Long-term Follow-up of Cytomegalovirus Retinitis in Non-HIV Immunocompromised Patients: Clinical Features and Visual Prognosis

Clinical manifestations and immune markers of non-HIV-related CMV retinitis

BACKGROUND

Since the HIV epidemic in the 1980s, CMV retinitis has been mainly reported in this context. CMV retinitis in persons living with HIV is usually observed when CD4 + cells are below 50 cells/mm3. This study aims to describe the immune markers of non-HIV-related CMV retinitis as well as to describe its clinical manifestations and outcomes.

METHODS

Retrospective chart review of consecutive patients with CMV retinitis not related to HIV seen at the uveitis clinic of Jules Gonin Eye Hospital between 2000 and 2023. We reported the clinical manifestations and outcomes of the patients. We additionally assessed immune markers during CMV retinitis (leukocyte, lymphocyte, CD4 + cell and CD8 + cell counts as well as immunoglobulin levels).

RESULTS

Fifteen patients (22 eyes) were included. Underlying disease was hematologic malignancy in 9 patients, solid organ transplant in 3 patients, rheumatic disease in 2 patients and thymoma in one patient. The median time between the onset of underlying disease and the diagnosis of retinitis was 4.8 years. Lymphopenia was observed in 8/15 patients (mild = 3, moderate = 4, severe = 1), and low CD4 counts were observed in 9/12 patients, with less than 100 cells/mm3 in 4 patients. Hypogammaglobulinemia was detected in 7/11 patients. Retinitis was bilateral in 7/15 patients, and severe visual loss was frequent (5/19 eyes). Disease recurrence was seen in 7/13 patients at a median time of 6 months after initial diagnosis. No differences in immune markers were observed in patients with vs. without recurrence.

CONCLUSION

CMV retinitis is a rare disorder that can affect patients suffering any kind of immunodeficiency. It is associated with a high visual morbidity despite adequate treatment. CD4 + cell counts are usually higher than those in HIV patients, but B-cell dysfunction is common.

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.

Proliferative Retinopathy in Non-human Immunodeficiency Virus CMV Retinitis

PURPOSE

To report a case series of human immunodeficiency virus (HIV)-negative patients with healed cytomegalovirus retinitis presenting with proliferative retinopathy (in the form of neovascularisation elsewhere).

METHODS

Retrospective case series. Multimodal imaging was performed at each follow-up visit.

RESULTS

Three patients with non-HIV immune dysfunction were followed up after healing of CMV retinitis. All three developed neovascularisation. Patient 1 after 4 months presented with vitreous haemorrhage for which pars plana vitrectomy was performed. Patient 2 developed neovascularization at disc and neovascularisation elsewhere 4 months after resolution, and patient 3 despite being affected by bilateral CMV retinitis, presented with unilateral neovascularization at 14 month after resolution of retinitis.

CONCLUSION

Increased incidence of this rare entity could be attributed to partial immune dysfunction in non-HIV patients, limited area of retinitis with a more aggressive occlusive vasculitis. Extensive occlusion with more area of viable retina for angiogenic factor production explains this phenomena. It emphasizes the need for continued follow-up even after healing and to differentiate it from reactivation of retinitis and immune recovery uveitis.Abbreviation: CMV: cytomegalovirus; HIV: human immunodeficiency virus; BCVA: best corrected visual acuity.

Risk Factors for Cytomegalovirus Retinitis in a National Survey in Sweden

PURPOSE

To investigate predisposing immunosuppressive conditions causing cytomegalovirus retinitis (CMVr) and risk factors for delayed diagnosis in patients diagnosed between 2008 and 2018 in the Swedish population of 10 million.

RESULTS

Sixty-three consecutive patients (100 eyes) were diagnosed with CMVr. The most common immunosuppressive state predisposing for CMVr was hematopoietic stem cell transplant recipients (27%) and hematological malignancy (24%). Two patients (3.2%) had no other predisposing factor than diabetes mellitus (DM). Patients with delayed diagnosis (≤30 days) were older than those with earlier diagnosis, mean age 68.7 (±9.8) and 48.8 (±17.6), respectively, p = .001. Signs of intraocular inflammation (IOI) were seen in 42 (70%) of cases and more common in delayed than early diagnosis, 16 (89%) and 21 (60%) respectively (p = .03).

CONCLUSION

Delayed diagnosis was more common in older individuals with signs of IOI. DM may be a risk factor for CMVr, and clinical signs can be mistaken for diabetic retinopathy.

Cytomegalovirus Uveitis: Taiwan expert consensus

Cytomegalovirus (CMV) uveitis, a type of herpetic uveitis, is a major cause of infectious uveitis. Anterior and posterior CMV uveitis have diverse clinical presentations and treatment modalities. Based on expert consensus in Taiwan, this article provides suggestions regarding clinical manifestations, diagnosis, and treatment strategies for CMV uveitis based on clinical practice experience in Taiwan. CMV uveitis may have a distinct clinical presentation. Polymerase chain reaction (PCR) is an essential diagnostic tool to confirm a diagnosis. Antiviral therapy is the mainstay of treatment. Different agents, routes, and other supplemental treatments have been summarized and discussed in this article. Early diagnosis and appropriate treatment of CMV uveitis are crucial to avoid irreversible complications and vision loss. This consensus provides practical guidelines for ophthalmologists in Taiwan.

Analysis of Clinical Characteristics of Patients with Recurrent Cytomegalovirus Retinitis after Hematopoietic Stem Cell Transplantation

OBJECTIVE

To analyze and summarize the clinical and imaging characteristics of patients with cytomegalovirus retinitis (CMVR) relapse after hematopoietic stem cell transplantation (HSCT).

METHODS

This retrospective case series study recruited patients with CMVR after HSCT. The study compared the patients with stable lesions and CMV-negative aqueous humor after treatment with those with relapse lesions and a CMV DNA load in aqueous humor which had increased again after treatment. The observation indexes were basic clinical information, best-corrected visual acuity, wide-angle fundus photography, optical coherence tomography (OCT), blood CD4⁺ T lymphocyte count, and aqueous humor CMV load of the patients. We summarized the data and statistically analyzed the differences between the relapse and non-relapse groups, as well as the correlations of the observed indicators.

RESULTS

The study recruited 52 patients with CMVR (82 eyes) after HSCT, of whom 11 patients (15 eyes) had recurrence after treatment (21.2%). The recurrence interval was 6.4 ± 4.9 months. The final best-corrected visual acuity of recurrent patients was 0.3 ± 0.3. The number of CD4⁺ T lymphocytes in recurrence patients at the time of onset was 126.7 ± 80.2/mm³. The median CMV DNA load detected in aqueous humor at the time of recurrence was 8.63 × 10³ copies/mL. There was a significant difference in the CD4⁺ T lymphocyte count between the recurrence and the non-recurrence groups at onset. The onset of visual acuity in recurrence patients was significantly correlated with final visual acuity and recurrence lesion area. The fundus of recurred CMVR showed increased marginal activity of the original stable lesion. Concurrently, yellow-white new lesions appeared around the stable, atrophic, and necrotic lesions. OCT showed new diffuse hyperreflexic lesions in the retinal neuroepithelial layer near the old lesions. Inflammatory punctate hyperreflexes were observed in the vitreous, with vitreous liquefaction and contraction.

CONCLUSION

This study suggests that the clinical features, fundus manifestations, and imaging features of CMVR recurrence after HSCT are different from those at the initial onset. Patients should be closely followed up after their condition is stable to be alert for CMVR recurrence.

CLINICAL CHARACTERISTICS AND PROGNOSTIC FACTORS AFFECTING CLINICAL OUTCOMES IN CYTOMEGALOVIRUS RETINITIS WITH OR WITHOUT HIV INFECTION

PURPOSE

To explore the clinical features and outcomes of cytomegalovirus retinitis (CMVR) in patients with HIV and non-HIV.

METHODS

This retrospective cohort study included all patients with CMVR in National Taiwan University Hospital from 2013 to 2018. Demographic data, clinical characteristics, CMVR recurrence, and overall survival were compared between the HIV and non-HIV groups. Generalized estimating equation models were implemented to analyze the risk factors of poor visual prognosis. The Kaplan-Meier survival analysis was performed to investigate recurrence and survival.

RESULTS

A total of 66 patients (95 eyes) with CMVR were enrolled, with no significant differences between the HIV (41 patients; 61 eyes) and non-HIV (25 patients; 34 eyes) groups in initial/final visual acuity, lesion area, or viral loads. Poor visual outcome was associated with poor initial visual acuity, retinal detachment, and a higher plasma cytomegalovirus titer. The HIV group had significantly longer survival rate ( P = 0.033) and lower recurrence rate ( P = 0.01) than the non-HIV group, and it also presented with better prognosis in recurrence-free survival analysis ( P = 0.01).

CONCLUSION

Patients with CMVR without HIV had higher mortality and recurrence rates than the HIV group. Risk factors of poor visual outcome included poor initial visual acuity, retinal detachment, and a high plasma cytomegalovirus titer.

Intraocular human cytomegaloviruses of ocular diseases are distinct from those of viremia and are capable of escaping from innate and adaptive immunity by exploiting HLA-E-mediated peripheral and central tolerance

Human cytomegalovirus (HCMV) infections develop into CMV diseases that result in various forms of manifestations in local organs. CMV-retinitis is a form of CMV disease that develops in immunocompromised hosts with CMV-viremia after viruses in the peripheral circulation have entered the eye. In the HCMV genome, extensive diversification of the UL40 gene has produced peptide sequences that modulate NK cell effector functions when loaded onto HLA-E and are subsequently recognized by the NKG2A and NKG2C receptors. Notably, some HCMV strains carry UL40 genes that encode peptide sequences identical to the signal peptide sequences of specific HLA-A and HLA-C allotypes, which enables these CMV strains to escape HLA-E-restricted CD8+T cell responses. Variations in UL40 sequences have been studied mainly in the peripheral blood of CMV-viremia cases. In this study, we sought to investigate how ocular CMV disease develops from CMV infections. CMV gene sequences were compared between the intraocular fluids and peripheral blood of 77 clinical cases. UL40 signal peptide sequences were more diverse, and multiple sequences were typically present in CMV-viremia blood compared to intraocular fluid. Significantly stronger NK cell suppression was induced by UL40-derived peptides from intraocular HCMV compared to those identified only in peripheral blood. HCMV present in intraocular fluids were limited to those carrying a UL40 peptide sequence corresponding to the leader peptide sequence of the host's HLA class I, while UL40-derived peptides from HCMV found only in the peripheral blood were disparate from any HLA class I allotype. Overall, our analyses of CMV-retinitis inferred that specific HCMV strains with UL40 signal sequences matching the host's HLA signal peptide sequences were those that crossed the blood-ocular barrier to enter the intraocular space. UL40 peptide repertoires were the same in the intraocular fluids of all ocular CMV diseases, regardless of host immune status, implying that virus type is likely to be a common determinant in ocular CMV disease development. We thus propose a mechanism for ocular CMV disease development, in which particular HCMV types in the blood exploit peripheral and central HLA-E-mediated tolerance mechanisms and, thus, escape the antivirus responses of both innate and adaptive immunity.

The Potential Association of Delayed T Lymphocyte Reconstitution Within Six Months Post-Transplantation With the Risk of Cytomegalovirus Retinitis in Severe Aplastic Anemia Recipients

Background

Delayed immune reconstitution after allogeneic hematopoietic stem cell transplantation (HSCT) is significantly associated with cytomegalovirus (CMV) infection. The aim of this study was to observe the recovery trend of peripheral lymphocyte subsets and immunoglobulins in HSCT recipients who developed CMV retinitis (CMVR).

Methods

We identified 37 CMVR cases and 303 non-CMVR controls in this case-control study from a database of 404 consecutive severe aplastic anemia patients who received allogeneic HSCT at a single center between 2015 and 2020. We analyzed the transplant outcomes and immune reconstitution principles with a focus on lymphocyte CD series and immunoglobulin series within the first year post-HSCT.

Results

Thirty-seven patients (55 eyes) were diagnosed with CMVR, with a mean onset time of 155 days post-HSCT. Among the 37 patients, one never had CMV detected in his blood but had a high CMV load in his intraocular fluid at the time of CMVR diagnosis. In the controls, 195 had CMV viremia and 108 did not. Compared with controls, CMVR cases had a longer duration of CMV viremia and a higher peak number of CMV load. T lymphocyte subsets including CD3, CD4 and CD8 were significantly lower in CMVR cases within six months after HSCT (all p < 0.05). Immunoglobulins also showed a slower recovery trend in CMVR cases. The recovery of B lymphocytes and natural killer cells exhibited no significant differences between the two groups.

Conclusions

It is not enough to develop fundus screening strategies by merely relying on the CMV serostatus of recipients. Dynamic and continuous monitoring of T lymphocyte subsets, especially within six months post-HSCT, as well as serum immunoglobulin levels, can provide assistance with screening program of CMVR in HSCT recipients with severe aplastic anemia.

Bendamustine treatment of haematological malignancies: significant risks of opportunistic viral, fungal and bacterial infections

OBJECTIVES

Bendamustine is a standard treatment for low-grade B-cell lymphomas, and considered safe in clinical trials. Its safety in routine practice might be different.

METHODS

We retrospectively analyzed the infection complications in an unselected cohort of patients treated with bendamustine over a nine-year period. Patients were regularly monitored for blood counts and cytomegalovirus (CMV) reactivation by antigen assay and polymerase chain reaction. They received granulocyte colony stimulating factor for neutropenia, and routine anti-pneumocystis and optional anti-fungal prophylaxis.

RESULTS

There were 179 men and 127 women at a median age of 61.5 (20-90) years, 52% receiving bendamustine for relapsed/refractory disease. Malignancies included low-grade B-cell lymphomas (54%), myeloma (10%), T-cell lymphomas (11%), Hodgkin lymphoma (2%) and other lymphoid neoplasms (23%). Most patients had good performance status (Eastern Cooperative Oncology Group score: 0-1, 72%). CMV reactivation occurred in 58 patients (19%) at a median age of 68 (39-85) years. Univariate analysis showed CMV reactivation to be significantly associated with elevated lactate dehydrogenase (P = 0.045), decreased albumin (P = 0.003) and older age (reactivation versus no reactivation: 66.3 ± 11.4 versus 59.4 ± 14.5 years, P = 0.0016). Age remained the only significant risk on multivariate analysis. CMV reactivation resulted in retinitis (N = 4), ependymitis/ventriculitis (N = 1) and duodenitis/colitis (N = 1). Invasive fungal disease occurred in five patients (candidemia, N = 2; aspergillosis N = 1; cryptococcemia, N = 1; scedosporiosis, N-1). Nineteen patients had culture positive septicaemia.

CONCLUSION

Our observations showed that even with a vigorous anti-infective strategy, bendamustine treatment was still associated with significant risks of bacterial and opportunistic viral and fungal infections.

Pre-Transplant Platelet Refractoriness and Alternative Donors Are Associated With Cytomegalovirus Retinitis in Hematopoietic Stem Cell Transplantation for Severe Aplastic Anemia

Background

Cytomegalovirus retinitis is a severe, vision-threatening opportunistic infection in an immunodeficient population. Reports on cytomegalovirus retinitis in hematopoietic stem cell transplant recipients due to severe aplastic anemia have been scant. This study assessed the risk of cytomegalovirus retinitis in relation to the pre-transplant status of severe aplastic anemia patients.

Methods

We conducted a retrospective nested case-control study of cytomegalovirus retinitis among severe aplastic anemia patients receiving allogeneic hematopoietic stem cell transplants in a tertiary care institution that attends severe aplastic anemia patients from southern China from January 1, 2013 to December 31, 2018. Each cytomegalovirus retinitis case was matched with four controls without cytomegalovirus retinitis by age and gender. Thirteen pre-transplant parameters were chosen to compare the risk factor levels between the cases and controls. Multivariable logistic regressions were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs).

Results

A total of 361 severe aplastic anemia patients received hematopoietic stem cell transplants in the study period 2013–2018 in our medical institution, and 31 (8.58%) developed cytomegalovirus retinitis. Cytomegalovirus retinitis was diagnosed in the median of 148 days after transplantation. We confirmed platelet refractoriness more frequently in cases than in controls (p = 0.0005). Compared with human leukocyte antigen-matched sibling donors, alternative donors were significantly more prone to cytomegalovirus retinitis (p = 0.0009). After stepwise selection in multivariate logistic regression, platelet refractoriness (OR 5.41, 95% CI 1.98–15.39), haploidentical donor (OR 7.46, 95% CI 2.19–34.87), and unrelated donor (OR 8.38, 95% CI 2.30–41.34) were associated with an increased risk of cytomegalovirus retinitis.

Conclusions

Pre-transplant platelet refractoriness and alternative donors were significant predictors of cytomegalovirus retinitis in severe aplastic anemia recipients. These results highlight the importance of accounting for existing risks while developing prevention strategies and preemptive treatment for severe aplastic anemia recipients. We recommend that the platelet count be closely monitored and thrombopoietin be properly applied during the period when cytomegalovirus retinitis is prone to occur.

Post-CD19 Chimeric Antigen Receptor T-Cell Therapy Cytomegalovirus Retinitis

The purpose of this case report was to present a case of cytomegalovirus (CMV) retinitis in a patient with diffuse large B-cell lymphoma (DLBCL) post-CD19 chimeric antigen receptor (CAR) T-cell therapy. A 43-year-old female patient who was complaining of metamorphopsia and sudden blurring in the vision of her left eye was referred to the ophthalmology department. The patient had DLBCL and was started on systemic chemotherapy, which showed no response to therapy and disease progression. Therefore, she was diagnosed with primary refractory DLBCL and treated with CAR T-cell therapy.

The visual acuity of the left eye was 20/25 in the left eye on the Snellen visual acuity chart. The dilated fundus examination of the left eye demonstrated a diffuse yellowish retinal infiltration radiating from the optic disc involving the inferior macula and inferotemporal arcade. A color fundus image of the left eye showed a creamy infiltrate involving the inferior half of the macula sparing the fovea with subtle small white lesions in the midperiphery. Horizontal cross-section optical coherence tomography (OCT) of the macula of the left eye showed islands of destruction of all the retinal layers, which are replaced with moderately hyperreflective material; these infiltrates spare the fovea but with subfoveal fluid. Further systemic evaluation indicated CMV viremia reactivation and an absolute CD4+ cells count of 13 cells/mcL. Thus, she was diagnosed with CMV retinitis.

After three days of the initial presentation, she received the first intravitreal ganciclovir injection; 17 days after presentation, she received five intravitreal ganciclovir injections. The patient responded well to intravitreal ganciclovir therapy. She regained very good vision, and the visual acuity was 20/20 in both eyes. Early recognition and initiation of proper treatment are crucial. Thus, any visual complaints in patients with immunodeficiency should be taken seriously and should be further assessed. As the right eye had retinal scaring indicating previous retinitis, prophylactic treatment with ganciclovir could have been used to reduce the risk of retinitis development in the left eye.

Macular dual retinitis with Herpes simplex and Cytomegalovirus following periocular corticosteroid in a patient of Pemphigus Vulgaris

BACKGROUND

Cytomegalovirus (CMV) retinitis may occur in non-HIV individuals following systemic immunosuppressive treatment or periocular corticosteroid administration. However, simultaneous multiple viral retinitis is rare in HIV-negative individuals. We report a case of dual viral retinitis in a non-HIV female on systemic immunosuppressive for pemphigus vulgaris who was administered a periocular corticosteroid injection.

METHOD

A 32-year-old female on double immunosuppressive therapy (prednisolone and cyclophosphamide) for pemphigus vulgaris, presented with gradual painless diminution of vision in the right eye for one month. She was initially diagnosed to have possible autoimmune neuroretinitis by the referring ophthalmologist and received a single injection of posterior subtenon triamcinolone acetonide for the same. Her vision however deteriorated further and she received an intravitreal ganciclovir injection with a revised diagnosis of CMV retinitis. Due to suboptimal response she was referred to us. Aqueous Polymerase chain reaction (PCR) revealed dual positivity for CMV and Herpes simplex virus. She was successfully managed with intravitreal ganciclovir injections, systemic acyclovir and tapering of systemic immunosuppressive drugs.

RESULT

The retinitis lesions resolved gradually leaving behind a pale optic disc and foveal atrophy at 12 weeks follow-up.

CONCLUSION

Infective etiology must be ruled out in immunosuppressed patients before considering periocular corticosteroids. Dual viral involvement, although rare, may cause fulminant retinitis in predisposed individuals. High index of suspicion and PCR from ocular fluids should be performed at the earliest in patients with atypical or poorly responding retinitis lesions.

Outcomes of 25-gauge pars plana vitrectomy for cytomegalovirus retinitis-related retinal detachment

Purpose:

The purpose of this study is to evaluate the anatomical and functional outcomes of 25-gauge (G) pars plana vitrectomy (PPV) in patients with cytomegalovirus retinitis (CMVR)-related rhegmatogenous retinal detachment (RRD).

Methods:

Single-center retrospective consecutive case series of patients who underwent 25-G PPV for CMVR-related RRD repair with a minimum follow-up of 3 months. Complete anatomic success was defined as the complete attachment of retina including the periphery. Best-corrected visual acuity (BCVA) of ≥20/400 was defined as functional success.

Results:

Sixteen eyes of 15 patients were included in the study. Eleven patients were human immunodeficiency virus positive, three patients had hematological malignancies, and one patient suffered from dyskeratosis congenita. The mean follow-up was 20.5 ± 17.4 months (range 3–60 months). Complete anatomical success was seen in 15 eyes (93.75%). One eye had a residual inferior detachment with attached macula. Silicone oil was used as tamponade in 15 eyes and C₃F₈ gas in one eye. The mean change in BCVA was statistically significant, preoperative LogMAR BCVA was 2.05 ± 0.94 while the final follow-up postoperative LogMAR BCVA was 1.03 ± 0.61 (P < 0.001). Thirteen eyes (81.25%) had final BCVA ≥20/400.

Conclusion:

Microincision vitrectomy surgery can achieve excellent retinal reattachment rates in post-CMVR RRDs without significant intraoperative and postoperative complications. The visual outcome varies depending on the status of the optic disc and macula. Majority of the patients maintained functional vision.

Presumed cytomegalovirus retinitis in a non-immune compromised patient with breast carcinoma during treatment: A case report

Purpose

Cytomegalovirus (CMV) retinitis is one of the most common opportunistic infections in immunocompromised patients, including patients with acquired immunodeficiency syndrome (AIDS). CMV retinitis in non-human immunodeficiency virus (HIV)-infected patients has been reported with variable presentations. Significant intraocular inflammation is common, and visual prognosis is poor if not properly managed.

Observations

We present a case of presumed CMV retinitis in a non-immunocompromised breast cancer patient that occurred during cancer treatment. The ocular symptoms developed one day after partial mastectomy with intra-operative radiotherapy following five months of chemotherapy treatment. Ocular manifestations included panuveitis with mild peripheral retinitis.

Conclusions and Importance

Early diagnosis and prompt treatment with oral valganciclovir based on the clinical manifestation and serologic test findings helped to preserve vision.

Presumed cytomegalovirus retinitis late after kidney transplant

Cytomegalovirus (CMV) retinitis is a rare manifestation of CMV invasive disease and potentially threatening to vision in immunocompromised individuals. Clinical suspicion is fundamental since it is an unusual entity with a progressive and often asymptomatic installation over a long period. The authors report a 70-year-old man with diabetic nephropathy who underwent a kidney transplant (KT) in August 2014 with good clinical evolution. No previous CMV infection or episodes of acute rejection were reported. Five years after transplant, he was admitted due to a reduced visual acuity of the left eye with seven days of evolution with associated hyperemia, without exudate. The ophthalmologic evaluation was compatible with acute necrosis of the retina and presumed associated with CMV infection. He had a progressive improvement after ganciclovir initiation. CMV retinitis is one of the most serious ocular complications in immune-suppressed individuals and can lead to irreversible blindness, and because of that, early diagnosis and treatment remains crucial in obtaining the best visual prognosis in affected patients. Secondary prophylaxis with ganciclovir is not consensual, neither is the safety of reintroducing the antimetabolite in these cases.

Patterns of cytomegalovirus retinitis at a tertiary referral center in Turkey

PURPOSE

To analyze predisposing conditions in Turkish patients with CMV retinitis and to compare HIV-positive and HIV-negative patients.

METHODS

We reviewed medical charts and ocular images of 41 patients with CMV retinitis diagnosed between 1996 and 2019.

RESULTS

Eleven patients (27%) had HIV infection and 30 were immunocompromised from diverse causes. Initial visual acuity, type, zone, and extent of CMV retinitis, and response to anti-CMV treatment were not significantly different between the two groups. Vitreous haze and panretinal occlusive vasculopathy were the presenting features only in non-HIV patients, seen in 34% and 16% of eyes, respectively. Although not statistically significant, recurrent CMV retinitis was more common in non-HIV patients (17.4% vs. 4.3%/eye-year) and immune recovery uveitis was more common in HIV patients (43% vs. 26%/eye-year). Visual outcomes were similar. Final visual acuity of 1 logMAR or worse was significantly associated with the recurrence of CMV retinitis (odds ratio 9.67; p = 0.01) and also with the occurrence of immune recovery uveitis (odds ratio 4.31; p = 0.058).

CONCLUSIONS

Diverse immunocompromising conditions are more commonly associated with CMV retinitis than HIV infection in Turkish patients. Intraocular inflammation was more commonly associated with active retinitis in non-HIV patients and immune recovery uveitis was more common in HIV patients.

Do we need separate screening strategies for cytomegalovirus retinitis in different underlying immunosuppressed states? A retrospective study from Western India

Purpose

The aim of this study was to describe the clinical features, course, and clinical outcomes of eyes with cytomegalovirus (CMV) retinitis in immunosuppressed patients of different etiologies.

Methods

This was a retrospective observational study from a single ophthalmic tertiary care center. The patients included referrals from the nodal cancer center and the local human immunodeficiency virus (HIV) treatment clinic. Demographics, history, visual acuity, ocular features, treatment protocol, and final visual outcome of patients who were diagnosed with CMV retinitis in the period of five years from 2014 to 2019 were studied.

Results

CMV retinitis was diagnosed in 25 eyes of 14 patients. Age of the patients ranged from 11-54 years. Ten (71.43%) patients were male and four (29.57%) were female. Eight of them had acute lymphoblastic leukemia (ALL), four were suffering from HIV infection and one patient each had lymphoma and history of a kidney transplant. The treatment for CMV retinitis ranged from two to sixty weeks depending on disease activity and systemic condition. Three of the patients were on maintenance therapy for ALL at the time of reactivation.

Conclusion

Duration of treatment for CMV retinitis in patients of ALL was longer as compared to the other etiologies, and in recurrences, it needed to be continued till the completion of maintenance therapy for ALL. It is prudent to advise regular ophthalmic screening of all immunocompromised patients, as they are at a high risk of developing CMV retinitis. Patients of ALL, especially while on maintenance therapy, should be monitored for possible development or reactivation of CMV retinitis.

The predictive value of interleukin-8 in the development of cytomegalovirus retinitis in HIV-negative patients

INTRODUCTION

To evaluate the value of interleukin (IL)-8 in the development and management of cytomegalovirus retinitis (CMVR) in HIV-negative patients.

INTRODUCTION

To evaluate the value of interleukin (IL)-8 in the development and management of cytomegalovirus retinitis (CMVR) in HIV-negative patients.

METHODS

A retrospective case series from January 2014 to May 2018 was conducted. Forty patients (40 eyes) received intravitreal injection of ganciclovir (IVG). The aqueous levels of the cytomegalovirus (CMV) DNA and IL-8 in each follow-up visit were tested. The initial and final best corrected visual acuity (BCVA), the course of treatment, the recurrence rate, and the occurrence of complications were recorded and analyzed.

RESULTS

The aqueous value of IL-8 was significantly correlated with the aqueous level of the CMV DNA during treatment but was not associated with the BCVA or the number of IVG. No recurrence occurred in the condition in which a low aqueous IL-8 level was set as the endpoint of the treatment.

CONCLUSION

In HIV-negative patients with CMVR, IL-8 was closely associated with CMV DNA concentration in the aqueous humor. The real-time aqueous level of IL-8 could be used as one of the evidences of disease recovery.

Development of cytomegalovirus retinitis after negative conversion of cytomegalovirus antigenemia due to systemic antiviral therapy

PURPOSE

Cytomegalovirus (CMV) antigenemia assays have been widely used as adjunct tests to diagnose tissue invasive CMV diseases, including cytomegalovirus retinitis (CMVR). In this study, we examined CMVR cases to assess the presence of CMV in sera and aqueous humor and antiviral therapy received prior to the onset of CMVR.

METHODS

A total of 37 eyes from 26 different cases of CMVR in patients who visited Hokkaido University Hospital between 2007 and 2015 were enrolled. The diagnosis of CMVR was established based on characteristic ophthalmoscopic findings and the presence of local and/or systemic CMV infection. Among the 26 cases, 3 cases (12%) were HIV-positive, while the other 23 cases (88%) were HIV-negative. The records of clinical and laboratory results were reviewed from clinical charts retrospectively.

RESULTS

CMV antigenemia was positive at the onset of CMVR in 14 cases (53.8%) and negative in the other 12 cases. In 9 cases among the antigenemia-negative cases (75.0%), the antigenemia had been previously positive and had turned negative before the onset of CMVR. In 12 of the 14 antigenemia-positive cases (85.7%) and in 8 of the 9 antigenemia-negative cases (88.9%) that were previously positive, systemic antiviral therapies had never been used or had been used before but had been discontinued prior to the onset of CMVR.

CONCLUSION

Even if viremia turns negative, the risk of developing CMVR exists for more than several weeks after the completion of systemic therapy.

RETINAL FINDINGS IN PRESUMED INFECTIOUS POSTERIOR UVEITIS AND CORRELATION WITH POLYMERASE CHAIN REACTION RESULTS

PURPOSE

To correlate demographics, retinal lesion characteristics, and host immune status with the pathogen found on polymerase chain reaction analysis of aqueous fluid in patients with suspected infectious posterior uveitis.

METHODS

Medical records of patients who underwent anterior chamber paracentesis for suspected infectious posterior uveitis and had retinal photographs between 2014 and 2016 at a single institution were reviewed. Data collection included demographics, clinical appearance of the lesions, and polymerase chain reaction results. Fundus photographs were evaluated by two masked observers for the clinical features of the retinitis.

RESULTS

Twenty-eight patients were included in the study. There was substantial to almost perfect agreement on retinitis location (κ = 0.67) and number (κ = 0.76) between the masked photograph graders. Polymerase chain reaction results were positive for herpes simplex virus or varicella zoster virus in 43%, cytomegalovirus in 11%, and toxoplasmosis in 3%; 43% had negative polymerase chain reaction results. Detection of herpes simplex virus or varicella zoster virus on polymerase chain reaction of the aqueous was associated with paucifocal lesions (82%, P = 0.021) and lesions involving the peripheral retina (91%, P = 0.023), consistent with the diagnosis of acute retinal necrosis.

CONCLUSION

These data suggest that the diagnosis of acute retinal necrosis can be reasonably inferred on clinical examination, providing a guide for initial empiric therapy.

Cytomegalovirus Retinitis in HIV and Non-HIV Individuals

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.

Prognostic Factors of Cytomegalovirus Infection Associated Retinitis in HIV-Negative Patients: A Retrospective Cohort Study

Purpose: To summarize the prognostic factors of cytomegalovirus (CMV) retinitis (CMVR) in HIV-negative patients treated with multiple intravitreal injections (IVs) of ganciclovir.Methods: A retrospective cohort study (70 eyes) was conducted. Clinical signs, initial and final best corrected visual acuity (BCVA), initial aqueous load of CMV DNA, course of treatment, and occurrence of complications were recorded and analyzed.Results: A positive correlation was found between the baseline and the final best corrected visual acuity (P < .001) and between the initial aqueous CMV DNA load and the number of IVs (P = .01). A lesion close to the posterior pole (P < .001) and a larger retinal lesion (P = .002) remarkably led to worse visual prognosis.Conclusions: Poor visual prognosis was significantly associated with poor initial visual acuity, proximity of lesion to the posterior pole, and an extensive CMV lesion. The treatment duration was positively correlated with the initial aqueous CMV DNA load.

Presenting Features, Treatment and Clinical Outcomes of Cytomegalovirus Retinitis: Non-HIV Patients Vs HIV Patients

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.

Initial intravitreal injection of high-dose ganciclovir for cytomegalovirus retinitis in HIV-negative patients

BACKGROUND

The purpose of this study is to examine the clinical outcomes achieved by using initial high-dose intravitreal ganciclovir injections to treat cytomegalovirus retinitis in patients without human immunodeficiency virus (HIV) infection.

METHODS

Twenty-four eyes (24 patients) with cytomegalovirus retinitis received multiple intravitreal injections of ganciclovir in weekly intervals. A higher dose (6 mg) of ganciclovir was applied at the first intravitreal injection, and a lower dose was used for maintenance. Anterior aqueous humour was obtained before each injection. The best-corrected visual acuity and cytomegalovirus loads in the anterior aqueous humour were measured.

RESULTS

The mean cytomegalovirus DNA load in aqueous humour decreased significantly from (2.59 ± 2.28) × 10⁵ copies/mL at baseline to (1 ± 1.76) × 10⁴ copies/mL one month later. The aqueous cytomegalovirus DNA load was negative in 17 eyes (70.8%) one month later. No obvious improvement of best-corrected visual acuity was found during the treatment. A positive correlation was proven between initial cytomegalovirus DNA titers in aqueous humour and the total number of intravitreal injections of ganciclovir, as well as between the baseline and final best-corrected visual acuities. No severe complications developed.

CONCLUSIONS

An initial high dose of ganciclovir (6 mg) and continuous intravitreal injections of ganciclovir could significantly decrease the cytomegalovirus load in HIV-negative patients with cytomegalovirus retinitis.

TRIAL REGISTRATION

http://clinicaltrials.gov, NCT03598452, retrospectively registered on 24 July 2018.

Cytomegalovirus retinitis in HIV-negative patients - associated conditions, clinical presentation, diagnostic methods and treatment strategy

In recent years, numerous reports have tied cytomegalovirus retinitis (CMVR) with multiple systemic conditions in the absence of human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). These range from reports in apparently healthy individuals, through conditions rendering limited immune dysfunction such as advanced age and diabetes mellitus, and finally severe immune dysfunction such as in haematological and rheumatological conditions. Reports are also emerging, suggesting that induced local ocular immunosuppression is a risk factor for CMVR. We herein present a comprehensive collection of the accumulated findings regarding CMVR in non-HIV patients. We summarize the spectrum of underlying morbidity that has been associated with CMVR, its clinical presentation, diagnostic methods and treatment choice in the attempt to suggest the optimal treatment strategy in this complicated and diverse patient population which is still currently lacking a consensus.

Comparison of intravitreal ganciclovir monotherapy and combination with foscarnet as initial therapy for cytomegalovirus retinitis

AIM

To compare the effectiveness between multiple intravitreal injections of ganciclovir alone and combined with foscarnet as initial treatment for patients with newly-onset cytomegalovirus retinitis (CMVR).

METHODS

The retrospective study observed 37 patients (58 eyes) who suffered from CMVR onset between 2013 and 2015. Among them, 35 eyes underwent 4 weekly intravitreal injections of 3.0 mg ganciclovir, and 23 eyes underwent 4 weekly injections of 3.0 mg ganciclovir combined with 2.4 mg foscarnet. Visual acuity, intraocular pressure and viral load of cytomegalovirus (CMV) in aqueous humor measured by real-time polymerase chain reaction were compared before and after each injection.

RESULTS

CMV-DNA copies in aqueous humor decreased remarkably in both groups. The average of CMV-DNA copies in patients' aqueous decreased from 38.3×10⁴ copies/mL at baseline to 2.2×10⁴ copies/mL after the 4^th injection in patients who were treated with ganciclovir monotherapy, and decreased from 76.9×10⁴ copies/mL to 11.3×10⁴ copies/mL after 4 continuous injections of ganciclovir combined with foscarnet. No significant difference was found in reduction of viral load, change of visual acuities or intraocular pressures between monotherapy or combined therapy.

CONCLUSION

Results of this study show that the initial effectiveness of treating CMVR after 4 weekly intravitreal injections is not significantly different from ganciclovir alone or combined with foscarnet. Continuous injection of ganciclovir alone is sufficient in treating immunosuppressive patients with newly-onset CMVR.

Cytomegalovirus retinitis in the post-cART era

Purpose of review

To review the epidemiology, diagnosis, and management of cytomegalovirus retinitis (CMVR) in the post-combined antiretroviral era (cART) era.

Recent findings

Although cART has dramatically reduced CMVR incidence and morbidity in the HIV population, CMVR continues to cause significant vision loss in both HIV and non-HIV patients, especially amongst patients without immune reconstitution. Advances in imaging including ultra-widefield fundus and autofluorescence imaging, optical coherence tomography, and adaptive optics may reflect CMVR activity; however, the diagnosis remains a clinical one. There have been minimal advances in therapy, with several agents no longer available due to market concerns.

Summary

Despite reduced incidence and morbidity in the post-cART HIV population, CMVR continues to cause vision loss amongst HIV and non-HIV patients. Diagnosis remains primarily clinical, and therapy centers upon immune reconstitution along with systemic and/or intravitreal antivirals. Further studies are necessary to determine whether advanced imaging can influence management, and whether novel antiviral agents or adoptive immune transfer have a role in treatment of drug-resistance CMVR.

Repeated intraocular crystallization of ganciclovir in one eye after bilateral intravitreal injections: a case report

BACKGROUND

Cytomegalovirus (CMV) retinitis is an opportunistic infection that primarily affects immunocompromised individuals. Intravitreal ganciclovir injection monotherapy or in combination with systemic anti-CMV therapy are effective treatments for CMV retinitis. Crystallization of ganciclovir after intravitreal injection is extremely rare. Only two cases had been reported in literature. Crystallization in only one eye after bilateral injections had not been reported before. We hereby report a case of intraocular ganciclovir crystallization in one eye after bilateral intravitreal injections, and repeated crystallization in the same eye after repeated injections.

CASE PRESENTATION

A 79-year-old patient had bilateral cytomegalovirus retinitis and received bilateral intravitreal ganciclovir injections of 2.5 mg in 0.05 ml sterile water. Fundus examination after injection showed formation of needle-shaped, golden-yellow crystals in the vitreous of right eye but not in left eye. The crystals dissolved spontaneously. Repeated bilateral intravitreal ganciclovir injections 4 days later resulted in repeated crystallization of ganciclovir in right eye but not in left eye. The crystals dissolved spontaneously and completely after 5 minutes. Visual acuity remained unchanged and intraocular pressure was normal.

CONCLUSIONS

Intraocular ganciclovir crystallization could occur after intravitreal injections. It is important to perform fundus examination after injection. The crystals may dissolve rapidly and vitrectomy may not be necessary. Our case suggested intraocular ganciclovir crystallization is an idiosyncratic phenomenon, subjects to distinctive intraocular environment which could be different between two eyes of the same patient. The susceptible intraocular environment could be persistent leading to repeated crystallization.

High ocular CMV copies and mismatched receipts may predict poor visual prognosis in CMV retinitis patients following allogeneic haematopoietic stem cell transplantation

BACKGROUND

To summarize the clinical characteristics and potential factors affecting the visual outcomes in patients with cytomegalovirus retinitis following allogeneic haematopoietic stem cell transplantation (HSCT).

METHODS

This retrospective study enrolled 12 patients (19 eyes) with cytomegalovirus retinitis after HSCT at Guangzhou First People's Hospital in China between January 2013 and December 2014. Demographic and clinical characteristics, ocular manifestations and visual outcomes were evaluated by reviewing medical records at the Departments of Hematology and Ophthalmology. All patients were followed up at least 6 months after stopping antiviral therapy. The visual outcome was defined as improvement, stabilization and deterioration.

RESULTS

The subjects were composed of 7 human leucocyte antigen-matched and 5 mismatched receipts. All patients received combined systemic and intravitreous antiviral therapy. Eleven eyes gained improved or stabilized visual acuity, while 8 eyes suffered deterioration. Eyes with cytomegalovirus load less than 1 × 10⁴ copies/ml in vitreous accounted for higher rate in eyes with good visual prognosis than those with cytomegalovirus copies above 1 × 10⁴ copies/ml (52.63% vs 5.26%, P < 0.001). Human leucocyte antigen-matched receipts gained better visual prognosis than those mismatched ones (47.37% vs10.53%, P < 0.05). The virus types, cytomegalovirus peak in the blood, involved retinal zone and size had no influence on the visual outcomes (all P > 0.05).

CONCLUSIONS

High ocular cytomegalovirus copies and mismatched receipts may be potential adverse factors affecting visual outcomes in cytomegalovirus retinitis patients following allogeneic HSCT.