Incidence and management of cataract after retinal detachment repair with silicone oil in immune compromised patients with cytomegalovirus retinitis

Correction of axial length measurement error by IOLMaster 700 could improve refractive prediction accuracy in silicone oil-filled eyes

PURPOSE

To determine whether correcting the axial length (AL) measurement error of the IOLMaster 700 could improve the refractive prediction accuracy in silicone oil-filled eyes.

METHODS

This study included 265 cataract patients (265 eyes) with silicone oil tamponade who were scheduled for phacoemulsification with intraocular lens (IOL) implantation. The performances of various formulas, including Barrett Universal II, Emmetropia Verifying Optical, Hoffer-QST, Kane, Ladas Super Formula, Pearl-DGS, Radial Basis Function and traditional formulas (Haigis, Hoffer Q, Holladay 1 and SRK/T), were evaluated. The refractive prediction errors (PE) calculated with measured AL (ALmeas ) and corrected AL with silicone oil adjustment (SOAL ) were compared. Subgroup analysis was performed based on the ALmeas (<23 mm; 23-26 mm; ≥26 mm).

RESULTS

Using SOAL significantly reduced the hyperopic PE of formulas when compared to ALmeas (-0.05 to 0.17 D vs 0.15 to 0.38 D, p < 0.001). After applying AL correction, all formulas showed a lower mean absolute PE (0.47-0.57 D vs 0.50-0.69 D). The percentage of eyes within ±1.0 D of PE increased from 84.91%-88.68% to 89.81%-91.32% for new formulas and from 78.11%-83.40% to 85.66%-88.68% for traditional formulas, with the use of SOAL . Subgroup analysis showed that the majority of formulas with SOAL in prediction accuracy for eyes with an AL ≥26 mm (p < 0.05).

CONCLUSIONS

The refractive prediction accuracy in silicone oil-filled eyes was improved by correcting the AL measurement error of the IOLMaster 700, especially for long eyes.

Risk of cataract among subjects with acquired immune deficiency syndrome free of ocular opportunistic infections

PURPOSE

To evaluate the risk of cataract in the setting of AIDS.

DESIGN

Prospective cohort study.

PARTICIPANTS

Subjects with AIDS free of ocular opportunistic infections throughout catamnesis.

METHODS

From 1998 through 2008, subjects 13 years of age or older were enrolled. Demographic characteristics and clinical characteristics were documented at enrollment and semiannually.

MAIN OUTCOME MEASURES

Cataract was defined as high-grade lens opacity observed by biomicroscopy judged to be the cause of a best-corrected visual acuity worse than 20/40. Eyes that underwent cataract surgery during follow-up were considered to have developed cataract before the first visit when pseudophakia or aphakia was observed.

RESULTS

Among 1606 participants (3212 eyes) at enrollment, 1.9% (95% confidence interval [CI]: 1.3%-2.7%) were observed to have cataract or prior cataract surgery. Among the 2812 eyes initially free of cataract and followed longitudinally (median follow-up, 4.6 years), the incidence of cataract was 0.37%/eye-year (95% CI: 0.26%-0.53%). In addition to age, significant cataract risk factors included prior cataract in the contralateral eye (adjusted hazard ratio [aHR], 21.6; 95% CI: 10.4-44.8), anterior segment inflammation (aHR, 4.40; 95% CI: 1.64-11.9), prior retinal detachment (aHR, 4.94; 95% CI: 2.21-11.0), and vitreous inflammation (aHR, 7.12; 95% CI: 2.02-25.0), each studied as a time-updated characteristic. Detectable human immunodeficiency virus RNA in peripheral blood was associated with lower risk of cataract at enrollment (adjusted odds ratio, 0.32; 95% CI: 0.12-0.80) but not of incident cataract (aHR, 1.58; 95% CI: 0.90-2.76). After adjustment for other factors, neither the then-current absolute CD4+ T-cell count nor antiretroviral therapy status showed consistent association with cataract risk, nor did an additive diagnosis of other comorbidities. Compared with the available population-based studies that used similar definitions of cataract, the age-specific prevalence of cataract in our cohort was higher than in 1 of 2 such studies, and the age-specific incidence of cataract surgery was higher.

CONCLUSIONS

Our results suggest cataract may occur earlier among patients with AIDS free of ocular opportunistic infections than in the general population. Cataract risk was associated most strongly with age and with other ocular morbidity in this population. With improved survival, the burden of cataract likely will increase for persons with the human immunodeficiency virus or AIDS.

Outcome of surgery in post-cytomegalovirus retinal detachment: experience before and in the era of highly active anti-retroviral therapy in Indian eyes

Purpose:

To evaluate the outcome of surgery for cytomegalovirus associated retinal detachment (CMVRD) in human immunodeficiency virus (HIV)-infected patients in pre-highly active antiretroviral therapy (HAART) and HAART era in Indian eyes.

Materials and Methods:

Retrospective, we reviewed medical records of all consecutive HIV patients, who underwent surgical repair for CMVRD from July 1998 to June 2011. We divided patients into two groups, i.e. group 1, pre HAART era and group 2, HAART era. We compared two groups for various parameters like visual outcome, surgical success, additional procedures, follow-up, etc.,

Results:

Twenty-eight eyes of 26 patients were included; 12 eyes of the 11 patients in group 1 and 16 eyes of the 15 patients in group 2. Significant visual acuity improvement was seen in both groups. Complete anatomic success was seen in 11 eyes in group 1 and 15 eyes in group 2. One additional procedure in group 1 and 29 additional procedures were done in group 2. A mean follow-up was 16 months in group 1 and 41 months in group 2.

Conclusion:

There was no difference in outcome in pre-HAART and HAART group, except for longer follow-up and additional surgical procedures in HAART group.

[Long-term use of silicone oil: indications and tolerance]

PURPOSE

The aim of this study was to analyze the indications and the effect of permanently maintaining silicone oil in the treatment of certain cases of vitreoretinal pathology.

PATIENTS AND METHODS

Twenty-seven cases seen from January 2002 to December 2008 were retrospectively studied. Silicone oil was kept in the eyes for more than 2years. The surgical file was analyzed in all cases. The evaluation criteria were ocular pressure, emulsification, cataract, corneal dystrophy, and the functional response of the retina and optic nerve. Ultrasound echography (12 MHz), magnetic resonance imaging, and electrophysiological explorations (visual evoked potential and electroretinography) were performed.

RESULTS

Twenty-seven eyes of 27 patients were included in this study. The main reasons for maintaining long-term silicone oil are recurrent vitreous hemorrhage, retinal detachment with severe proliferative vitreoretinopathy, and penetrating injury. The patients were distributed into two groups: group 1 included patients with both functional and anatomic failure, group 2 patients had achieved ambulatory vision. Follow-up ranged from 27 to 72months. Cataract incidence was approximately 91% in group 2. Emulsification was noted without high pressure in 50% of the cases in group 1. High pressure averaged 31.8% in group 2. Keratopathy was observed in 9% of the cases in group 2. Intraorbital migration of silicone oil was found in one case. The visual field was improved in 77% of the cases in group 2.

CONCLUSION

This study provided interesting insights into certain clinical situations in which silicone oil has to be maintained permanently. The complications stem not only from the presence of silicone oil, but also from the preoperative status of the eye and the vitreoretinal surgery.

Risk of cataract in persons with cytomegalovirus retinitis and the acquired immune deficiency syndrome

OBJECTIVE

To evaluate cataract risk in eyes of patients with AIDS and cytomegalovirus (CMV) retinitis and to identify risk factors.

DESIGN

Prospective cohort study.

PARTICIPANTS

Patients with AIDS and CMV retinitis.

METHODS

Patients 13 years of age and older were enrolled between 1998 and 2008. Demographic and clinical characteristics, slit-lamp biomicroscopy findings, and dilated ophthalmoscopy results were documented at quarterly visits. Cataract status was determined at the initial visit (prevalence) and at follow-up visits (incidence).

MAIN OUTCOME MEASURES

For cataract, a high grade of lens opacity by biomicroscopy to which best-corrected visual acuity worse than 20/40 was attributed. Eyes that had undergone cataract surgery before enrollment or between visits also were counted as having cataract.

RESULTS

Seven hundred twenty-nine eyes of 489 patients diagnosed with CMV retinitis were evaluated. Higher prevalence was observed for patients with bilateral versus unilateral CMV retinitis (adjusted odds ratio [aOR], 2.74; 95% confidence interval [CI], 1.76-4.26) and, among unilateral CMV retinitis cases, for eyes with retinitis versus without retinitis (15% vs. 1.4%; P<0.0001). The age-adjusted prevalence of cataract among CMV retinitis cases was higher than that in a population-based sample (P<0.0001). Cataract prevalence increased with age (aOR, 11.77; 95% CI, 2.28-60.65 for age ≥ 60 years vs. younger than 40 years) and longer duration of retinitis (aOR, 1.36; 95% CI, 1.20-1.54 per year). Among eyes with CMV retinitis initially free of cataract, the cataract incidence was 8.1%/eye-year (95% CI, 6.7%-10.0%). Prior retinal detachment was associated with higher cataract risk (if repaired with silicone oil: adjusted hazard ratio [aHR], 10.37; 95% CI, 6.51-16.52; otherwise: aHR, 2.90; 95% CI, 1.73-4.87). Large CMV retinitis lesions also were associated with higher risk of cataract (for involvement of 25-49% retinal area: aHR, 2.30; 95% CI, 1.51-3.50; for ≥ 50% involvement: aHR, 3.63; 95% CI, 2.18-6.04), each with respect to ≤ 24% involvement, as were anterior segment inflammation (aHR, 2.27; 95% CI, 1.59-3.25) and contralateral cataract (aHR, 2.52; 95% CI, 1.74-3.66).

CONCLUSIONS

Cytomegalovirus retinitis is associated with a high absolute and relative risk of cataract. Among several risk factors, large retinal lesion size and use of silicone oil in retinal detachment repair are potentially modifiable, albeit not in all cases. Cataract is likely to be an increasingly important cause of visual morbidity in this population.

Cytomegalovirus retinitis and the acquired immunodeficiency syndrome--bench to bedside: LXVII Edward Jackson Memorial Lecture

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.

A NEW HEAVY SILICONE OIL (HWS 46-3000) USED AS A PROLONGED INTERNAL TAMPONADE AGENT IN COMPLICATED VITREORETINAL SURGERY

PURPOSE

To report the results of a prospective pilot study using a new heavy agent, HWS 46-3000, as long-term endotamponade in complicated retinal detachment.

METHODS

Thirty-two consecutive patients were enrolled in the study. Indications for enrollment included retinal detachment with proliferative vitreoretinopathy arising from inferior or posterior tears. The patients underwent pars plana vitrectomy, membrane peeling, and HWS 46-3000 filling. Follow-up examinations were scheduled at 1 day to 7 days and 1 month to 3 months after initial surgery and 7 days and 1 month to 6 months after endotamponade removal.

RESULTS

At baseline examination, mean best-corrected Snellen visual acuity was 2.44 logarithm of the minimal angle of resolution (logMAR). HWS 46-3000 was removed after 45 days to 96 days. Initial retinal reattachment was achieved in all eyes. HWS 46-3000 endotamponade was associated with a success rate of 84.6% with a single surgery and an overall success rate of 100% at 6 months with the second operation and conventional silicone oil endotamponade. At 6 months, mean best-corrected visual acuity was +1.09 logMAR (P < 0.0001). Complications were posterior subcapsular cataract formation (100%), membrane formation (3 eyes, 9%), and increased intraocular pressure (1 eye). Emulsification and intraocular inflammation were not observed.

CONCLUSION

HWS 46-3000 was well tolerated, effective in the inferior quadrants with a low incidence of membrane development. The main complication was the high rate of tamponade-related cataract formation.