Evaluation of the United States public health service guidelines for discontinuation of anticytomegalovirus therapy after immune recovery in patients with cytomegalovirus retinitis

Predictors for Recurrence of Cytomegalovirus Retinitis in HIV-Negative Patients

PURPOSE

To investigate the incidence of and predictive factors for recurrent cytomegalovirus retinitis (CMVR) in human immunodeficiency virus (HIV)-negative patients.

METHODS

A retrospective review of HIV-negative patients who were newly diagnosed with CMVR between January 2005 and February 2019.

RESULTS

Of 28 patients (44 eyes), 35.9% of eyes had a recurrence of CMVR after discontinuation of anti-CMV therapy. The incidence of CMVR recurrence was 17 per 100 eye-years. The factors significantly associated with CMVR recurrence were eyes with retinitis area of more than 25% (P = .013), absence of vitreous haze (P = .003), neutropenia at presentation (P = .001), and absence of systemic immunosuppression therapy prior to presentation (P = .002).

CONCLUSION

Eyes with a large area of retinitis, absence of vitreous haze, and neutropenia at presentation are predictive of CMVR recurrence while receiving systemic immunosuppression prior to CMVR presentation has a lower risk of CMVR recurrence.

Clinical features of Cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome and efficacy of the current therapy

Background

Cytomegalovirus retinitis (CMVR) is the most common and sight-threatening opportunistic retinal infection in patients with acquired immunodeficiency syndrome (AIDS) and several controversies remain to be settled. We aimed to summarize the current evidence and clarify the clinical features and prognosis of CMVR in AIDS patients.

Methods

The databases PubMed, EMBASE, and Ovid from inception to April 2022 were searched to identify the relevant studies. R software version 3.6.3 was used to perform the statistical analyses. Results in proportion with 95% confidence interval (CI) were calculated using the Freeman-Tukey variant of arcsine square transformation.

Results

We finally included 236 studies comprising 20,214 patients. CMVR in AIDS was male-dominated (88%, 95%CI 86%-89%), with 57% (95%CI 55%-60%) aged <41 years and 44% (95%CI 41%-47%) being bilaterally involved. CMVR was preponderant in AIDS patients with the following characteristics: white and non-Hispanic, homosexual, HIV RNA load ≥ 400 copies/mL, and CD4+ T-cells <50 cells/μL. The positivity of CMV-DNA in blood, aqueous humor, and vitreous humor was 66% (95%CI 52%-79%), 87% (95%CI 76%-96%), and 95% (95%CI 85%-100%), respectively. The most common symptoms were blurred vision (55%, 95%CI 46%-65%), followed by asymptomatic, visual field defect, and floaters. CMVR was first diagnosed and regarded as the clue to AIDS diagnosis in 9% (95%CI 6%-13%) of CMVR patients. Approximately 85% (95%CI 76%-93%) of the CMVR patients have received cART. CMVR remission was observed in 72%-92% of patients depending on the specific category of anti-CMV therapy. The general incidence of CMVR-related RD in the entire course was 24% (95%CI 18%-29%), of which most patients received PPV with SO or gas tamponade and the rate of anatomic success was 89% (95%CI 85%-93%).

Conclusion

CMVR is a common opportunistic infection with diverse clinical features in AIDS patients, preponderant in those who are male, homosexual, or with CD4+ T-cells <50 cells/μL. Current therapies for CMVR and CMVR-related RD were shown to be effective. Early detection and routine ophthalmic screening should be promoted in AIDS patients.

Systematic review registration

PROSPERO, identifier CRD42022363105.

Cytomegalovirus retinitis in patients of non-Hodgkin's lymphoma: clinical presentations and outcomes

Background

Cytomegalovirus (CMV) retinitis in patients with Non-Hodgkin’s Lymphoma (NHL) can occur even in the presence of high CD 4 counts and can behave differently when compared to CMV retinitis in human immunodeficiency (HIV) patients. It, therefore, becomes important to understand its varied presentations and the challenges in management of these cases. The aim of this study was to analyse the various patterns of presentations and outcomes of CMV Retinitis in patients with NHL.

Study design

A retrospective chart review of seven eyes of four patients of NHL presenting with CMV retinitis between June 2017 and May 2020 was done.

Methods

Clinical patterns of CMV Retinitis, CD4 counts at the time of presentation and the duration of treatment along with recurrences and time for recurrence of retinitis were assessed.

Results

Granular or indolent retinitis (6 out of 7 eyes) was the commonest form of CMV retinitis in patients of NHL. Three patients had a presenting CD4 count above 150 cells/mm³ and none of them were below 50 cells/mm³. Floaters were the commonest presenting complaint. All patients had vitritis and majority of the patients (3 out of 4) had anterior chamber (AC) inflammation. Two out of the 4 patients had a recurrence (mean time 33.8 days) after stopping the maintenance phase of ganciclovir and one patient had significant myelosuppression related to oral valganciclovir which required discontinuation of the drug.

Conclusion

CMV retinitis in NHL patients is usually of an indolent or granular type and can occur even in the presence of high CD4 counts as compared to patients with HIV. These patients may require a long term maintenance in view of frequent recurrences after discontinuation of treatment.

Classification Criteria for Cytomegalovirus Retinitis

PURPOSE

The purpose of this study was to determine classification criteria for cytomegalovirus (CMV) retinitis.

DESIGN

Machine learning of cases with CMV retinitis and 4 other infectious posterior/ panuveitides.

METHODS

Cases of infectious posterior/panuveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on diagnosis using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used in the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the infectious posterior/panuveitides. The resulting criteria were evaluated in the validation set.

RESULTS

A total of 803 cases of infectious posterior/panuveitides, including 211 cases of CMV retinitis, were evaluated by machine learning. Key criteria for CMV retinitis included: 1) necrotizing retinitis with indistinct borders due to numerous small satellites; 2) evidence of immune compromise; and either 3) a characteristic clinical appearance, or 4) positive polymerase chain reaction assay results for CMV from an intraocular specimen. Characteristic appearances for CMV retinitis included: 1) wedge-shaped area of retinitis; 2) hemorrhagic retinitis; or 3) granular retinitis. Overall accuracy for infectious posterior/panuveitides was 92.1% in the training set and 93.3% (95% confidence interval: 88.2-96.3) in the validation set. The misclassification rates for CMV retinitis were 6.9% in the training set and 6.3% in the validation set.

CONCLUSIONS

The criteria for CMV retinitis had a low misclassification rate and appeared to perform sufficiently well for use in clinical and translational research.

Cytomegalovirus retinitis in a patient of granulomatosis with polyangiitis on long-term immunosuppressants

A 69-year-old male patient presented to the retina clinic with a sudden decrease in vision in his right eye since 1 day. He was a known case of granulomatosis with polyangiitis and was on systemic immunosuppression for the past 3 years. The best-corrected visual acuity (BCVA) in his right eye was 20/60 and he has no perception of light in the left eye. Fundus examination revealed the presence of retinitis lesions in the right eye and total optic atrophy in the left eye. A vitreous biopsy was done and the PCR was found to be positive for cytomegalovirus (CMV). He was treated with intravitreal ganciclovir injections. Subsequently, the retinitis lesions regressed and BCVA in the right eye improved to 20/40.This case report elaborates on the risks of the development of opportunistic ocular infections in patients receiving long-term systemic immunosuppressants and the need for regular ocular examinations in such cases.

Cytomegalovirus infection associated with severe intraocular inflammation in an HIV patient: a case report

This is a report of a case of severe intraocular inflammation associated with cytomegalovirus in an untreated HIV+ patient with a marked CD4⁺ T-cell depletion. The atypical presentation shown could confuse and delay the diagnosis. Early suspicion and appropriate treatment (ganciclovir, valganciclovir, HAART) increase the likelihood of a favourable outcome.

Clinical Features and CD4+ T Cells Count in AIDS Patients with CMV Retinitis: Correlation with Mortality

PURPOSE

To explore the all-cause mortality in patients with acquired immune deficiency syndrome (AIDS) and Cytomegalovirus (CMV) retinitis.

METHODS

A retrospective cohort study of patients with CMV retinitis (CMVR) presented to a tertiary referral center in Singapore from January 1, 2004, through December 31, 2015.

RESULTS

A total of 144 patients were studied (87 survived, 11 lost to follow up, 46 died). Patients with bilateral CMVR and six-month follow up CD4 + T cell count < 50 cells/mm³ have shorter time to mortality, compared to patients with CD4 + T cell count > 50 cells/mm³ (p < .001) and unilateral disease (p = .043). Baseline CD4 + T cell count, size and zone of initial primary retinitis lesions, recurrences of retinitis, and timing of combined antiretroviral therapy (cART) are not significantly associated with mortality.

CONCLUSION

Bilateral ocular involvement and lack of immune recovery in patients with AIDS and CMVR are associated with shorter survival time.

Ophthalmic manifestations of cytomegalovirus infection in HIV (literature review)

Cytomegalovirus (CMV) contamination is very common: in several countries, the number of seropositive people reaches 90% among the adult population. It is a latent infection able to affect any human organs and tissues that assumes special importance in severe immunosuppression cases. Cytomegalovirus retinitis is a disabling disease, and often leads to blindness. The article deals with some issues of epidemiology, clinical course, clinical presentation characteristics of cytomegalovirus eye disease in the context of HIV-infection. A special attention is given to detection methods, problems of diagnosis against the background of immune reconstruction syndrome, treatment approaches in clinical practice, and existing recommendations.

Opportunistic ocular infections in the setting of HIV

PURPOSE OF REVIEW

The aim of this review is to highlight recent changes in opportunistic ocular infections (OOIs) in the era of modern combination antiretroviral therapy (cART), in the setting of HIV-infected patients.

RECENT FINDINGS

Improvements in modern cART has led to a progressive decline in the incidence of OOIs and mortality among patients with AIDS. Not only has there been a decreasing incidence of cytomegalovirus (CMV) retinitis, but there also has been a decline in progression of such retinitis when it does occur in AIDS patients, since the introduction of cART. Nevertheless, CMV retinitis remains the major cause of vision loss in AIDS patients. Although the incidence of CMV retinitis has declined overall, the incidence of ocular syphilis has increased during the cART era. Moreover, the impact of having HIV plays a role with respect to multidrug-resistant (MDR) tuberculosis and has resulted in a high prevalence of presumed ocular tuberculosis in HIV/MDR-TB co-infected patients. Although immune reconstitution uveitis (IRU) has been an important cause of visual deficits in developed countries, OOIs remain an important cause of blindness in the developing world.

SUMMARY

Reconstituting the immune system with effective cART while increasing accessibility of screening examinations is key to the success of blindness prevent in HIV-infected individuals, particularly in developing countries.

Incidence Rates and Risk Factors for Vision Loss among AIDS-Related Cytomegalovirus Retinitis Patients in Southern Thailand

PURPOSE

To describe the incidence of and risk factors for visual acuity (VA) loss in patients with AIDS and cytomegalovirus (CMV) retinitis.

METHODS

A total of 132 patients were included. The main outcome measurements were the incidences of VA loss to ≤20/50 and ≤20/200.

RESULTS

The incidences of VA loss to ≤20/50 and ≤20/200 were 0.22/eye-year (EY) and 0.12/EY, respectively. Risk factors for the incidence of VA loss to ≤20/50 were low nadir CD4⁺ T-cell count (adjusted hazard ratio [aHR], 3.1), large area of retinitis (aHR, 3.7), and no immune recovery (IR) (aHR, 13.9). Risk factors for the incidence of VA loss to ≤20/200 were not receiving highly active antiretroviral therapy (HAART) (aHR, 4.4) and large retinitis area (aHR, 2.1).

CONCLUSIONS

The incidence of VA loss in eyes affected by CMV retinitis was high. The use of HAART, particularly with subsequent immune recovery, substantially reduced the incidence of VA loss.

Cytomegalovirus Retinitis in Patients With Acquired Immunodeficiency Syndrome After Initiating Antiretroviral Therapy

PURPOSE

To evaluate the rates of new-onset cytomegalovirus (CMV) retinitis and worsening existing CMV retinitis in patients with AIDS after initiating combination antiretroviral therapy (cART) and the role of an immune recovery inflammatory syndrome (IRIS).

DESIGN

Cohort study.

METHODS

Immune recovery was defined as an increase in CD4⁺ T cells to ≥100 cells/μL; rates of new-onset CMV retinitis and of worsening of CMV retinitis (either increasing border activity or retinitis progression) were compared between those with and without immune recovery.

RESULTS

Among patients without CMV retinitis, 1 of 75 patients with immune recovery developed CMV retinitis in the first 6 months after initiating cART vs 1 of 31 without immune recovery (P = .14). Among patients with CMV retinitis, the rates of retinitis progression and increasing retinitis border activity among patients during the first 6 months after initiating cART in those with immune recovery were 0.11 per person-year (PY; 95% confidence interval [CI] 0-0.62) and 0.11 per PY (95% CI 0-0.62), respectively, vs 0.67 per PY (95% CI 0.22-1.56) and 0.40 per PY (95% CI 0.08-1.17), respectively, for those without immune recovery (P = .11 and .47).

CONCLUSIONS

Among persons with AIDS who experience immune recovery, there was neither an increased rate of new-onset CMV retinitis nor worsening of existing CMV retinitis in the first 6 months after initiating cART vs those without immune recovery. These data are consistent with the known 3- to 6-month lag in recovery of specific immunity to CMV after initiating cART and suggest that "immune recovery retinitis," a proposed immune recovery inflammatory syndrome phenomenon, is rare.

Ocular Manifestations in Patients with Human Immunodeficiency Virus Infection in the Pre-HAART Versus the HAART Era in the North Indian Population

PURPOSE

To compare changes in the demographic profile and ocular manifestations in patients with HIV in the pre-HAART and HAART era in North India.

METHODS

In this single-center cross-sectional study, 100 HIV patients receiving HAART and 96 HIV patients in the pre-HAART era were enrolled. Prevalence of ocular manifestations of HIV was calculated for both cohorts.

RESULTS

The prevalence of ocular manifestations was not statistically different in the two eras (38%, SE: 4.85% in HAART era; 41.67%, SE: 5% in pre-HAART era) (p = 0.60). Mean CD4 counts were lower in the pre-HAART era compared with the HAART era (p < 0.001). In the HAART era, cytomegalovirus (CMV) retinitis and HIV retinopathy continued to remain the most common infectious and non-infectious cause of visual morbidity.

CONCLUSIONS

While the introduction of HAART has resulted in a major impact on the overall health of patients with HIV, the spectrum of ocular disease remains largely unchanged in developing countries such as India.

Immune recovery uveitis in a patient with previously undiagnosed cytomegalovirus retinitis

A 40-year-old man presented to the emergency service of the Department of Ophthalmology, Fundación Oftalmológica de Santander, Floridablanca, Colombia, with blurred vision in his right eye. Anamnesis revealed that he also had newly diagnosed stage C HIV. He had recently started highly active antiretroviral therapy (HAART). Examination disclosed intraocular inflammation, along with plain white peripheral non-exudative lesions with sparse haemorrhaging. The differential diagnosis included cytomegalovirus (CMV) retinitis and immune recovery uveitis (IRU). On follow-up, the patient's left eye presented with decreased visual acuity and increased vitreous haze. A vitrectomy with vitreous tap was performed for microbiological studies. PCR for CMV in the vitreous sample was negative. The patient was discharged with the final diagnosis of IRU. In HIV patients with uveitis, the knowledge of characteristic signs and symptoms of particular entities such as opportunistic infections and IRU will enable the clinician to give the appropriate treatment.

Retrospective study of cytomegalovirus retinitis complicated with acquired immunodeficiency syndrome

PURPOSE

This study was designed to explore the characteristics and therapy of cytomegalovirus retinitis (CR) in patients diagnosed with acquired immunodeficiency syndrome (AIDS).

METHODS

A total of 67 AIDS patients (78 eyes) with CR findings of were collected from January 2009 to January 2013. The correlation between CR, cellular immunity, risk factor, clinical characteristics, treatment and prognosis of CR was assessed. The incidence of CR in different CD4+T lymphocyte count groups was analyzed.

RESULTS

Among all participants, 58 were male and 9 females, aged from 18-60 years, (38±9) years on average. CD4+ T lymphocyte count of CR patients ranged from 0-141 cells/µl and < 50 cells/µl in 81.3% of cases. CR was the primary manifestation in 10.2%, retinal lesions in 25.1%, best corrected visual acuity (BCVA) < 0.3 in 54% of AIDS patients. Retinal necrosis was involved near the posterior pole in 62.5% of CR patients. The visual acuity of 60 (47.6%) eyes was improved after treatment and 94.1% cases were cured within 3 months. Anti-CMV treatments including induction and maintenance of ganciclovir or foscarnet were discontinued when CD4+T lymphocyte count was > 150 cells/µl for three consecutive months. Complicated cataract, retinal detachment and immune reconstitution uveitis were observed in 20.5%, 12.1% and 13.1% of cases, respectively.

CONCLUSION

Decreased CD4+T lymphocyte count is a risk factor for CR. HAART and anti-CMV therapy are efficacious treatment of CR. Conventional eye examinations should be conducted to early diagnose CR or other opportunistic infections in all AIDS patients.

Long-term Outcomes of Cytomegalovirus Retinitis in the Era of Modern Antiretroviral Therapy: Results from a United States Cohort

PURPOSE

To describe the long-term outcomes of patients with cytomegalovirus (CMV) retinitis and AIDS in the modern era of combination antiretroviral therapy.

DESIGN

Prospective, observational cohort study.

PARTICIPANTS

Patients with AIDS and CMV retinitis.

METHODS

Immune recovery, defined as a CD4+ T-cell count >100 cells/μl for ≥3 months.

MAIN OUTCOME MEASURES

Mortality, visual impairment (visual acuity <20/40), and blindness (visual acuity ≤20/200) on logarithmic visual acuity charts and loss of visual field on quantitative Goldmann perimetry.

RESULTS

Patients without immune recovery had a mortality of 44.4/100 person-years (PYs) and a median survival of 13.5 months after the diagnosis of CMV retinitis, whereas those with immune recovery had a mortality of 2.7/100 PYs (P < 0.001) and an estimated median survival of 27.0 years after the diagnosis of CMV retinitis. The rates of bilateral visual impairment and blindness were 0.9 and 0.4/100 PYs, respectively, and were similar between those with and without immune recovery. Among those with immune recovery, the rate of visual field loss was approximately 1% of the normal field per year, whereas among those without immune recovery it was approximately 7% of the normal field per year.

CONCLUSIONS

Among persons with CMV retinitis and AIDS, if there is immune recovery, long-term survival is likely, whereas if there is no immune recovery, the mortality rate is substantial. Although higher than the rates in the population not infected by human immunodeficiency virus, the rates of bilateral visual impairment and blindness are low, especially when compared with rates in the era before modern antiretroviral therapy.

Comparison of treatment regimens for cytomegalovirus retinitis in patients with AIDS in the era of highly active antiretroviral therapy

PURPOSE

To describe the outcomes of different treatment approaches for cytomegalovirus (CMV) retinitis in the era of highly active antiretroviral therapy (HAART).

DESIGN

Prospective cohort study, the Longitudinal Study of the Ocular Complications of AIDS.

PARTICIPANTS

A total of 250 patients with CMV retinitis and a CD4+ T-cell count <100 cells/μl (n = 221) at enrollment or incident retinitis (n = 29) during cohort follow-up.

METHODS

The effects of systemic therapy (vs. intraocular therapy only) on systemic outcomes and the effect of intraocular therapies (ganciclovir implants, intravitreal injections) on ocular outcomes were evaluated.

MAIN OUTCOME MEASURES

Mortality, CMV dissemination, retinitis progression, and treatment side effects.

RESULTS

Regimens containing systemic anti-CMV therapy were associated with a 50% reduction in mortality (adjusted hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.3-0.7; P = 0.006), a 90% reduction in new visceral CMV disease (adjusted HR, 0.1; 95% CI, 0.04-0.4; P = 0.004), and among those with unilateral CMV retinitis at presentation, an 80% reduction in second eye disease (adjusted HR, 0.2; 95% CI, 0.1-0.5; P = 0.0005) when compared with those using only intraocular therapy (implants or injections). Compared with systemic treatment only, regimens containing intravitreal injections had greater rates of retinitis progression (adjusted HR, 3.4; P = 0.004) and greater visual field loss (for loss of one half of the normal field, adjusted HR, 5.5; P < 0.01). Intravitreal implants were not significantly better than systemic therapy (adjusted HR for progression, 0.5; P = 0.26; adjusted HR for loss of one half of the visual field, 0.5; P = 0.45), but the sample size was small. Hematologic and renal side effect rates were similar between those groups with and without systemic anti-CMV therapy. The rate of endophthalmitis was 0.017 per eye-year (EY) (95% CI, 0.006-0.05) among those treated with intravitreal injections and 0.01 per EY (95% CI, 0.002-0.04) among those treated with an implant.

CONCLUSIONS

In the HAART era, systemic anti-CMV therapy, while there is immune compromise, seems to provide benefits in terms of longer survival and decreased CMV dissemination.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

CMV retinopathy in the antiretroviral therapy era: prevention, diagnosis, and management

Before the advent of antiretroviral therapy (ART), CMV retinitis was a common, debilitating opportunistic infection in the HIV-infected population. ART has had such a favorable impact on the prevention and management of CMV retinitis that it can be considered in some ways to be CMV therapy. Currently available CMV directed antiviral therapies are quite successful at limiting vision loss, but in resource limited settings there is still significant morbidity associated with the disease. This review summarizes the pathology, diagnosis, clinical course and treatment of retinitis in the pre-ART era to provide context for the contemporary clinical scenario, and highlights current management strategies. Important questions concerning host correlates of susceptibility and ideal therapy in the context of drug resistance are also briefly reviewed.