu JS, Chen SN. CMV Retinitis with Panretinal Occlusive Vasculitis. Ocul Immunol Inflamm 2024; 32:477-484. [PMID: 36508707 DOI: 10.1080/09273948.2022.2148113] [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: 06/01/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To report the clinical features of cytomegalovirus (CMV) retinitis with panretinal occlusive vasculitis. METHODS Retrospective case series. RESULTS Four eyes in 3 non-HIV patients (male: female = 3:0) were included. Previous medical history included diabetes mellitus (n = 2), age-related macular degeneration (n = 1), and Multiple myeloma under chemotherapy (n = 1). All patients were treated with oral valganciclovir and intravitreal ganciclovir. Slow resolution of retinitis related retinal opacification was noted in all 4 eyes. Two eyes had anti-viral agents discontinued despite the persistent retinitis related opacification and the lesions slowly resolved in the following months. The final decimal visual acuity was equal to or worse than 0.02 in 3 of the 4 eyes. CONCLUSION In eyes of CMV retinitis with panretinal occlusive vasculitis, rapid resolution of retinitis lesions is an unreliable sign evaluating the therapeutic efficacy of anti-viral agents. Besides, despite treatment of anti-viral agents, deteriorating vascular occlusion may further endanger macular function.
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Affiliation(s)
- I Wang
- Department of Ophthalmology, Eye Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Benjamin Chi-Lan Yang
- Department of Ophthalmology, Eye Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Kun-Hsien Li
- Department of Ophthalmology, Changhua Christian Hospital, Changhua, Taiwan
| | - Jian-Sheng Wu
- Department of Ophthalmology, Changhua Christian Hospital, Changhua, Taiwan
| | - San-Ni Chen
- Department of Ophthalmology, Eye Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
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2
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Servillo A, Berni A, Marchese A, Bodaghi B, Khairallah M, Read RW, Miserocchi E. Posterior Herpetic Uveitis: A Comprehensive Review. Ocul Immunol Inflamm 2023; 31:1461-1472. [PMID: 37364039 DOI: 10.1080/09273948.2023.2221338] [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: 10/11/2022] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023]
Abstract
PURPOSE To report and illustrate the main clinical presentations of posterior herpetic uveitis. METHODS Narrative review. RESULTS The ocular manifestations of posterior herpetic uveitis include different clinical presentations. Herpes simplex and varicella zoster can cause acute retinal necrosis, progressive outer retinal necrosis, and non-necrotizing herpetic retinopathies. Cytomegalovirus has been associated with fulminant retinitis with confluent areas of retinal necrosis and retinal hemorrhages, indolent/granular retinitis, and frosted branch angiitis. These diverse clinical presentations are often associated with specific risk factors and different immunological profiles of the host. CONCLUSIONS Herpetic viruses can cause posterior uveitis, presenting various clinical findings. Specific ocular manifestations and the immunological status of the host can help to differentiate the various herpetic entities before laboratory tests confirm the diagnosis.
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Affiliation(s)
- Andrea Servillo
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Berni
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Marchese
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, Paris, France
| | - Moncef Khairallah
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Russell W Read
- Department of Ophthalmology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Elisabetta Miserocchi
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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3
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Mostafa M, Al Fatease A, Alany RG, Abdelkader H. Recent Advances of Ocular Drug Delivery Systems: Prominence of Ocular Implants for Chronic Eye Diseases. Pharmaceutics 2023; 15:1746. [PMID: 37376194 PMCID: PMC10302848 DOI: 10.3390/pharmaceutics15061746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/02/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Chronic ocular diseases can seriously impact the eyes and could potentially result in blindness or serious vision loss. According to the most recent data from the WHO, there are more than 2 billion visually impaired people in the world. Therefore, it is pivotal to develop more sophisticated, long-acting drug delivery systems/devices to treat chronic eye conditions. This review covers several drug delivery nanocarriers that can control chronic eye disorders non-invasively. However, most of the developed nanocarriers are still in preclinical or clinical stages. Long-acting drug delivery systems, such as inserts and implants, constitute the majority of the clinically used methods for the treatment of chronic eye diseases due to their steady state release, persistent therapeutic activity, and ability to bypass most ocular barriers. However, implants are considered invasive drug delivery technologies, especially those that are nonbiodegradable. Furthermore, in vitro characterization approaches, although useful, are limited in mimicking or truly representing the in vivo environment. This review focuses on long-acting drug delivery systems (LADDS), particularly implantable drug delivery systems (IDDS), their formulation, methods of characterization, and clinical application for the treatment of eye diseases.
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Affiliation(s)
- Mahmoud Mostafa
- Department of Pharmaceutics, Faculty of Pharmacy, Minia University, Minya 61519, Egypt;
| | - Adel Al Fatease
- Department of Pharmaceutics, College of Pharmacy, King Khalid University, Abha 62223, Saudi Arabia;
| | - Raid G. Alany
- School of Pharmacy, Kingston University London, Kingston Upon Tames KT1 2EE, UK;
- School of Pharmacy, The University of Auckland, Auckland 1010, New Zealand
| | - Hamdy Abdelkader
- Department of Pharmaceutics, College of Pharmacy, King Khalid University, Abha 62223, Saudi Arabia;
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4
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Cytomegalovirus Retinitis Screening Using Machine Learning Technology. Retina 2022; 42:1709-1715. [DOI: 10.1097/iae.0000000000003506] [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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5
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Furtado JM, Simões M, Vasconcelos-Santos D, Oliver GF, Tyagi M, Nascimento H, Gordon DL, Smith JR. Ocular syphilis. Surv Ophthalmol 2021; 67:440-462. [PMID: 34147542 DOI: 10.1016/j.survophthal.2021.06.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/13/2021] [Accepted: 06/14/2021] [Indexed: 01/01/2023]
Abstract
Multiple studies around the world suggest that syphilis is re-emerging. Ocular syphilis - with a wide range of presentations, most of which are subtypes of uveitis - has become an increasingly common cause of ocular inflammation over the past 20 years. Its rising incidence, diagnostic complexity, and manifestations that have only recently been characterized make ocular syphilis relevant from the public health, clinical, and scientific perspectives. We review the demographics, epidemiology, clinical features, ocular imaging findings, diagnosis, and medical management of this condition.
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Affiliation(s)
- João M Furtado
- Divisão de Oftalmologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil.
| | - Milena Simões
- Divisão de Oftalmologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Daniel Vasconcelos-Santos
- Departamento de Oftalmologia e Otorrinolaringologia, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Genevieve F Oliver
- Flinders University College of Medicine and Public Health, Adelaide, Australia
| | - Mudit Tyagi
- Ocular Inflammation and Immunology Services, LV Prasad Eye Institute, Hyderabad, India
| | - Heloisa Nascimento
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil; Instituto Paulista de Estudos e Pesquisas em Oftalmologia-IPEPO, São Paulo, Brazil
| | - David L Gordon
- Flinders University College of Medicine and Public Health, Adelaide, Australia; SA Pathology, Microbiology and Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia
| | - Justine R Smith
- Flinders University College of Medicine and Public Health, Adelaide, Australia
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6
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Leal SM, Rodino KG, Fowler WC, Gilligan PH. Practical Guidance for Clinical Microbiology Laboratories: Diagnosis of Ocular Infections. Clin Microbiol Rev 2021; 34:e0007019. [PMID: 34076493 PMCID: PMC8262805 DOI: 10.1128/cmr.00070-19] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The variety and complexity of ocular infections have increased significantly in the last decade since the publication of Cumitech 13B, Laboratory Diagnosis of Ocular Infections (L. D. Gray, P. H. Gilligan, and W. C. Fowler, Cumitech 13B, Laboratory Diagnosis of Ocular Infections, 2010). The purpose of this practical guidance document is to review, for individuals working in clinical microbiology laboratories, current tools used in the laboratory diagnosis of ocular infections. This document begins by describing the complex, delicate anatomy of the eye, which often leads to limitations in specimen quantity, requiring a close working bond between laboratorians and ophthalmologists to ensure high-quality diagnostic care. Descriptions are provided of common ocular infections in developed nations and neglected ocular infections seen in developing nations. Subsequently, preanalytic, analytic, and postanalytic aspects of laboratory diagnosis and antimicrobial susceptibility testing are explored in depth.
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Affiliation(s)
- Sixto M. Leal
- Department of Pathology and Laboratory Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kyle G. Rodino
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - W. Craig Fowler
- Department of Surgery, Campbell University School of Medicine, Lillington, North Carolina, USA
| | - Peter H. Gilligan
- Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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7
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Weinlander E, Wubben TJ, Johnson MW. Subacute Vision Loss in a Patient With Limited Immune Dysfunction. JAMA Ophthalmol 2020; 138:208-209. [PMID: 31830229 DOI: 10.1001/jamaophthalmol.2019.4915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Eric Weinlander
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Thomas J Wubben
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Mark W Johnson
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
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8
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Ausayakhun S, Lu LJ, Ausayakuhn S, Nanegrungsunk O, Apivatthakakul A, Luewattananont D, Photcharapongsakul C, Liu Y, Holland GN, Margolis TP, Heiden D, Keenan JD. Contralateral Eye Involvement and Retinal Detachment in Patients with Cytomegalovirus Retinitis Treated with Intravitreous Ganciclovir. Ocul Immunol Inflamm 2020; 29:1145-1150. [DOI: 10.1080/09273948.2020.1728344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Somsanguan Ausayakhun
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Louise J. Lu
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sakarin Ausayakuhn
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Onnisa Nanegrungsunk
- 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
| | - Dao Luewattananont
- 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
- Department of Ophthalmology, University of California, San Francisco, California, USA
| | - Gary N. Holland
- Department of Ophthalmology, Ocular Inflammatory Disease Center, UCLA 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
| | - David Heiden
- Department of Ophthalmology and Pacific Vision Foundation, California Pacific Medical Center, San Francisco, California, 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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9
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Munro M, Yadavalli T, Fonteh C, Arfeen S, Lobo-Chan AM. Cytomegalovirus Retinitis in HIV and Non-HIV Individuals. Microorganisms 2019; 8:microorganisms8010055. [PMID: 31905656 PMCID: PMC7022607 DOI: 10.3390/microorganisms8010055] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/18/2019] [Accepted: 12/25/2019] [Indexed: 02/07/2023] Open
Abstract
Cytomegalovirus retinitis (CMVR) is a severe, vision-threatening disease that primarily affects immunosuppressed patients. CMVR is the most common ocular opportunistic infection in human immunodeficiency virus (HIV) infected patients and is the leading cause of blindness in this group; however, the incidence of CMVR in HIV patients has dramatically decreased with antiretroviral therapy. Other causes of immunosuppression, including organ transplantation, hematologic malignancies, and iatrogenic immunosuppression, can also lead to the development of CMVR. Herein, we describe the pathogenesis of CMVR and compare clinical features, epidemiology, and risk factors in HIV and non-HIV infected individuals with CMVR.
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Affiliation(s)
- Monique Munro
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Tejabhiram Yadavalli
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
- Department of Microbiology and Immunology, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Cheryl Fonteh
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Safa Arfeen
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Ann-Marie Lobo-Chan
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
- Correspondence:
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10
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Holland GN, Van Natta ML, Goldenberg DT, Ritts R, Danis RP, Jabs DA. Relationship Between Opacity of Cytomegalovirus Retinitis Lesion Borders and Severity of Immunodeficiency Among People With AIDS. Invest Ophthalmol Vis Sci 2019; 60:1853-1862. [PMID: 31042791 PMCID: PMC6890425 DOI: 10.1167/iovs.18-26517] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose To evaluate risk factors for severity of cytomegalovirus (CMV) retinitis lesion whitening (opacity), using a standardized scoring system. Methods We performed a cross-sectional, observational investigation of all individuals with newly diagnosed AIDS-related CMV retinitis in three randomized clinical trials and one prospective observational study. Opacity was scored by masked readers, using a prospectively defined ordinal 6-point scale. Demographic factors, laboratory data (CD4+, CD8+ T-lymphocyte counts, human immunodeficiency virus [HIV] blood levels), and lesion characteristics (location, size) were compared to the highest opacity score assigned to either eye. Among eyes with active lesions (scores ≥3), factors associated with severe opacity (scores 5, 6) were identified. Results There were 299 participants (401 eyes with CMV retinitis). In one or more comparisons, increased opacity was associated with lower CD4+ and lower CD8+ T-lymphocyte counts, higher HIV blood level, lack of antiretroviral therapy, male sex, race/ethnicity, and bilateral disease. In eyes with active disease, severe opacity was associated with lower CD4+ T-lymphocyte count, higher HIV blood level, older age, Karnofsky score, lesion size, and bilateral disease. No relationship was identified between opacity and lesion location. Conclusions Lesion border opacity (resulting from CMV activity) reflects level of immune function; as immunodeficiency becomes worse, CMV activity (and opacity) increases. The positive relationship between opacity and HIV blood level may reflect both immunodeficiency and increased CMV activity caused by transactivation of CMV by HIV. Scoring of opacity may be a useful, standard measure for continued study of CMV retinitis across different settings and populations. (Clinicaltrials.gov number for the HPMPC CMV Retinitis Trial: NCT00000142; Clinicaltrials.gov number for the Monoclonal Antibody CMV Retinitis Trial: NCT00000135; Clinicaltrials.gov number for the Ganciclovir-Cidofovir CMV Retinitis Trial: NCT0000014; Clinicaltrials.gov number for the Longitudinal Study of the Ocular Complications of AIDS: NCT00000168.).
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Affiliation(s)
- Gary N Holland
- Ocular Inflammatory Disease Center, UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Mark L Van Natta
- Center for Clinical Trials, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - David T Goldenberg
- Ocular Inflammatory Disease Center, UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Rory Ritts
- Ocular Inflammatory Disease Center, UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Ronald P Danis
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, Wisconsin, United States
| | - Douglas A Jabs
- Center for Clinical Trials, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States.,Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York, United States.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
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11
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Ho M, Invernizzi A, Zagora S, Tsui J, Oldani M, Lui G, McCluskey P, Young AL. Presenting Features, Treatment and Clinical Outcomes of Cytomegalovirus Retinitis: Non-HIV Patients Vs HIV Patients. Ocul Immunol Inflamm 2019; 28:651-658. [PMID: 31166809 DOI: 10.1080/09273948.2019.1604003] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare clinical features, complications, and outcomes of CMV retinitis in non-HIV immunocompromised patients with HIV infected patients. METHODS A retrospective study of patients diagnosed with CMV retinitis with or without HIV infection was performed. Results: Thirty-five eyes from 27 patients (median follow up 26 months) were included. Six patients had HIV infection, the others were immunocompromised from a range of causes. The baseline visual acuity (VA) was similar in the two groups. Prevalence of different types of retinitis (fulminant/indolent) was similar in the two groups. Presence of vitreous haze ≥1+ (p = .041), presence of arteritis, (p = .016) and widespread vascular occlusion (p = .003) were more common in the non-HIV group. CONCLUSION CMV retinitis can present with different features depending on the cause of immunocompromise. Evidence of intraocular inflammation such as vitritis, retinal arteritis, and vascular occlusions was more common in HIV-negative subjects.
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Affiliation(s)
- Mary Ho
- Department of Ophthalmology & Visual Sciences, Chinese University of Hong Kong, Prince of Wales Hospital , Shatin, Hong Kong SAR
| | - Alessandro Invernizzi
- Department of Biomedical and Clinical Science "Luigi Sacco", Luigi Sacco Hospital, University of Milan , Milan, Italy.,Faculty of Medicine and Health, University of Sydney, Save Sight Institute , Sydney, NSW, Australia
| | - Sophia Zagora
- Faculty of Medicine and Health, University of Sydney, Save Sight Institute , Sydney, NSW, Australia
| | - Jolly Tsui
- Department of Ophthalmology & Visual Sciences, Chinese University of Hong Kong, Prince of Wales Hospital , Shatin, Hong Kong SAR
| | - Marta Oldani
- Department of Biomedical and Clinical Science "Luigi Sacco", Luigi Sacco Hospital, University of Milan , Milan, Italy
| | - Grace Lui
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital , Shatin, Hong Kong SAR
| | - Peter McCluskey
- Faculty of Medicine and Health, University of Sydney, Save Sight Institute , Sydney, NSW, Australia
| | - Alvin L Young
- Department of Ophthalmology & Visual Sciences, Chinese University of Hong Kong, Prince of Wales Hospital , Shatin, Hong Kong SAR
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12
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Hwang DK, Chao YJ, Huang YM, Chung YC, Chen SJ, Liu CL. Bilateral cytomegalovirus retinitis comorbid with diabetic macular edema. Taiwan J Ophthalmol 2019; 9:122-126. [PMID: 31198672 PMCID: PMC6557065 DOI: 10.4103/tjo.tjo_84_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cytomegalovirus (CMV) retinitis comorbid with diabetic retinopathy is uncommon. We report a case of bilateral CMV retinitis and diabetic retinopathy in a patient who underwent pancreas transplantation and share the experience of the treatment outcome. An 18-year-old male diagnosed with type-1 diabetes mellitus received pancreas transplantation and immunosuppressive therapy suffered from progressively blurred vision in both eyes for several days. His visual acuity was 20/100 in the right eye and 20/50 in the left eye. Ophthalmic examination revealed bilateral diabetic macular edema (DME) without intraocular inflammatory signs in either eye. The DME subsided after 2 monthly intravitreal injections of aflibercept. However, bilateral panuveitis with CMV retinitis was observed after antivascular endothelial growth factor therapy. The retinitis subsided gradually but completely after systemic and intravitreal antiviral therapy. However, bilateral DME recurred and persisted despite repeated injections of aflibercept during the resting follow-up period. Our case suggests that CMV retinitis can coexist with other retinal diseases, including diabetic retinopathy. Treatment is difficult in such cases.
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13
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Singh SR, Dogra M, Kaur S, Bajgai P, Tigari B, Handa S, Katoch D, Gupta V, Dogra MR, Sharma A, Singh R. Spectrum of Newly Diagnosed Cytomegalovirus Retinitis in a Developing Country in the HAART Era. Ocul Immunol Inflamm 2018; 28:119-125. [PMID: 30395753 DOI: 10.1080/09273948.2018.1538460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: To characterize the presenting features of cytomegalovirus (CMV) retinitis in HIV-positive patients in a developing country in the HAART era.Methods: Retrospective chart review of all patients with CMV retinitis seen at a tertiary-care referral center between January 2006 to June 2017. Demographic and clinical data were collected to study the presenting features and risk factors for blindness.Results: Fifty-five patients with treatment-naïve CMV retinitis were enrolled; 75% were males. CD4 counts were below 50 cells/µL in 51.1%. Bilateral presentation was seen in 61.5%. Half (50.6%) of the eyes were blind at first examination. Zone 1 involvement was present in 46% of the eyes. Retinal area involvement > 25% was the only factor associated significantly with higher incidence of blindness (p = 0.016).Conclusions: There was extensive and bilateral presentation of CMV retinitis due to delayed presentation. Screening for CMV retinitis, irrespective of CD4 counts, may help in developing nations.
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Affiliation(s)
- Simar Rajan Singh
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mohit Dogra
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Savleen Kaur
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Priya Bajgai
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Basavaraj Tigari
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sabia Handa
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Deeksha Katoch
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishali Gupta
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mangat R Dogra
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramandeep Singh
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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14
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Suppressor of Cytokine Signaling 1 (SOCS1) and SOCS3 Are Stimulated within the Eye during Experimental Murine Cytomegalovirus Retinitis in Mice with Retrovirus-Induced Immunosuppression. J Virol 2018; 92:JVI.00526-18. [PMID: 29976680 DOI: 10.1128/jvi.00526-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/15/2018] [Indexed: 11/20/2022] Open
Abstract
AIDS-related human cytomegalovirus retinitis remains the leading cause of blindness among untreated HIV/AIDS patients worldwide. To study mechanisms of this disease, we used a clinically relevant animal model of murine cytomegalovirus (MCMV) retinitis with retrovirus-induced murine AIDS (MAIDS) that mimics the progression of AIDS in humans. We found in this model that MCMV infection significantly stimulates ocular suppressor of cytokine signaling 1 (SOCS1) and SOCS3, host proteins which hinder immune-related signaling by cytokines, including antiviral type I and type II interferons. The present study demonstrates that in the absence of retinal disease, systemic MCMV infection of mice without MAIDS, but not in mice with MAIDS, leads to mild stimulation of splenic SOCS1 mRNA. In sharp contrast, when MCMV is directly inoculated into the eyes of retinitis-susceptible MAIDS mice, high levels of intraocular SOCS1 and SOCS3 mRNA and protein are produced which are associated with significant intraocular upregulation of gamma interferon (IFN-γ) and interleukin-6 (IL-6) mRNA expression. We also show that infiltrating macrophages, granulocytes, and resident retinal cells are sources of intraocular SOCS1 and SOCS3 protein production during development of MAIDS-related MCMV retinitis, and SOCS1 and SOCS3 mRNA transcripts are detected in retinal areas histologically characteristic of MCMV retinitis. Furthermore, SOCS1 and SOCS3 are found in both MCMV-infected cells and uninfected cells, suggesting that these SOCS proteins are stimulated via a bystander mechanism during MCMV retinitis. Taken together, our findings suggest a role for MCMV-related stimulation of SOCS1 and SOCS3 in the progression of retinal disease during ocular, but not systemic, MCMV infection.IMPORTANCE Cytomegalovirus infection frequently causes blindness in untreated HIV/AIDS patients. This virus manipulates host cells to dysregulate immune functions and drive disease. Here, we use an animal model of this disease to demonstrate that cytomegalovirus infection within eyes during retinitis causes massive upregulation of immunosuppressive host proteins called SOCS. As viral overexpression of SOCS proteins exacerbates infection with other viruses, they may also enhance cytomegalovirus infection. Alternatively, the immunosuppressive effect of SOCS proteins may be protective against immunopathology during cytomegalovirus retinitis, and in such a case SOCS mimetics or overexpression treatment strategies might be used to combat this disease. The results of this work therefore provide crucial basic knowledge that contributes to our understanding of the mechanisms of AIDS-related cytomegalovirus retinitis and, together with future studies, may contribute to the development of novel therapeutic targets that could improve the treatment or management of this sight-threatening disease.
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Iu LP, Fan MC, Lau JK, Chan TS, Kwong YL, Wong IY. Long-term Follow-up of Cytomegalovirus Retinitis in Non-HIV Immunocompromised Patients: Clinical Features and Visual Prognosis. Am J Ophthalmol 2016; 165:145-53. [PMID: 27005706 DOI: 10.1016/j.ajo.2016.03.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/04/2016] [Accepted: 03/10/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate clinical features and long-term visual outcome of cytomegalovirus (CMV) retinitis in patients without human immunodeficiency virus (HIV) infection, and to determine factors that predict visual outcome. DESIGN Retrospective cohort study. METHODS Consecutive patients with CMV retinitis without HIV infection were reviewed. Main outcome measures included clinical features, proportion of eyes with 6-month and final visual acuity (VA) <20/70 and <20/400, and odds ratios of factors associated with poor visual outcome. RESULTS A total of 20 eyes from 13 patients were included with a median follow-up time of 17 months. All had at least 6 months of follow-up except 1 patient who died from sepsis at 1 month. At presentation, 50% of eyes had VA <20/70 and 25% had VA <20/400. Zone 1 involvement occurred in 55% and vitreous haze ≥grade 2+ occurred in 25%. Recurrence occurred in 33.3% at a mean time of 6.4 ± 3.3 weeks after discontinuation of anti-CMV therapy. The retinal detachment rate was 21.7% per eye-year and mortality rate was 11.7% per person-year. At final visit, 60% had VA <20/70 and 35% had VA <20/400. Macular involvement was significantly associated with poor final VA <20/400 (odds ratio = 25.00, P = .016). CONCLUSIONS CMV retinitis without HIV infection was often aggressive at presentation. Significant intraocular inflammation was not uncommon. The long-term visual outcome was poor, especially in those with macular involvement.
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Jirawison C, Yen M, Leenasirimakul P, Chen J, Guadanant S, Kunavisarut P, Patikulsila D, Watanachai N, Ausayakhun S, Heiden D, Holland GN, Margolis TP, Keenan JD. Telemedicine screening for cytomegalovirus retinitis at the point of care for human immunodeficiency virus infection. JAMA Ophthalmol 2015; 133:198-205. [PMID: 25412344 DOI: 10.1001/jamaophthalmol.2014.4766] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Cytomegalovirus (CMV) retinitis is a leading cause of blindness in many developing countries, likely the result of inadequate screening. Telemedicine screening for CMV retinitis instituted at the point of care for human immunodeficiency virus (HIV) infection may allow for earlier detection. OBJECTIVES To determine the diagnostic accuracy of retinal photography in detecting CMV retinitis at the point of HIV care and to characterize the clinical manifestations of CMV retinitis detected through the screening program. DESIGN, SETTING, AND PARTICIPANTS We enrolled 103 participants from a population of 258 patients with HIV and a CD4 level of less than 100/μL treated at an HIV clinic in Thailand from June 2010 through June 2012. We captured mosaic fundus photographs through a dilated pupil using a digital fundus camera. An experienced on-site ophthalmologist masked to the results of the fundus images subsequently examined each eye with indirect ophthalmoscopy and recorded the clinical findings on a standardized form. Three remote graders evaluated each image for CMV retinitis. INTERVENTION Fundus photography and indirect ophthalmoscopy. MAIN OUTCOMES AND MEASURES Sensitivity and specificity of telemedicine relative to indirect ophthalmoscopy for diagnosis of CMV retinitis and clinical features of CMV retinitis lesions. RESULTS Sixteen patients (15.5%) were diagnosed as having CMV retinitis, of whom 5 (31%) had bilateral disease. Of the 21 eyes (10.2%) with CMV retinitis, 7 (33%) had visual symptoms. Retinitis lesions occupied less than 10% of the total retinal surface area in 13 of 21 eyes (62%) and did not involve the posterior pole (ie, zone 1) in 15 of 21 eyes (71%). Mean logMAR visual acuity in affected eyes was 0.41 (95% CI, 0.11-0.71; Snellen equivalent, 20/50 [95% CI, 20/25-20/100]). The mean sensitivity for the 3 remote graders in detecting CMV retinitis on fundus photography was 30.2% (95% CI, 10.5%-52.4%), and mean specificity was 99.1% (95% CI, 97.8%-100.0%). The CMV retinitis lesions missed by the remote graders (false-negative findings) were more likely to be small (P = .001) and located in the peripheral retina (P = .04). CONCLUSIONS AND RELEVANCE Patients undergoing screening at a clinic for HIV treatment had less extensive retinitis than patients in recent reports from an ophthalmology clinic. Retinal photography with the camera used in this study was not highly sensitive in detecting CMV retinitis but may identify disease with an immediate threat to vision. Improved accuracy will require a camera that can more easily image the peripheral retina.
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Affiliation(s)
- Choeng Jirawison
- Department of Ophthalmology, Nakornping Hospital, Chiang Mai, Thailand
| | - Michael Yen
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco3currently a medical student, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jenny Chen
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco4Ocular Inflammatory Disease Center, Jules Stein Eye Institute, University of California, Los Angeles5Department of Ophthalmology, David Geffen School of M
| | - Siripim Guadanant
- Department of Ophthalmology, Nakornping Hospital, Chiang Mai, Thailand
| | - Paradee Kunavisarut
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Direk Patikulsila
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nawat Watanachai
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Somsanguan Ausayakhun
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - David Heiden
- Department of Ophthalmology, California Pacific Medical Center, San Francisco
| | - Gary N Holland
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, University of California, Los Angeles
| | - Todd P Margolis
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco8Department of Ophthalmology, University of California, San Francisco9currently with the Department of Ophthalmology and Visual Sciences, Washington Univer
| | - Jeremy D Keenan
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco8Department of Ophthalmology, University of California, San Francisco
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Yen M, Chen J, Ausayakhun S, Kunavisarut P, Vichitvejpaisal P, Ausayakhun S, Jirawison C, Shantha J, Holland GN, Heiden D, Margolis TP, Keenan JD. Retinal detachment associated with AIDS-related cytomegalovirus retinitis: risk factors in a resource-limited setting. Am J Ophthalmol 2015; 159:185-92. [PMID: 25448999 DOI: 10.1016/j.ajo.2014.10.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 10/10/2014] [Accepted: 10/10/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine risk factors predictive of retinal detachment in patients with cytomegalovirus (CMV) retinitis in a setting with limited access to ophthalmic care. DESIGN Case-control study. METHODS Sixty-four patients with CMV retinitis and retinal detachment were identified from the Ocular Infectious Diseases and Retina Clinics at Chiang Mai University. Three control patients with CMV retinitis but no retinal detachment were selected for each case, matched by calendar date. The medical records of each patient were reviewed, with patient-level and eye-level features recorded for the clinic visit used to match cases and controls, and also for the initial clinic visit at which CMV retinitis was diagnosed. Risk factors for retinal detachment were assessed separately for each of these time points using multivariate conditional logistic regression models that included 1 eye from each patient. RESULTS Patients with a retinal detachment were more likely than controls to have low visual acuity (odds ratio [OR], 1.24 per line of worse vision on the logMAR scale; 95% confidence interval [CI], 1.16-1.33) and bilateral disease (OR, 2.12; 95% CI, 0.92-4.90). Features present at the time of the initial diagnosis of CMV retinitis that predicted subsequent retinal detachment included bilateral disease (OR, 2.68; 95% CI, 1.18-6.08) and lesion size (OR, 2.64 per 10% increase in lesion size; 95% CI, 1.41-4.94). CONCLUSION Bilateral CMV retinitis and larger lesion sizes, each of which is a marker of advanced disease, were associated with subsequent retinal detachment. Earlier detection and treatment may reduce the likelihood that patients with CMV retinitis develop a retinal detachment.
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Al-Dhibi HA, Al-Mahmood AM, Arevalo JF. A systematic approach to emergencies in uveitis. Middle East Afr J Ophthalmol 2014; 21:251-8. [PMID: 25100911 PMCID: PMC4123279 DOI: 10.4103/0974-9233.134687] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Uveitis is a common cause of preventable blindness although it is consider a sight-threatening condition particularly in cases with posterior segment inflammation. To deal with emergency conditions in uveitis, we must aware of the essential signs and symptoms that reflect a true uveitic emergency. Failure to recognize these essential signs and symptoms of a true uveitic emergency may result in a devastating visual outcome. This review provides general ophthalmologists and residents, clinical guidelines for the main uveitic entities that require immediate recognition and urgent intervention in the emergency room to prevent severe permanent visual loss.
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Affiliation(s)
- Hassan A Al-Dhibi
- Division of Vitreoretinal Surgery and Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Ammar M Al-Mahmood
- Division of Anterior Segment and Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | - J Fernando Arevalo
- Division of Vitreoretinal Surgery and Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia ; Retina Division, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hiwarkar P, Gajdosova E, Qasim W, Worth A, Breuer J, Chiesa R, Ridout D, Edelsten C, Moore A, Amrolia P, Veys P, Rao K. Frequent Occurrence of Cytomegalovirus Retinitis During Immune Reconstitution Warrants Regular Ophthalmic Screening in High-Risk Pediatric Allogeneic Hematopoietic Stem Cell Transplant Recipients. Clin Infect Dis 2014; 58:1700-6. [DOI: 10.1093/cid/ciu201] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Chronic retinal necrosis: cytomegalovirus necrotizing retinitis associated with panretinal vasculopathy in non-HIV patients. Retina 2014; 33:1791-9. [PMID: 23584702 DOI: 10.1097/iae.0b013e318285f486] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To characterize a unique cytomegalovirus (CMV)-associated retinopathy in patients with limited immune dysfunction. METHODS Retrospective observational case series. CMV was confirmed as the pathogenic agent via polymerase chain reaction analysis of aqueous or vitreous humor samples or via immunohistochemical analysis of retinal biopsy specimens. RESULTS Five non-HIV patients with granular necrotizing retinitis, vitritis, and severe occlusive vasculopathy were identified. Patient histories all suggested a basis for limited immune dysfunction including advanced age (n = 4), diabetes mellitus (n = 4), and noncytotoxic immunotherapy (n = 3). Diagnosis of CMV retinitis was delayed in all cases and patients received either no antiviral therapy (n = 2) or incorrect antiviral therapy (n = 3) for presumed herpes simplex/varicella zoster-related acute retinal necrosis. Retinitis subsequently regressed in all cases with introduction of systemic ganciclovir/valganciclovir (n = 5) and/or intravitreal foscarnet (n = 2). Four of five patients developed neovascularization because of extensive retinal ischemia. CONCLUSION The clinical expression of CMV-associated retinopathy is strongly related to immune status. In patients with limited immune dysfunction, a mixed clinical picture of intraocular inflammation with panretinal occlusive vasculopathy, more characteristic of acute retinal necrosis, and peripheral slowly progressive granular retinitis, more characteristic of classic CMV retinitis, is observed. Recognition of this atypical clinical presentation, which the authors term chronic retinal necrosis, should prompt molecular testing for CMV to determine the appropriate antiviral therapy. Consideration should also be given to prophylactic panretinal photocoagulation in such eyes, given the high risk of neovascular complications.
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Bittencourt MG, Agbedia OO, Liu HT, Annam R, Sepah YJ, Leder HA, Sophie R, Ibrahim M, Akhtar A, Akhlaq A, Do DV, Nguyen QD. Ocular complications of HIV/AIDS in the era of HAART. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.12.65] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pathai S, Lawn SD, Weiss HA, Cook C, Bekker LG, Gilbert CE. Retinal nerve fibre layer thickness and contrast sensitivity in HIV-infected individuals in South Africa: a case-control study. PLoS One 2013; 8:e73694. [PMID: 24069225 PMCID: PMC3777952 DOI: 10.1371/journal.pone.0073694] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 07/26/2013] [Indexed: 12/11/2022] Open
Abstract
Background Antiretroviral treatment (ART) has altered the spectrum of HIV-related eye disease, resulting in a lower prevalence of retinal opportunistic infections (OIs). However, abnormalities in visual function have been reported in HIV-infected individuals despite effective viral suppression and the absence of retinal OIs. These changes may be mediated by an HIV-associated ‘neuroretinal disorder’, characterized by changes in the retinal nerve fibre layer (RNFL). HIV infection may also be associated with accelerated biological aging. The aim of this study was to investigate the relationships between contrast sensitivity, RNFL thickness, HIV infection and frailty in South African adults. Methods Case-control study of 225 HIV-infected individuals without retinal OIs and 203 gender/age-matched HIV-seronegative individuals. Peri-papillary RNFL thickness was determined with spectral domain optical coherence tomography in four quadrants. CS was measured using a Pelli-Robson chart. Frailty was assessed using standard criteria. Multivariable linear and logistic regression were used to assess associations between HIV status and RNFL/CS and frailty. Results The median age of both groups was similar (41.2 vs. 41.9 years, p = 0.37). 88% of HIV-infected individuals were receiving ART and their median CD4 count was 468 cells/μl. Adjusted CS score was lower in HIV-infected participants compared to HIV-seronegative individuals (1.76 vs. 1.82, p = 0.002). Independent predictors of poor CS in the HIV-infected group were positive frailty status and current HIV viral load >2 log copies/ml. Lower CS score was also associated with thin temporal RNFL in HIV-infected individuals (p = 0.04). Superior quadrant RNFL thickness was greatest in ART-naïve participants relative to the HIV-uninfected group (p-trend = 0.04). Longer ART duration was associated with thinning of inferior and nasal RNFL quadrants (p-trend = 0.03 and 0.04, respectively). Conclusions Contrast sensitivity is reduced in HIV-infected individuals and functionally associated with frailty and unsuppressed viraemia. This may reflect structural changes in the RNFL that are evident despite the absence of OIs.
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Affiliation(s)
- Sophia Pathai
- International Centre for Eye Health, Dept. of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom ; Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Rose-Nussbaumer J, Goldstein DA, Thorne JE, Arantes TE, Acharya NR, Shakoor A, Jeng BH, Yeh S, Rahman H, Vemulakonda GA, Flaxel CJ, West SK, Holland GN, Smith JR. Uveitis in human immunodeficiency virus-infected persons with CD4+ T-lymphocyte count over 200 cells/mL. Clin Exp Ophthalmol 2013; 42:118-25. [PMID: 23777456 DOI: 10.1111/ceo.12141] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 05/19/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Introduction of highly active antiretroviral therapy has altered the course of disease for persons infected with human immunodeficiency virus by elevating CD4+ T-lymphocyte levels. Changes in the spectrum of systemic diseases encountered in human immunodeficiency virus-positive individuals are reported in the general medical literature. DESIGN Retrospective case series. PARTICIPANTS Sixty-one individuals infected with human immunodeficiency virus, who presented with uveitis when the peripheral CD4+ T-lymphocyte count was over 200 cells/μL. METHODS Standardized data collection at seven tertiary-referral inflammatory eye disease clinics. MAIN OUTCOME MEASURES Standardization of Uveitis Nomenclature anatomic classification and descriptors, cause of uveitis, and visual acuity RESULTS Peripheral CD4+ T cell counts varied between 207 and 1777 (median = 421) cells/μL at the time of diagnosis of uveitis. Uveitis was classified anatomically as anterior (47.5%), intermediate (6.6%), anterior/intermediate (16.4%), posterior (14.8%) and pan (14.8%). Specific causes of uveitis included infections (34.4%), with syphilis responsible for 16.4% of all cases, and defined immunological disorders (27.0%); no cause for the inflammation was identified in 34.4% of persons. Visual acuity was better than 6/15 in 66.7% and 6/60 or worse in 11.8% of 93 eyes at presentation, and better than 6/15 in 82.4% and 6/60 or worse in 8.8% of 34 eyes at 1 year of follow-up. CONCLUSIONS Both infectious and non-infectious forms of uveitis occur in individuals who are infected with human immunodeficiency virus and have preserved or restored peripheral CD4+ T cell levels. Individuals who are human immunodeficiency virus-positive and present with uveitis should be evaluated in the same way all patients with uveitis are assessed.
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Affiliation(s)
- Jennifer Rose-Nussbaumer
- Casey Eye Institute and Department of Ophthalmology, Oregon Health Sciences University, Portland, Oregon, USA
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Krause DD, May WL, Butler KR. Determining unmet, adequately met, and overly met needs for health care and services for persons living with HIV/AIDS in Mississippi. AIDS Care 2012; 25:973-9. [PMID: 23252519 DOI: 10.1080/09540121.2012.748880] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A statewide needs assessment of persons living with HIV/AIDS (PLWHA) was conducted to determine what is known about access to care, utilization of services, and perceived barriers to receiving care and services. Our objective was to determine which needs were being met or unmet among PLWHA in Mississippi to provide a better understanding of how effectively to allocate funding to provide for the needs of that group. In this cross-sectional study, a true random sample of PLWHA in Mississippi was interviewed in 2005-2006. Questions were asked to identify opinions about respondents' experiences with 23 health care services and 30 public or private assistance services. The kappa statistic was used to measure agreement between level of services needed and level of services provided. Services with the lowest kappa scores revealed which services were being either mostly unmet, or even overly met. Greatest service needs were HIV viral load test, Pap smear, CD4/T-cell count test, and medication for HIV/AIDS, which were reasonably well met. The most significantly unmet needs were dental care and dental exams, eye care and eye exams, help paying for housing, subsidized housing assistance, mental health therapy or counseling, access to emotional support groups, and job placement or employment. Overly met services included medical care at a physician's office or clinic and free condoms. This study identified needs perceived to be significantly unmet by PLWHA, as well as areas that were perceived to be adequately or overly met. This information may be used to target areas with the greatest impact for improvement and provide insight into how to effectively allocate health care resources and public/private assistance.
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Affiliation(s)
- Denise D Krause
- School of Dentistry, University of Mississippi Medical Center, Jackson, MS, 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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Clinical features of newly diagnosed cytomegalovirus retinitis in northern Thailand. Am J Ophthalmol 2012; 153:923-931.e1. [PMID: 22265148 DOI: 10.1016/j.ajo.2011.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 10/06/2011] [Accepted: 10/07/2011] [Indexed: 11/20/2022]
Abstract
PURPOSE To characterize the clinical manifestations of cytomegalovirus (CMV) retinitis in northern Thailand. DESIGN Prospective, observational, cross-sectional study. METHODS We recorded characteristics of 52 consecutive patients newly diagnosed with CMV retinitis at a tertiary university-based medical center in northern Thailand. Indirect ophthalmoscopy by experienced ophthalmologists was supplemented with fundus photography to determine the proportion of eyes with various clinical features of CMV retinitis. RESULTS Of the 52 patients with CMV retinitis, 55.8% were female. All were HIV-positive. The vast majority (90.4%) had started antiretroviral therapy. CMV retinitis was bilateral in 46.2% of patients. Bilateral visual acuity worse than 20/60 was observed in 23.1% of patients. Of 76 eyes with CMV retinitis, 61.8% had zone I disease and 21.6% had lesions involving the fovea. Lesions larger than 25% of the retinal area were observed in 57.5% of affected eyes. CMV retinitis lesions commonly had marked or severe border opacity (47.4% of eyes). Vitreous haze often was present (46.1% of eyes). Visual impairment was more common in eyes with larger retinitis lesions. Retinitis lesion size, used as a proxy for duration of disease, was associated with fulminant appearance (odds ratio, 1.24; 95% confidence interval, 1.01 to 1.51) and marked or severe border opacity (odds ratio, 1.36; 95% confidence interval, 1.11 to 1.67). Based on lesion size, retinitis preceded antiretroviral treatment in each patient. CONCLUSIONS Patients seeking treatment at a tertiary medical center in northern Thailand had advanced CMV retinitis, possibly because of delayed diagnosis. Earlier screening and treatment of CMV retinitis may limit progression of disease and may prevent visual impairment in this population.
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Stewart MW. Human immunodeficiency virus and its effects on the visual system. Infect Dis Rep 2012; 4:e25. [PMID: 24470932 PMCID: PMC3892652 DOI: 10.4081/idr.2012.e25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 02/05/2012] [Accepted: 02/06/2012] [Indexed: 12/13/2022] Open
Abstract
During the first 15 years of the AIDS epidemic patients experienced a high incidence of blindness due to cytomegalovirus (CMV) retinitis and other severe ocular opportunistic infections. Highly active anti-retroviral therapy, introduced in 1996, dramatically decreased the incidence of CMV retinitis. Though CMV retinitis still causes 40% of vision loss in AIDS patients, other conditions such as immune reconstitution uveitis, cataracts, and a significant othercategory -which most investigators believe is directly due to HIV - comprise the majority of cases. HIV causes vascular abnormalities of the conjunctiva and retina in the majority of AIDS patients, as well as retinitis, anterior and posterior uveitis and vasculitis. HIV frequently causes an optic neuropathy and is responsible for the majority of eye movement disorders among HIV patients. Physicians need to be aware that these problems may be the initial manifestation of HIV infections or a sign of highly active anti-retroviral therapy (HAART) failure. Therefore, patients with identifiable risk factors for AIDS who present with ophthalmologic conditions of unknown etiology should be considered for HIV testing. Finally, anti-retroviral therapy has been reported to cause asymptomatic deposits as well as degenerative conditions of both the anterior and posterior segments of the eye.
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Affiliation(s)
- Michael W Stewart
- Department of Ophthalmology, Mayo College of Medicine, Jacksonville, FL, USA
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Jabs DA. Cytomegalovirus retinitis and the acquired immunodeficiency syndrome--bench to bedside: LXVII Edward Jackson Memorial Lecture. Am J Ophthalmol 2011; 151:198-216.e1. [PMID: 21168815 PMCID: PMC3057105 DOI: 10.1016/j.ajo.2010.10.018] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 10/08/2010] [Accepted: 10/11/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE To update information on cytomegalovirus (CMV) retinitis in patients with acquired immunodeficiency syndrome (AIDS) and to integrate information on its pathogenesis and clinical outcomes. DESIGN Literature review. METHODS Selected articles from the medical literature, particularly large epidemiologic studies, including the Johns Hopkins Cytomegalovirus Retinitis Cohort Study, the Longitudinal Study of the Ocular Complications of AIDS, and the Cytomegalovirus Retinitis and Viral Resistance Study, were reviewed. Clinical information is discussed in light of knowledge on CMV, its pathogenesis, and its interactions with human immunodeficiency virus (HIV). RESULTS Cytomegalovirus uses several mechanisms to evade the immune system and establish latent infection in immunologically normal hosts. With immune deficiency, such as late-stage AIDS, CMV reactivates, is disseminated to the eye, and establishes a productive infection, resulting in retinal necrosis. HIV and CMV potentiate each other: CMV accelerates HIV disease, and CMV retinitis is associated with increased mortality. Randomized clinical trials have demonstrated the efficacy of treatments for CMV retinitis. Systemically administered treatment for CMV retinitis decreases AIDS mortality. Highly active antiretroviral therapy (HAART) effectively suppresses HIV replication, resulting in immune recovery, which, if sufficient, controls retinitis without anti-CMV therapy. Resistant CMV, detected in the blood, correlates with resistant virus in the eye and is associated with worse clinical outcomes, including mortality. Host factors, including host genetics and access to care, play a role in the development of CMV retinitis. CONCLUSIONS Clinical outcomes of CMV retinitis in patients with AIDS are dependent on characteristics of the virus and host and on HIV-CMV interactions.
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Affiliation(s)
- Douglas A Jabs
- Department of Ophthalmology, the Mount Sinai School of Medicine, New York, New York 10029, USA.
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Abdollahi A, Heidari-Bateni G, Zarei R, Kheirandish P, Malekmadani M, Mohraz M, Abdollahi M, Rajabi MT. Clinical spectrum of 15 patients with HIV-related ocular involvement in Tehran. Int J Ophthalmol 2010; 3:331-6. [PMID: 22553586 DOI: 10.3980/j.issn.2222-3959.2010.04.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 11/30/2010] [Indexed: 11/02/2022] Open
Abstract
AIM To determine the frequency of HIV-related ocular involvement and to describe the characteristics of involvement in a special clinic in Tehran. METHODS In this cross sectional study, 141 patients (125 male and 16 female, 282 eyes) of HIV-infected patients with various stages of HIV infection that were referred to Center of behavioral diseases were evaluated during a period of 7 months. Every patient had a complete profile including demographic data, method of HIV transmission, recent CD4 T cell lymphocyte count, serological studies for common sexual or blood-born viruses and toxoplasmosis, history of antiretroviral therapy, and associated systemic disease. RESULTS A total of 141 patients were evaluated. HIV-related ocular involvement was detected in 15 patients (10.6%), including 3 mycobacterium tuberculosis-related choroiditis, 2 cytomegalovirus retinitis, 2 retinal toxoplasmosis, 2 herpes simplex virus-related lesions, 1 HIV-associated retinopathy, 1 herpes zoster ophthalmicus, 1 undetermined vitritis, and 3 cases of cranial nerve involvement including 2 cases of gaze palsy and 1 case of papilitis. In our study, mean CD4 T cell lymphocyte count was fewer in patients with ocular involvement than in patients without ocular involvement (204.7±123.8 vs 403.7±339.7, P=0.029), but there was no difference in other possible associated factors between two groups. CONCLUSION Mycobacterium tuberculosis-related choroiditis and neurophthalmic lesions are the most common HIV-related ocular involvements in Tehran that is different from those of recent publications in developed countries.
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Affiliation(s)
- Ali Abdollahi
- Department of Ophthalmology, Eye Research Center, Farabi Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Jabs DA, Ahuja A, Van Natta M, Lyon A, Srivastava S, Gangaputra S. Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: five-year outcomes. Ophthalmology 2010; 117:2152-61.e1-2. [PMID: 20673591 DOI: 10.1016/j.ophtha.2010.03.031] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 03/09/2010] [Accepted: 03/10/2010] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To describe the 5-year outcomes of patients with cytomegalovirus (CMV) retinitis and AIDS in the era of highly active antiretroviral therapy (HAART). DESIGN Prospective, multicenter, observational study. PARTICIPANTS A total of 503 patients with AIDS and CMV retinitis. METHODS Follow-up every 3 months with medical history, ophthalmologic examination, laboratory testing, and retinal photographs. Participants were classified as having previously diagnosed CMV retinitis and immune recovery (CD4+ T cells ≥ 100 cells/μl), previously diagnosed retinitis and immune compromise, and newly diagnosed CMV retinitis (diagnosis <45 days before enrollment). MAIN OUTCOME MEASURES Mortality, retinitis progression (movement of the border of a CMV lesion ≥ ½ disc diameter or occurrence of a new lesion), retinal detachment, immune recovery uveitis (IRU), and visual loss (< 20/40 and ≥ 20/200). RESULTS Overall mortality was 9.8 deaths/100 person-years (PY). Rates varied by group at enrollment from 3.0/100 PY for those with previously diagnosed retinitis and immune recovery to 26.1/100 PY for those with newly diagnosed retinitis. The rate of retinitis progression was 7.0/100 PY and varied from 1.4/100 PY for those with previously diagnosed retinitis and immune recovery to 28.0/100 PY for those with newly diagnosed retinitis. The rate of retinal detachment was 2.3/100 eye-years (EY) and varied from 1.2/100 EY for those with previously diagnosed retinitis and immune recovery to 4.9/100 EY for those with newly diagnosed retinitis. The rate of IRU was 1.7/100 PY and varied from 1.3/100 PY for those with previously diagnosed retinitis and immune recovery at enrollment to 3.6/100 PY for those with newly diagnosed retinitis who subsequently experienced immune recovery. The rates of visual loss to < 20/40 and to ≤ 20/200 were 7.9/100 EY and 3.4/100 EY, respectively; they varied from 6.1/100 EY and 2.7/100 EY for those with previously diagnosed retinitis and immune recovery to 11.8/100 EY and 5.1/100 EY for those with newly diagnosed retinitis. Although the event rates tended to decline with time, in general, at no time did they reach zero. CONCLUSIONS Despite the availability of HAART, patients with AIDS and CMV retinitis remain at increased risk for mortality, retinitis progression, complications of the retinitis, and visual loss over a 5-year period. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Douglas A Jabs
- Department of Ophthalmology, the Mount Sinai School of Medicine, New York, New York, USA.
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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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Kailing Y, Cullen JF. Ocular Presentation as the First Manifestation of Cranial Tuberculosis. Neuroophthalmology 2010. [DOI: 10.3109/01658101003602525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Recent advances in drug delivery systems for treating ocular complications of systemic diseases. Curr Opin Ophthalmol 2009; 20:511-9. [DOI: 10.1097/icu.0b013e328330ccb9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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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: 100] [Impact Index Per Article: 6.3] [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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Characteristics of untreated AIDS-related cytomegalovirus retinitis. I. Findings before the era of highly active antiretroviral therapy (1988 to 1994). Am J Ophthalmol 2008; 145:5-11. [PMID: 18154750 DOI: 10.1016/j.ajo.2007.09.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Revised: 09/14/2007] [Accepted: 09/17/2007] [Indexed: 11/23/2022]
Abstract
PURPOSE To identify factors related to variations in the appearance of untreated AIDS-related cytomegalovirus (CMV) retinitis in severely immunodeficient individuals before the availability of highly active antiretroviral therapy (HAART) and to draw inferences regarding early events in the natural history of CMV retinitis based on clinical findings. DESIGN Retrospective, observational case series. METHODS We evaluated a series of 100 adult patients with AIDS and newly diagnosed CMV retinitis before the HAART era who were not being treated with specific anti-CMV therapy. Demographic factors, ophthalmic findings, and the influence of drug therapy (zidovudine, acyclovir) on lesion characteristics were evaluated. Lesion border opacity was scored using a four-point scale of severity. RESULTS Lesions could be categorized by type (fulminant/edematous or indolent/granular) in only 66% of eyes. Severe lesion border opacity (4+) was related to presence of zone 1 lesions (P = .032) and greater extent of disease (P = .004). Acyclovir use was associated with less severe opacity (P = .029) and less zone 1 involvement (P = .016). Early lesions were adjacent to vessels in 73% of eyes; the fovea was involved in 13% of eyes. CONCLUSIONS Lesion location and drug use that affects virus activity may influence the severity of lesion border opacity, a measure that may be more useful than lesion type in future clinical studies of CMV retinitis. In contrast to earlier concepts, CMV retinitis does not seem to be a fovea-sparing disease. Findings in this study can serve as a reference for investigations into possible changes in CMV retinitis since the introduction of HAART.
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