Management of retinal detachment associated with CMV retinitis in AIDS patients

EYE DISEASE IN KIDNEY TRANSPLANTATION: CLINICAL CHALLENGES IN A UNIQUE PATIENT POPULATION

Eye disease is common among kidney transplant recipients and their management is challenging. Chronic kidney disease is associated with ocular complications, both independently and in the context of various systemic disorders. In addition, chronic immunosuppression predisposes kidney transplant recipients to an array of long-term ocular issues. This may be broadly categorized into infections, malignancies, and other immunosuppression-specific side effects. The interdependence of kidney disease, transplant pharmacotherapy and ocular health therefore requires a multispecialty approach. Although the kidney transplant population has grown along with the burden of associated oculopathies, systematic guidelines targeting this patient group are lacking. This evidenced-based narrative review summarizes the pertinent issues that may present in the ophthalmic and optometric clinical settings, with emphasis on collaborative management and directions for future research.

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.

Surgical outcomes and prognostic factors following vitrectomy in acquired immune deficiency syndrome patients with cytomegalovirus retinitis-related retinal detachment

To determine the surgical outcomes and prognostic factors of cytomegalovirus (CMV) retinitis-related retinal detachment (RD) in acquired immune deficiency syndrome (AIDS) patients following vitrectomy.A retrospective charts review was carried out on AIDS patients who were diagnosed with CMV retinitis-related RD and treated with vitrectomy between 2002 and 2016. The main outcome measures were the rates of primary anatomical success and final visual acuity (VA) success defined as postoperative VA ≥20/200. Kaplan-Meier curves on the time to retinal redetachment were performed. Multivariate logistic regression models based on a directed acyclic graph were used to identify independent factors associated with achieving VA success.Forty five AIDS patients (52 eyes) were included. Over a mean follow-up period of 41.7 months, primary anatomical success was achieved in 44 eyes (84.6%) and VA success was achieved in 34 eyes (65.4%). Receiving highly active antiretroviral therapy (HAART) prior to RD (adjusted odds ratio [aOR]=4.9, P = .043), better preoperative VA (aOR = 4.3, P = .006), undergoing vitrectomy within 3 months (aOR=6.7, P = .008), absence of optic atrophy (aOR=58.1, P < .001), and absence of retinal redetachment (aOR=38.1, P = .007) increased the odds of achieving final VA success.Vitrectomy provided favorable anatomical reattachment in AIDS patients with CMV retinitis-related RD. Majority of patients was able to retain functional vision postoperatively. The use of HAART and early vitrectomy increased the probability of achieving both anatomical and VA success.

The Role of Nystagmus in Silicone Oil Emulsification after Pars Plana Vitrectomy and Silicone Oil Injection for Complex Retinal Detachment

Purpose

The purpose of this study was to determine whether nystagmus has a role in silicone oil emulsification after pars plana vitrectomy and silicone oil injection for complex retinal detachment.

Methods

A retrospective review was conducted of the clinical and operative records of eight eyes with nystagmus that underwent pars plana vitrectomy and silicone oil injection for repair of retinal detachment associated with proliferative vitreoretinopathy. Three male (37.5%) and 5 female (62.5%) patients were included in this study. The mean age was 36.4 years (range, 19 to 54 years) and the mean follow-up time was 18.3 months (range, 5 to 49 months).

Results

Three eyes underwent combined lensectomy and vitrectomy. During the initial postoperative period, retinal attachment was obtained in 6 (75%) patients. Two of eight eyes required further surgery. Silicone oil emulsification occurred in all eyes to different degrees in the 1- to 3-month postoperative period. No inverse hypopyon was observed in any of patients. Three of eight eyes developed open angle glaucoma due to silicone oil emulsification before the silicone oil removal. In these patients, intraocular pressure was controlled successfully by medical therapy. Silicone oil removal was performed before the planned time because of early emulsification. After the removal of silicone oil, two of three eyes had established open angle glaucoma and medical therapy was maintained. After the removal of silicone oil, recurrent retinal detachment developed in two eyes and one of them developed phthisis bulbi.

Conclusions

Silicone oil emulsification may develop earlier than expected in patients with nystagmus who underwent pars plana vitrectomy combined with silicone oil injection.

Un-explained visual loss following silicone oil removal: results of the Pan American Collaborative Retina Study (PACORES) Group

PURPOSE

To report the incidence and clinical features of patients that experienced un-explained visual loss following silicone oil (SO) removal.

METHODS

Multicenter retrospective study of patients that underwent SO removal during 2000-2012. Visual loss of ≥2 lines was considered significant.

RESULTS

A total of 324 eyes of 324 patients underwent SO removal during the study period. Forty two (13%) eyes suffered a significant visual loss following SO removal. Twenty three (7.1%) of these eyes lost vision secondary to known causes. In the remaining 19 (5.9%) eyes, the loss of vision was not explained by any other pathology. Eleven of these 19 patients (57.9%) were male. The mean age of this group was 49.2 ± 16.4 years. Eyes that had an un-explained visual loss had a mean IOP while the eye was filled with SO of 19.6 ± 6.9 mm Hg. The length of time that the eye was filled with SO was 14.8 ± 4.4 months. In comparison, eyes that did not experience visual loss had a mean IOP of 14 ± 7.3 mm Hg (p < 0.0002) and a mean tamponade duration of 9.3 ± 10.9 months (p < 0.0001).

CONCLUSIONS

An un-explained visual loss after SO removal was observed in 5.9% of eyes. Factors associated with this phenomenon included a higher IOP and longer SO tamponade duration.

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.

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

PURPOSE

To determine the incidence of and risk factors for cataract and to describe the visual outcomes of cataract surgery in eyes with cytomegalovirus-related retinal detachments repaired with silicone oil.

STUDY DESIGN

Retrospective cohort study.

METHODS

A prospectively generated database of all patients with cytomegalovirus retinitis examined at a single tertiary care institution was used to identify all cases of retinal detachment between October 1983 and August 1997. Data on retinal detachment repair, development of cataract, and outcomes of cataract surgery were obtained retrospectively.

RESULTS

Among 904 eyes of 587 immune-compromised patients diagnosed with cytomegalovirus retinitis, 198 eyes of 155 patients developed retinal detachment. Among these, 106 eyes of 90 patients underwent retinal detachment repair with silicone oil. The Kaplan-Meier estimated median time to cataract was 1.8 months after surgery with silicone oil. The adjusted relative risk of cataract in eyes that underwent retinal detachment repair with silicone oil compared with eyes that did not was 6.74 (P <.0001). Eight of the eyes that developed cataract underwent uncomplicated cataract surgery by phacoemulsification and posterior chamber intraocular lens implantation. Among these, six eyes experienced >or=2 lines of improvement in visual acuity. All developed posterior capsule opacification a median of 7 days after cataract surgery. Four of five eyes that that underwent neodymium:yttrium-aluminum-garnet laser capsulotomy experienced >or=2 lines improvement in visual acuity.

CONCLUSIONS

There is a high incidence of cataract after surgery with silicone oil tamponade for cytomegalovirus-related retinal detachment. Posterior capsule opacification occurs rapidly after cataract surgery in these patients.

Clear lens extraction with intraocular lens implantation during retinal detachment repair in patients with Acquired Immune Deficiency Syndrome (AIDS) [correction of autoimmune deficiency syndrome] and cytomegalovirus retinitis

OBJECTIVE

To assess the outcomes of clear lens extraction with intraocular lens (IOL) implantation during repair of retinal detachment by vitrectomy with silicone oil tamponade in patients with acquired immunodeficiency syndrome (AIDS) and cytomegalovirus (CMV) retinitis.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Twelve eyes of 10 patients with AIDS, CMV retinitis, and retinal detachment.

INTERVENTION

All patients underwent phacoemulsification with posterior chamber IOL placement at the time of vitrectomy with silicone oil tamponade for repair of retinal detachment. A targeted postoperative refractive error of -5.00 diopters (D) to -3.00 D was chosen in an attempt to counteract the hyperopic effect of silicone oil.

MAIN OUTCOME MEASURES

The following factors were evaluated: postoperative visual acuity, refractive error, and intraoperative and postoperative complications.

RESULTS

Median follow-up was 7 months (range, 1-46 months). For patients without macular necrosis, median best-corrected preoperative visual acuity was 20/75 (range, 20/20-20/800), and median best postoperative visual acuity was 20/50 (range, 20/20-20/400). Median final visual acuity was 20/140 (range, 20/25 to count fingers at 1 foot). The median postoperative refractive error (spherical equivalent) was -1.00 D (range, -4.00 D to +7.88 D). Reoperation was required in 3 of 12 eyes for recurrent macular detachment (1 with silicone oil underfill; 2 with proliferative vitreoretinopathy). The macula was attached in all eyes at last follow-up. Reattachment of the peripheral retina was achieved in 10 of 12 eyes. There were no anterior segment complications.

CONCLUSIONS

Clear lens extraction with IOL placement during repair of retinal detachment with silicone oil tamponade does not seem to increase complications and may improve long-term visual rehabilitation, improve retinitis management by allowing better posterior segment visualization throughout the postoperative course, and decrease overall cost and morbidity associated with cataract extraction as a second procedure.

Silicone oil in the repair of pediatric complex retinal detachments: a prospective, observational, multicenter study

OBJECTIVE

To report anatomic and visual acuity outcomes, as well as complications, after using 1000-centistoke silicone oil as a retinal tamponade for the treatment of complex retinal detachments in a pediatric population.

DESIGN

A prospective, observational, multicenter study.

PARTICIPANTS

The study cohort consisted of 205 patients 16 years of age or younger (211 eyes) treated at community and university-based ophthalmology clinics for complex retinal detachments associated with trauma, proliferative vitreoretinopathy (PVR), giant retinal tear (GRT), or retinopathy of prematurity (ROP).

INTERVENTION

Vitrectomy surgery for complex retinal detachment with 1000-centistoke silicone oil as the retinal tamponade.

MAIN OUTCOME MEASURES

Anatomic outcomes include complete retinal attachment and macular attachment. Visual acuity outcomes include ambulatory vision (> or = 4/200) and preservation of preoperative visual acuity. Complications include rates of secondary intraocular pressure (IOP) elevation (> or = 30 mmHg), hypotony (< or = 5 mmHg), corneal opacification (including band keratopathy, corneal edema, and corneal abrasions), oil emulsification, and cataract. All outcome measures were assessed 6, 12, and 24 months after surgery and at last examination.

RESULTS

At the 6-month examination, the retina was completely attached in 43 (57%) of 76 eyes in the trauma group, 24 (63%) of 38 PVR eyes, 23 (68%) of 34 GRT eyes, and 6 (33%) of 18 ROP eyes. The macula was attached in 60 (79%), 33 (87%), 26 (76%), and 8 (44%) eyes, respectively. Ambulatory vision was achieved in 19 (25%) eyes in the trauma group, 18 (47%) PVR eyes, 19 (56%) GRT eyes, and 4 (22%) ROP eyes. Visual acuity was preserved in 53 (70%), 26 (68%), 28 (82%), and 9 (50%) eyes, respectively. The corresponding rates of complications for traumatic, PVR, GRT, and ROP eyes were: elevated IOP-3 (4%) of 76, 1 (3%) of 38, 1 (3%) of 34, and 0 (0%) of 18; hypotony--9 (12%), 3 (8%), 2 (6%), and 2 (11%); corneal opacity--25 (33%), 8 (21%), 15 (44%), and 5 (28%); emulsification--4 (5%), 1 (3%), 3 (9%), and 1 (6%); and cataract in phakic eyes--1 (33%) of 3, 2 (67%) of 3, 2 (50%) of 4, and 1 (33%) of 3.

CONCLUSIONS

Retinal reattachment and preserved visual acuity were achieved in the majority of eyes using vitrectomy and silicone oil retinal tamponade. Complete retinal and macular attachment was achieved less frequently in ROP eyes than in eyes in the other diagnostic groups. Use of 1000-centistoke silicone oil can be considered in the management of pediatric complex retinal detachments associated with multiple etiologies.

Silicone oil in the repair of complex retinal detachments. A prospective observational multicenter study

OBJECTIVE

This study aimed to report anatomic and visual acuity outcomes and complications after 1000-centistoke silicone oil was used as a retinal tamponade for the treatment of complex retinal detachments.

DESIGN

Prospective observational multicenter study conducted at community and university-based ophthalmology clinics.

PARTICIPANTS

The study cohort consisted of 2439 patients (2573 eyes) treated for complex retinal detachments associated with cytomegalovirus (CMV) necrotizing retinitis or a non-CMV etiology, including proliferative diabetic retinopathy, giant retinal tears, proliferative vitreoretinopathy, or ocular trauma.

INTERVENTION

Vitrectomy surgery was performed for complex retinal detachment with 1000-centistoke silicone oil as the retinal tamponade.

MAIN OUTCOME MEASURES

Anatomic outcomes were complete retinal attachment and macular attachment. Visual acuity outcomes were ambulatory vision (> or = 4/200) and preservation of preoperative visual acuity. Complications were rates of secondary intraocular pressure elevation (> or = 30 mmHg), hypotony (< or = 5 mmHg), corneal opacification (including band keratopathy, corneal edema, and corneal abrasions), oil emulsification, and cataract. Outcomes were assessed 6, 12, and 24 months after surgery.

RESULTS

At the 6-month examination, the retina was completely attached in 178 (78%) of 228 CMV eyes and in 855 (70%) of 1219 non-CMV eyes. The macula was attached in 216 (95%) of 228 and 1062 (89%) of 1189 CMV and non-CMV eyes, respectively. Ambulatory vision was noted in 151 (65%) of 234 CMV eyes and in 480 (38%) of 1251 non-CMV eyes. Visual acuity was preserved in 106 (46%) of 230 and 1035 (84%) of 1229 CMV and non-CMV eyes, respectively. The corresponding rates of complications for CMV and non-CMV eyes were: elevated intraocular pressure, 0 (0%) of 196 and 35 (3%) of 1196; hypotony, 11 (6%) of 196 and 228 (19%) of 1196; corneal opacity, 13 (6%) of 229 and 326 (26%) of 1248; emulsification, 3 (1%) of 211 and 29 (3%) of 959; and cataract in phakic eyes, 118 (64%) of 185 and 50 (63%) of 80.

CONCLUSIONS

Retinal reattachment was achieved in the majority of eyes using vitrectomy and silicone oil retinal tamponade. Complication rates generally were less frequent in CMV eyes, but follow-up was shorter in this group of patients, largely because of reduced life expectancy. Cataract frequently developed in phakic eyes of study patients. Use of 1000-centistoke silicone oil can be considered in the management of complex retinal detachments associated with multiple etiologies.

Laser photocoagulation for retinal detachments and retinal tears in cytomegalovirus retinitis

OBJECTIVE

Retinal detachment complicates the course of cytomegalovirus (CMV) retinitis in nearly 30% of human immunodeficiency virus-infected patients. The study goal was to evaluate laser photocoagulation in the treatment of CMV retinitis-related retinal detachments and retinal tears.

DESIGN

Nonrandomized, observational cohort study.

PARTICIPANTS

Sixty-three patients with CMV retinitis-related retinal detachments and nine patients with peripheral retinal tears in eyes with CMV retinitis were studied.

INTERVENTION

Of the 63 eyes with retinal detachment, 23 patients were treated with demarcating laser photocoagulation, 24 patients underwent vitrectomy with silicone oil, and 16 patients were observed without treatment. All nine patients with peripheral retinal tears received laser photocoagulation.

MAIN OUTCOME MEASURES

Time to progression of retinal detachment, final visual acuity, and need for vitrectomy surgery were studied.

RESULTS

Median time to progression of the retinal detachment in the laser-treated patients was 175 days versus 39 days in observed patients (P = 0.012). Both initial (P < 0.001) and final (P = 0.005) visual acuities were better in the patients with laser-treated detachment than in the observed or vitrectomy patients. The retinal detachment groups were comparable in follow-up, zone and location of detachment, and size of holes, but the vitrectomy and observed groups had more cases with extensive CMV retinitis. Vitrectomy surgery was required in 9 of 16 (56%) in the observed group and 7 of 23 (30%) in the laser group. Two of nine patients (22%) who failed to respond to laser treatment for retinal breaks required vitrectomy surgery.

CONCLUSIONS

Laser photocoagulation of selected retinal detachments and retinal tears delayed or avoided vitrectomy with silicone oil. It may be an important treatment modality for patients with nonmacular detachments and for those who are receiving local anti-CMV therapy with intravitreal injections or pellets, in whom silicone oil may affect the efficacy of the local treatment.

Management of viral retinitis-associated retinal detachment in AIDS

We retrospectively reviewed the results of surgery in 27 cases of retinal detachment related to viral necrotising retinitis in acquired immune deficiency syndrome (AIDS). Vitrectomy and silicone oil tamponade were performed in all cases. Scleral buckling was applied to 9 eyes. Silicone oil was left in the eye in all cases. Mean follow-up period was 13 weeks. Post-operative flattening of the retina at the posterior pole was achieved in 89% of the eyes. Anatomical results were not related to the intraoperative use of an encircling procedure. Visual acuity improved by 2 Snellen lines or more in 40% of cases and 67% of the eyes retained a post-operative ambulatory vision. Phacosclerosis and optic atrophy developed in 29% and 22% of cases, respectively. Vitrectomy and silicone oil tamponade without scleral buckling are effective in the management of retinitis-associated retinal detachments. This procedure is short and can be performed under local anaesthesia.

Intraocular silicone oil for retinal detachment in AIDS: CT and MR appearances

AIM

To describe the CT and MR features of intraocular silicone oil which is used to treat complex retinal detachments in patients with acquired immune deficiency syndrome (AIDS).

PATIENTS AND METHODS

Seven male patients with AIDS were treated by pars plana vitrectomy and intraocular silicone oil injection for complex retinal detachments due to biopsy proven cytomegalovirus retinitis. Two patients had bilateral therapy.

RESULTS

Silicone oil was hyperdense to muscle on CT with attenuation values of 106-139 HU (mean 115, SD 4.5). On MR, when compared with normal vitreous, intraocular silicone oil appeared hyperintense on T1-, proton density, and T2-weighted spin-echo sequences. A chemical shift artifact was seen on all MR images, being most marked on the T2-weighted images.

CONCLUSION

The high attenuation value of silicone oil on CT and its hyperintensity on T1 weighted MR images my cause diagnostic confusion with haemorrhage. These entities can be distinguished at CT by directly measuring the attenuation number (silicone oil > 100 HU; blood < 90 HU), and at MR by the presence of a chemical shift artifact.

Cytomegalovirus retinitis in patients with AIDS: current status

About 20%-30% of patients with AIDS will develop cytomegalovirus (CMV) retinitis when they are severely immunodeficient (CD4 cell count below 40 cells/microL). It causes extensive retinal damage with visual deficits, and relapses are frequent. Intravenous ganciclovir and foscarnet are standard therapy, but their high toxicity and long term intravenous access mean that advances in treatment, including oral prophylactic agents, intravitreal injections and surgical implants, may provide a better quality of life for patients. Prophylactic ophthalmological screening of patients with CD4 cell counts below 100 cells/microL to detect asymptomatic retinitis is needed.

Retinal detachment and herpesvirus retinitis in patients with AIDS

BACKGROUND

The prolongation of survival of patients with herpesvirus retinitis and AIDS has been associated with a rise in the incidence of retinal detachment. In such cases, however, retinal reattachment may be difficult to achieve, and postoperative visual acuity may be poor despite anatomically successful surgery.

METHODS

In order to examine factors affecting the visual outcome of surgery, a retrospective review of 29 patients with retinal detachment, herpesvirus retinitis, and AIDS was performed. Retinal reattachment surgery (32 procedures) or prophylactic laser demarcation (five procedures) was performed in 28 eyes of 23 patients.

RESULTS

The macula was attached in 23/28 (82%) eyes at the last outpatient visit. Best postoperative visual acuity (median 6/18, range 6/6-hand movements) was significantly greater than final postoperative acuity (median counting fingers, range 6/6-no perception of light) (Wilcoxon sign rank test, p = 0.003), and was retained for a median of 3 months (1-91 weeks) after surgery. Poor visual outcome as evidenced by submedian final visual acuity was invariably associated with persistence of macular detachment, and significantly associated with the occurrence of optic atrophy (odds ratio = 5, p = 0.02).

CONCLUSION

Retinal reattachment surgery appears justified in patients with herpesvirus retinitis and AIDS, but postoperative visual deterioration may occur in association with optic atrophy.

Retinal detachments in patients with AIDS and CMV retinopathy: a role for laser photocoagulation

A retrospective review of all patients with a cytomegalovirus (CMV) related retinal detachment and HIV infection managed at the ocular immunology clinic at St Vincent's Hospital between January 1985 and June 1992 was performed. Over this period 142 patients with CMV retinopathy were managed and 17 eyes from 14 of these patients developed a retinal detachment related to CMV retinopathy. Fourteen eyes from 11 of these patients were treated surgically with combinations of laser photocoagulation, cryopexy, scleral buckling, vitrectomy, and silicone oil tamponade. The use of laser photocoagulation alone in five patients resulted in an excellent visual outcome. The majority of patients (90.9%) benefited from surgery in that vision was either stabilised or improved.

Macular serous exudation in patients with acquired immunodeficiency syndrome and cytomegalovirus retinitis

Central visual loss in cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome (AIDS) occurs in two forms: direct macular tissue destruction and secondary involvement as part of rhegmatogenous retinal detachment. We treated 32 patients (35 eyes) with macular exudation that caused reversible visual loss and initially manifested as neurosensory retinal detachment and lipid exudates. Of 35 eyes, 25 showed papillary or peripapillary active retinitis and ten showed retinitis 1,500 to 3,000 microns from the fovea. Of 23 eyes with reduced vision that were followed up until healing of the retinitis and resolution of subretinal fluid and lipid exudates, 22 (96%) showed visual improvement with anti-cytomegalovirus treatment. Our findings suggest that macular exudation is a reversible cause of visual loss in patients with cytomegalovirus retinitis.

Cytomegalovirus retinitis: diagnosis and treatment

Cytomegalovirus (CMV) is a non-pathogenic organism in the immunocompetent, but is a major cause of morbidity and mortality amongst patients with AIDS, and the retina is the commonest site of infection. If left untreated, patients with CMVR will develop disease in their second eye and ultimately become blind. However, with correct diagnosis and treatment useful vision can be maintained in the majority of cases. Fifteen to 20% of patients with AIDS will contract cytomegalovirus retinitis (CMVR) and this may be the AIDS-defining diagnosis though more commonly it occurs months after the diagnosis of AIDS. Given the increasing number of HIV positive patients and their longer survival, it is likely that CMVR will become an increasingly prevalent condition. In these patients loss of sight from CMVR has devastating consequences in terms of loss of independence and quality of life and therefore ophthalmologists and physicians should be aware of the presenting characteristics of CMVR, be familiar with therapy and its complications, and be able to recognize relapsing infection.