Local therapy for cytomegalovirus retinopathy

Ocular manifestations in HIV patients attending a tertiary care hospital in Eastern India and correlation of posterior segment lesions with CD4+ counts

PURPOSE

We aimed to study the ocular manifestations in human immunodeficiency virus (HIV)-infected patients and the correlation of posterior segment lesions with CD4+ counts.

METHODS

This hospital-based, cross-sectional study enrolled HIV-positive patients attending the ophthalmology department of a tertiary care hospital in Eastern India. Complete demographic information was obtained for each patient. Comprehensive ophthalmic evaluation was done in each case.

RESULTS

A total of 184 HIV-positive patients were enrolled in the study. Ocular manifestations were detected in 62 cases. The prevalence of ocular manifestations in the present study was 33.69%. Mean age of patients included in the study was 34.8 ± 10.77 years. Prevalence of ocular manifestations was highest in the age group of 30-39 years (41.93%). Highest prevalence of ocular manifestations was noted in patients with low level of education and poor socioeconomic status. Sexual transmission was the major route of HIV transmission (in 92% of cases). Posterior segment lesions were seen in 69.35% of cases. HIV retinopathy was the most common posterior segment manifestation noted in 25 eyes. Significant positive correlation was noted between severities of posterior segment findings and CD4+ counts, which we found to increase with decrease in CD4+ counts (P < 0.001).

CONCLUSION

Detailed ophthalmic evaluation including fundus examination is must in all cases of HIV/acquired immunodeficiency syndrome (AIDS) patients as it may help in early diagnosis, treatment, and prevention of sight-threatening complications due to opportunistic infections.

Prognostic Factors for Outcome after Vitrectomy for Retinal Detachment Secondary to Cytomegalovirus Retinitis in Patients with AIDS: A Retrospective Single-center Analysis

Purpose: To analyze the clinical characteristics and relevant prognostic factors of vitrectomy for retinal detachment (RD) secondary to cytomegalovirus retinitis (CMVR) in patients with acquired immune deficiency syndrome (AIDS).Methods: This study involved 39 eyes that underwent vitrectomy. Best-corrected visual acuity (BCVA), CD4⁺ cell counts, retinal attachment rate, and prognostic factors were assessed 1, 3, and 6 months postoperatively.Results: The rate of retinal attachment at 1 month (87.2%) was higher than at 3 (82.1%) and 6 (71.8%) months. Factors significantly related with recurrent RD at 6 months were CD4⁺ cell count <50 cell/µL (p = .000) and relaxed retinotomy (p = .002). Factors significantly related with the visual (≤logMAR1.0) prognosis at 6 months include band keratopathy (p = .015) and macular involvement by the RD (p = .012).Conclusion: CD4⁺ cell counts <50 cell/µL and relaxed retinotomy are associated with worse prognosis, while band keratopathy and macular involvement by the RD are related to poorer vision.

Retinal detachment associated with AIDS-related cytomegalovirus retinitis: risk factors in a resource-limited setting

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.

Incidence of endophthalmitis related to intravitreal injection of bevacizumab and ranibizumab

PURPOSE

To report the overall incidence of endophthalmitis associated with office based intravitreal injections of bevacizumab and ranibizumab.

METHODS

This is a retrospective, consecutive, multicenter case series involving four large clinical sites. Included were all patients receiving at least one injection of intravitreal bevacizumab or intravitreal ranibizumab. Follow-up after each injection was at least 4 weeks.

RESULTS

A total of 12,585 injections of intravitreal bevacizumab and 14,320 injections of intravitreal ranibizumab were given during the study period. Infectious endophthalmitis developed in three patients after administration of bevacizumab and in three patients after administration of ranibizumab. Four of these patients were culture positive. Rates of endophthalmitis were 0.02% and 0.02%, respectively, with an overall rate of 0.02%.

CONCLUSION

The rate of endophthalmitis associated with intravitreal bevacizumab and ranibizumab is low, with an incidence of approximately 1 in 4,500 injections.

Treatment of CMV retinitis with intravitral ganciclovir in the HAART era

OBJECTIVE

To describe the course and outcome of cytomegalovirus (CMV) retinitis among AIDS patients treated with intravitreal ganciclovir and systemic highly active antiretroviral therapy (HAART). The secondary objective was to compare the course of CMV retinitis between patients receiving HAART and those not receiving this treatment.

DESIGN

A retrospective cohort design consisting of 21 eyes from 16 patients with AIDS and CMV retinitis consecutively enrolled between January 1996 and August 1999. All patients received intravitreal ganciclovir therapy, and half of the patients began HAART as well. Duration of intravitreal therapy and ensuing disease quiescence, as well as CD4+ T cell counts at diagnosis and at cessation of ganciclovir, were calculated. Secondly, instantaneous hazards for outcomes such as CMV retinitis progression, ocular complications and mortality were compared.

SETTING

Tertiary care centre in Ottawa, Ontario.

RESULTS

Five of eight patients receiving HAART discontinued intravitreal ganciclovir after a mean treatment period of 428 days. During this period, their mean CD4+ count rose from 7.5 to 190microL. Subsequently, none of these patients experienced retinitis progression during follow-up periods lasting up to 820 days (mean of 617 days). Progression of CMV retinitis was 11.4 times more likely among those not receiving HAART (P=0.049).

CONCLUSIONS

On initiating HAART, patients with CMV retinitis may enjoy significant recovery in CD4+ counts and sustained retinitis quiescence without specific anti-CMV therapy. Intravitreal ganciclovir injections seem well suited to offer effective CMV control during temporary periods of decreased CD4+ counts while awaiting HAART-mediated immune system reconstitution.

Intraocular implants for extended drug delivery: therapeutic applications

An overview of ocular implants with therapeutic application potentials is provided. Various types of implants can be used as slow release devices delivering locally the needed drug for an extended period of time. Thus, multiple periocular or intraocular injections of the drug can be circumvented and secondary complications minimized. The various compositions of polymers fulfilling specific delivery goals are described. Several of these implants are undergoing clinical trials while a few are already commercialized. Despite the paramount progress in design, safety and efficacy, the place of these implants in our clinical therapeutic arsenal remains limited. Miniaturization of the implants allowing for their direct injection without the need for a complicated surgery is a necessary development avenue. Particulate systems which can be engineered to target specifically certain cells or tissues are another promising alternative. For ocular diseases affecting the choroid and outer retina, transscleral or intrasscleral implants are gaining momentum.

Outcomes Associated with Ganciclovir Implants in Patients with AIDS-Related Cytomegalovirus Retinitis

PURPOSE

To investigate complications associated with ganciclovir implants used to treat AIDS-related cytomegalovirus (CMV) retinitis, and to identify factors that predict poor outcomes.

DESIGN

Retrospective chart review.

PARTICIPANTS

Consecutive patients with AIDS-related CMV retinitis from 3 clinical facilities who underwent implantation procedures during the period January 1, 1995 through December 31, 2001.

METHODS

Baseline for each patient was the date of the first implantation procedure performed during the study period by one of the facilities' surgeons (index implant). Medical and ophthalmological data were collected at baseline and at specific time points after baseline. The dates on which additional implantation procedures were performed and the dates on which complications or vision loss were identified were also recorded. Relationships between potential risk factors and outcomes were studied by Kaplan-Meier analyses and Cox proportional hazards regression models.

MAIN OUTCOME MEASURES

Primary outcome measures included postoperative complications specifically related to or possibly related to ganciclovir implants. A secondary outcome measure was vision loss after implantation procedures.

RESULTS

The charts of 174 patients (one study eye per patient; 279 implants) were reviewed. Median follow-up was 14.4 months (range, 0-7 years). Complications specifically related to implants occurred throughout follow-up at a rate of 0.064 events per patient-year. Complications possibly related to implants occurred at an overall rate of 0.377 per patient-year, but seemed to be more common during the first 2 years after baseline. During the first 2 years of follow-up, retinal detachments occurred at a rate of 0.156 events per patient-year. The cumulative risk of vision loss (> or =3 lines of Snellen visual acuity) at 7 years was 70%. Poor outcomes were associated with disease factors (size and activity of lesions), lack of highly active antiretroviral therapy (HAART), and lack of HAART-associated immune reconstitution, but not with surgical factors or implant-specific complications.

CONCLUSIONS

Complications specifically associated with ganciclovir implants can occur many years after implantation procedures, but the incidence of such complications is low. Continued vision loss is not attributable directly to complications of implants in most cases. This information will help in planning of treatment strategies for CMV retinitis in long-term survivors of human immunodeficiency virus disease.

Complications of intravitreal steroid injections

BACKGROUND

Intravitreal corticosteroid injections are a new therapeutic procedure used to treat various retinal edematous and neovascular conditions. They have been used in the treatment of diabetic macular edema, exudative macular degeneration, pseudophakic cystoid macular edema, macular edema associated with retinal vein occlusion, and chronic uveitis as well as other conditions. Because the use of this therapeutic technique is becoming increasingly more common, adverse effects are now being seen. The most common adverse effects associated with intravitreal steroid injection are elevation of intraocular pressure and progression of cataract. Endophthalmitis, pseudoendophthalmitis, and retinal detachment have also been reported.

CASE REPORTS

This report describes 2 patients who were followed up at the VA Connecticut Healthcare System Newington Campus Optometry Clinic for steroid-induced elevation of intraocular pressure after intravitreal corticosteroid injection. One patient exhibited elevation of intraocular pressure after his first intravitreal steroid injection for treatment of clinically significant macular edema secondary to diabetes. The second patient did not exhibit a steroid response to the first intravitreal steroid injection utilized as treatment for choroidal neovascularization from age-related macular degeneration. However, he did show a rise in intraocular pressure after a second intravitreal corticosteroid injection. Intraocular pressures, treatment, and frequency of follow-up in both patients pre- and postinjection are discussed.

CONCLUSION

Elevation of intraocular pressure after intravitreal steroid injection can commonly be controlled with topical glaucoma medications. Cataract progression is common in patients after intravitreal injection of corticosteroid; however, findings show these patients are at no additional risk for cataract surgery complications. Therefore, these do not appear to be major contraindications. However, because 30% to 50% of patients experience intraocular pressure rise up to a few months postinjection, and patients are at higher risk for complications such as endophthalmitis, optometrists should be aware of appropriate management after this increasingly utilized therapeutic procedure.

Presumed sterile endophthalmitis following intravitreal triamcinolone acetonide injection

BACKGROUND AND OBJECTIVE

To report acute postoperative, presumed sterile endophthalmitis following intravitreal injection of triamcinolone acetonide (IVTA).

PATIENTS AND METHODS

Retrospective, interventional, multicenter study of patients with acute sterile endophthalmitis following IVTA injection.

RESULTS

A total of 922 IVTA injections were performed. Eight eyes of 8 patients with presumed sterile endophthalmitis were identified. The incidence of endophthalmitis was 0.87% (95% confidence interval, 0.38% to 1.70%). Median time to presentation was 1.5 days (range, 1 to 7 days). Median presenting visual acuity was 20/563 (range, 20/80 to light perception). Initial treatment included vitreous tap and injection of antibiotics (n = 4), pars plana vitrectomy and injection of intravitreal antibiotics (n = 2), or systemic treatment alone with oral levofloxacin (n = 2). Six of 6 intraocular cultures were sterile. Median follow-up was 5.9 months (range, 4 to 9 months) with a median visual acuity at last follow-up of 20/75 (range, 20/40 to counting fingers).

CONCLUSIONS

Acute presumed sterile endophthalmitis following IVTA injection presents early in the postoperative period. Visual outcomes are generally good.

Canadian consensus guidelines for the management of cytomegalovirus disease in HIV/AIDS

BACKGROUND

The management of HIV-infected patients with cytomegalovirus (CMV) disease has changed significantly with the availability of highly active antiretroviral therapy (HAART).

OBJECTIVES

These updated guidelines are intended to provide practical help to physicians managing HIV-positive patients with or at risk for CMV disease.

METHODS

The 10 members of the Canadian CMV Disease in HIV/AIDS Consensus Group were infectious disease specialists, a primary care physician and ophthalmologists with expertise in HIV and CMV infection. Financial support by Hoffmann-La Roche Canada Ltd was unrestricted, and was limited to travel expenses and honoraria. The consensus group met in June and October 2002. Key areas to be considered were identified, and group members selected, reviewed and presented relevant recent literature for their assigned section for the group's consideration. Evidence was assessed based on established criteria, which were expert opinions of the members. Draft documents were circulated to the entire group and modified until consensus was reached. The final guidelines represent the group's consensus agreement. The guidelines were approved by the Canadian Infectious Disease Society.

RESULTS AND CONCLUSIONS

The guidelines address symptom monitoring, screening for early detection and prevention, and treatment using oral, intravenous and intraocular anti-CMV therapies in conjunction with HAART.

MINIMIZING THE RISK OF ENDOPHTHALMITIS FOLLOWING INTRAVITREOUS INJECTIONS

PURPOSE

To review techniques that are important in preventing endophthalmitis following intravitreous injections based on the available evidence.

METHODS

A review of the literature regarding existing evidence that is relevant to post-injection endophthalmitis prophylaxis.

RESULTS

The available evidence regarding endophthalmitis prophylaxis is largely based on intraocular surgery, particularly cataract surgery. Despite the controversy and the paucity of evidence regarding endophthalmitis prophylaxis for intravitreous injections, it is recommended that povidone-iodine should be used prior to intravitreous injections to minimize or eliminate the presence of ocular surface bacteria. Administration of topical antibiotics may also be considered before and after the intravitreous injections. Strict adherence to aseptic techniques, including the use of an eyelide speculum is also important.

CONCLUSION

Endophthalmitic can occur following intravitreous injections. Prophylaxis with topical povidone-iodine, and possibly antibiotics, as well as adherence to aseptic technique may minimize the risk of post-injection endophthalmitis.

"Senseless" antiviral polyribonucleotides: poly (1-propargylinosinic acid)

Previous work has shown that novel amphipathic oligo and polyribonucleotides exhibiting secondary structure in solution are potent inhibitors of HIV and HCMV replication and cytopathicity in tissue culture. It was hypothesized that the mechanism(s) of action for these compounds might be inhibition of retroviral reverse transcriptase (RT) and/or viral uptake by cells. Pursuit of the essential pharmacophore has led to the discovery of poly (1-propargylinosinic acid) (10), an HIV and HCMV-active polyribonucleotide lacking the secondary structure previously thought to be essential for the observed antiviral activity.

Safety of intravitreous fomivirsen for treatment of cytomegalovirus retinitis in patients with AIDS

PURPOSE

To report data regarding the safety of intravitreous fomivirsen for treatment of cytomegalovirus (CMV) retinitis in patients with acquired immunodeficiency syndrome (AIDS).

DESIGN

Critical review of safety data from three randomized controlled clinical trials with supplemental information from an expanded drug access program.

METHODS

Adverse ocular events reported by clinician investigators were listed using terms modified from the COSTART dictionary. Data for two doses (165-microg/injection [35 eyes, 30 patients] and 330-microg/injection [153 eyes, 120 patients]) and two 330-microg/injection dose schedules of different intensity were pooled to calculate incidence rates for each event. Rates were calculated as "events/patient-year" (based on total cumulative reported events and duration of treatment) for events that could recur during treatment. Rates were calculated as "patients with events/person-year" for the following events: retinal detachment, cataract, visual field disturbance, and retinal pigment epitheliopathy. To assess the ability to manage events, we reviewed treatments given for two events (anterior chamber inflammation, increased intraocular pressure) in one trial. We also report an analysis comparing the proportion of eyes that developed one or more key events to the cumulative number of injections.

RESULTS

Incidence rates were dose and schedule dependent (165 microg/injection, 4.06 events/patient-year; 330 microg/injection, 6.58 events/patient-year [less intense regimen] and 8.35 events/patient-year [more intense regimen]). The most frequently reported events were anterior chamber inflammation and increased intraocular pressure. We found no evidence that the proportion of patients with events increased as the number of injections increased.

CONCLUSIONS

Intravitreous fomivirsen is well tolerated with an acceptable safety profile. Adverse ocular events associated with doses and schedules used clinically can be managed successfully with medical therapy.

Contact dermatitis from topical antiviral drugs

The literature has been reviewed for contact dermatitis from topical antiviral drugs. 15 agents have been identified including acyclovir, imiquimod, podophyllin, podofilox, cidofovir, penciclovir, vidarabine, idoxuridine, trifluridine, tromantadine, lamivudine, interferon intralesional injections and ophthalmic solution, fomivirsen and foscarnet intravitreal injections and ganciclovir intraocular implants. Patch testing has been documented in certain individuals and cross-sensitization has been observed to contribute significantly to some allergic reactions.

Ganciclovir-loaded albumin nanoparticles: characterization and in vitro release properties

Ganciclovir is one of the most widely used antiviral drug for the treatment of cytomegalovirus retinitis. Due to its short half-life in the vitreous, frequent administrations are necessary to maintain the therapeutic levels. In this context, the aim of this study was to characterise and in vitro evaluate the drug release properties of three different formulations of ganciclovir-loaded albumin nanoparticles. These carriers were prepared by a coacervation method and chemical cross-linking with glutaraldehyde. Depending on the step where the drug and/or cross-linking agent were added three different formulations were obtained, named models A, B and C. For model A nanoparticles, ganciclovir was incubated with the just-formed albumin nanoparticles. For the other two types of nanoparticulate formulations, the drug was added to a solution of albumin (model B) and glutaraldehyde (model C) prior to the formation of the carriers by coacervation. In all cases, the size of the different nanoparticulate formulations was comprised between 200 and 400 nm and the yield ranged from 50%, in model A, to 65% in model B. Concerning the ganciclovir loading, model B nanoparticles offered the higher capacity to carry this antiviral drug (around 30 microg ganciclovir/mg nanoparticle). On the contrary, the drug loading calculated for model A nanoparticles was only 14.6 microg/mg. The in vitro release profiles of the nanoparticles showed a biphasic pattern, with an initial and rapid release, followed by a slower step for up 5 days. This burst effect was especially relevant in model A (around 60% in 1 h), followed by model B (40%) and less important in model C (20%). The addition of trypsin to the release medium did not have a significant influence on the release characteristics. However, the release of the drug was increased in acidic or basic mediums, due to the disruption of the covalent binding between ganciclovir and the protein matrix via glutaraldehyde. This strong linkage was also confirmed by TLC experiences. In summary, a first step of incubation between the drug and the protein, prior to the preparation of nanoparticles, enabled us to obtain albumin carriers able to release ganciclovir in a sustained way.

Antiviral oligo- and polyribonucleotides containing selected triazolo[2,3-a]purines

Several amphipathic (hydrophobic base, hydrophilic backbone) polyribonucleotides have recently been shown to have potent antiviral activity against HIV and human cytomegalovirus (HCMV). The working hypothesis developed during these studies was that the ability to form an ordered, non-hydrogen-bonded array in solution was an important criterion for activity. To explore further the role of structure and molecular size on the inhibition of virus replication, one new polynucleotide and two 32-mer oligonucleotides based on the triazolo[2,3-a]purine ring system have now been prepared. High-molecular-weight polynucleotide 4a (PTPR) and sulfur-containing 32-mer 5b (TTPR) were moderately active against HIV but showed greater potency against HDMV than ganciclovir. Both 4a and 5b gave clear evidence of cooperative melting behavior, whereas inactive 32-mer 5a showed no such behavior.

Treatment of cytomegalovirus retinitis with intraocular implants

Cytomegalovirus (CMV) retinitis affects 20% to 40% of patients with AIDS and is the leading cause of vision loss associated with AIDS. Three treatment options currently exist (ie, IV administration of antiviral medications, intravitreal injections of ganciclovir, surgical implantation of devices that provide sustained release of ganciclovir). As patients with AIDS live longer, perioperative nurses may care for more patients with CMV retinitis who undergo implantation of these devices.

Treatment of cytomegalovirus retinitis with a sustained-release ganciclovir implant. The Ganciclovir Implant Study Group

BACKGROUND

Sustained-release, intraocular implants that deliver ganciclovir are an alternative method for the treatment of cytomegalovirus retinitis in patients with the acquired immunodeficiency syndrome (AIDS).

METHODS

We conducted a randomized study of 188 patients with AIDS and newly diagnosed cytomegalovirus retinitis. The patients were randomly assigned to treatment with an implant delivering 1 microg of ganciclovir per hour, an implant delivering 2 microg of ganciclovir per hour, or intravenous ganciclovir. The primary outcome we studied was progression of cytomegalovirus retinitis.

RESULTS

The median time to progression of retinitis was 221 days with the 1-microg-per-hour implant (75 eyes), 191 days with the 2-microg-per-hour implant (71 eyes), and 71 days with ganciclovir administered intravenously (76 eyes; P<0.001). The risk of progression of retinitis was almost three times as great among patients treated with intravenous ganciclovir as among those treated with a ganciclovir implant (risk ratio, 2.8; P<0.001). However, the risk of disease in the initially uninvolved eye was lower with intravenous ganciclovir than with a ganciclovir implant (risk ratio, 0.5; P=0.19). Patients treated with intravenous ganciclovir were also less likely to have extraocular cytomegalovirus infections (0, vs. 10.3 percent in the two implant groups; P=0.04).

CONCLUSIONS

For the treatment of cytomegalovirus retinitis, the sustained-release ganciclovir implant is more effective than intravenous ganciclovir, but patients treated with a ganciclovir implant alone remain at greater risk for the development of cytomegalovirus disease outside of the treated eye.

Summary of the International Consensus Symposium on Advances in the Diagnosis, Treatment and Prophylaxis and Cytomegalovirus Infection

CMV infection and CMV disease can be difficult to differentiate and the diagnosis is usually based on a compatible clinical picture and the results of a diagnostic test for CMV. The only exception to this rule is in HIV-infected patients where fundoscopy is sufficient to diagnose CMV retinitis. Of the current diagnostic tests, qualitative and quantitative PCR, branched DNA and Hybrid Capture, are the most promising. The pp65 antigenemia assay has the disadvantage of being more labor-intensive than the DNA based tests. Preliminary data show that a positive qualitative PCR in a HIV-infected patient has a predictive value for the development of CMV retinitis. However, of the patients positive by qualitative PCR, those with high viral loads in quantitative PCR were at the greatest risk of CMV disease. This might make it possible to identify with great certainty the patients who will go on to develop CMV retinitis, thereby decreasing the number of patients eligible for preemptive or prophylactic therapy and increasing the cost-benefit of this therapeutic measure. Quantitative test might also be useful in monitoring response to therapy, but randomized trials comparing the test are needed. Prophylactic antiviral agents should not be used in seronegative transplant recipients receiving organs from seronegative donors. In high-risk transplant recipients, ganciclovir should be used. CMV vaccines are useful for the protection of babies from CMV seronegative mothers against congenital CMV disease. It also may be useful in seronegative transplant recipients receiving a seropositive donor organ, although the benefit of chemo prophylaxis may surpass that of vaccine. HIV-infected patients with CMV retinitis who relapse under either ganciclovir or foscarnet benefit from subsequent combination therapy, rather than switching to the other drug. However, the cost is high in terms of quality of life. Intravitreal therapy for CMV retinitis is very efficacious, suggesting that drug delivery is a problem in systemic therapy. However, intravitreal therapy does not protect against the development of CMV retinitis in the contralateral eye or from CMV disease elsewhere. Therefore, systemic therapy should be added. CMV disease of the CNS should be diagnosed early and treated agressively, possible with combination therapy. A diagnosis of CMV disease should be based on a compatible clinical picture and the demonstration of CMV in CSF by DNA or antigen assays which are more sensitive than culture.

Treatment of clinically resistant cytomegalovirus retinitis with combined intravitreal injections of ganciclovir and foscarnet

PURPOSE

To determine the efficacy of combined ganciclovir and foscarnet intravitreal injections in controlling clinically resistant cytomegalovirus retinitis in a 37-year-old man with the acquired immunodeficiency syndrome who refused systemic therapy.

METHODS

The patient refused systemic therapy and was treated with intravitreal injections of ganciclovir and foscarnet, which were then combined when the retinitis became resistant to either drug alone.

RESULTS

The retinitis was initially controlled with bilateral intravitreal ganciclovir injections. After reactivation of retinitis in the left eye, intravitreal foscarnet was effective until recurrent retinitis threatened the center of the fovea. The retinitis continued to progress until combined intravitreal injections of ganciclovir and foscarnet were administered.

CONCLUSIONS

Combined intravitreal injections of ganciclovir and foscarnet may be effective in treating cytomegalovirus retinitis when the infection is clinically resistant to either intravitreal drug alone. Intravitreal injections can be effective in controlling cytomegalovirus retinitis in patients who are intolerant of or refuse systemic therapy.