SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN MACULA-INVOLVING CYTOMEGALOVIRUS RETINITIS

Overview of Cytomegalovirus Ocular Diseases: Retinitis, Corneal Endotheliitis, and Iridocyclitis

Cytomegalovirus (CMV) infection is a significant clinical concern in newborns, immunocompromised patients with acquired immunodeficiency syndrome (AIDS), and patients undergoing immunosuppressive therapy or chemotherapy. CMV infection affects many organs, such as the lungs, digestive organs, the central nerve system, and eyes. In addition, CMV infection sometimes occurs in immunocompetent individuals. CMV ocular diseases includes retinitis, corneal endotheliitis, and iridocyclitis. CMV retinitis often develops in infected newborns and immunocompromised patients. CMV corneal endotheliitis and iridocyclitis sometimes develop in immunocompetent individuals. Systemic infections and CMV ocular diseases often require systemic treatment in addition to topical treatment.

Optical coherence tomography biomarkers as outcome predictors to guide dexamethasone implant use in patients with iERM: a randomized controlled trial

BACKGROUND

We aimed to investigate the anatomical features of optical coherence tomography (OCT) and vitreous cytokine levels as predictors of outcomes of combined phacovitrectomy with intravitreal dexamethasone (DEX) implants for idiopathic epiretinal membrane (iERM) treatment.

METHODS

A prospective, single-masked, randomized, controlled clinical trial included 48 eyes. They were randomly assigned in a 1:1 ratio to undergo the DEX group (combined phacovitrectomy with ERM peeling and Ozurdex implantation) and control group (phacovitrectomy only). Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were assessed at 1 d, 1 week, 1 month, and 3 months. The structural features of OCT before surgery were analysed for stratified analysis. Baseline soluble CD14 (sCD14) and sCD163 levels in the vitreous fluid were measured using ELISA.

RESULTS

BCVA and CMT were not significantly different in the DEX and control groups. Eyes with hyperreflective foci (HRF) at baseline achieved better BCVA (Ptime*group=0.746; Pgroup=0.043, Wald χ²=7.869) and lower CMT (Ptime*group = 0.079; Pgroup = 0.001, Wald χ²=6.774) responses to DEX during follow-up. In all patients, the mean vitreous level of sCD163 in eyes with HRF was significantly higher than that in eyes without HRF (P = 0.036, Z=-2.093) at baseline. In the DEX group, higher sCD163 predicted greater reduction in CMT from baseline to 1 month (r = 0.470, P = 0.049).

CONCLUSIONS

We found that intraoperative DEX implantation did not have beneficial effects on BCVA and CMT over a 3-month period in all patients with iERM, implying that the use of DEX for all iERM is not recommended. In contrast, for those with HRF on OCT responded better to DEX implants at the 3-month follow-up and thier vitreous fluid expressed higher levels of sCD163 at baseline. These data support the hypothesis that DEX implants may be particularly effective in treating cases where ERM is secondary to inflammation.

TRIAL REGISTRATION

The trail has been registered at Chinese Clinical Trail Registry( https://www.chictr.org.cn ) on 2021/03/12 (ChiCTR2100044228). And all patients in the article were enrolled after registration.

Diffuse retinal dysfunction following immune reconstitution uveitis in patients with prior cytomegalovirus retinitis: a novel observation

PURPOSE

To report continuing diffuse retinal dysfunction following resolution of immune reconstitution uveitis (IRU) in patients with cytomegalovirus retinitis (CMVR).

METHODS

Retrospective case series describing two patients with IRU following CMVR who underwent serial fundus photography and macular optical coherence tomography. One patient had serial electrophysiology.

RESULTS

Both patients had CMVR successfully treated with antiviral medication. The affected eyes later developed IRU that resolved with steroids. However, following resolution, chronic retinal damage was evidenced by ellipsoid line loss in one case and gradual optic disc cupping in the other. Electrophysiology in both cases revealed generalized retinal dysfunction worse in the eye with more severe IRU and demonstrated objectively the efficacy of treatment intervention in the patient with serial recordings.

CONCLUSIONS

Patients with IRU following CMV retinitis may have continuing diffuse retinal dysfunction despite apparent recovery and normal visual acuity. An aggressive approach to inflammation control may be warranted in such patients.

Clinical application of optical coherence tomography angiography in diabetic macular edema

Diabetic macular edema (DME) is characterized by a retinal thickening or hard exudation deposition in the fundus microvasculature, capillary leakage, increased vascular permeability, extracellular fluid accumulation in the fovea of a foveal disc. Optical coherence tomography angiography (OCTA) is a new item of fundus structure examination. OCTA is to reconstruct the retinal choroidal vascular structure from the continuous same cross-sectional views and blood flow signals obtained by optical scanning, thereby obtaining an image. It is very significant to evaluate, diagnose, treat and manage the disease.

Optical Coherence Tomography and Optical Coherence Tomography Angiography in Neglected Diseases

A group of self-limiting and frequently neglected diseases exist in the literature like Rickettsial disease, Malaria, Dengue fever, Chikungunya, West Nile virus infection, Rift Valley fever, Bartonellosis, or Lyme disease which are poorly understood due to lack of proper diagnostic testing. Currently, multimodal imaging has become a critical modality in the diagnosis and management of ocular diseases. Optical coherence tomography (OCT) is one such remarkable imaging modality in the field of ophthalmology providing high-resolution, cross-sectional images of the retina and choroid with the recent advances such as enhanced depth imaging and swept source OCT. Additionally, OCT angiography (OCTA) has further revolutionised dynamic imaging of retinal and choroidal vasculature non-invasively. This review article highlights the OCT and OCTA biomarkers in the diagnosis and prognosis of the aforementioned neglected diseases.

Spectral Domain Optical Coherence Tomography Findings in Vision-Threatening Rhino-Orbital Cerebral Mucor Mycosis-A Prospective Analysis

Rhino-orbital cerebral mucor mycosis is a rare disease entity, where retinal involvement is described in the literature mostly as CRAO. However, pathological studies have shown mucor invading the choroid and retina with a neutrophilic reaction. So, it is pertinent that retinal inflammation secondary to invading mucor has some role in microstructural changes seen in the vitreous and retina of these patients. This novel study aims to describe the vitreal and retinal features of patients with vision-threatening rhino-orbital cerebral mucor mycosis and how they evolve on spectral domain optical coherence tomography (SD-OCT). This study shall also provide insight into the pathophysiology of these vitreoretinal manifestations by in vitro analysis of the exenterated orbital content. Fifteen eyes of fifteen patients with vision-threatening ROCM treated with standard care were enrolled in this study and underwent complete ophthalmic examination, serial colour fundus photography, and SD-OCT for both qualitative and quantitative analysis, at baseline and follow-up visits. SD-OCT on serial follow-up revealed thickening and increased inner-retinal reflectivity at presentation followed by thinning of both, other features such as the loss of the inner-retinal organized layer structure, external limiting membrane (ELM) disruption, necrotic spaces in the outer retina, and hyperreflective foci. Vitreous cells with vitreous haze were also seen. There was a significant reduction in CMT, inner and outer retinal thickness, total retinal thickness (all p < 0.05) with time, the quantum of reduction concentrated primarily to the inner retina. In summary, in vivo and in vitro analysis revealed that early microstructural changes were primarily a result of retinal infarctions secondary to thrombotic angioinvasion. With the late microstructural changes, there was possible sequelae of retinal infarction with some contribution from the inflammation, resulting from mucor invading the choroid and retina.

Macular Structure and Microvasculature Changes in AIDS-Related Cytomegalovirus Retinitis Using Optical Coherence Tomography Angiography

Background: Cytomegalovirus retinitis (CMVR) is a crucial blind-causing disease of AIDS-related ocular opportunistic infection. The CMVR lesions produced retinal necrosis. It is not entirely clear whether CMVR eyes without macular-involved necrotic lesions may have subtle macular damage. In this study, we conducted a cross-sectional study using optical coherence tomography angiography (OCTA) to evaluate macular microvasculature and structure in eyes with AIDS-related CMVR.

Methods: Acquired immune deficiency syndrome (AIDS)-related CMVR patients (active and inactive CMVR) and healthy controls treated in the Department of Ophthalmology, Beijing Youan Hospital, Capital Medical University between August 25, 2019, and October 18, 2019, were recruited. All OCTA parameters, including the foveal avascular zone (FAZ), retinal vessel density (VD), choroidal vascularity index (CVI), retinal thickness, and choroidal thickness, were compared between groups after the signal strength was corrected.

Results: Signal strength in the 3 × 3 and 6 × 6 mm scan patterns was significantly weaker in the inactive CMVR group than in the control group (both p < 0.001). After adjusting for signal strength, heterogeneity in the central fovea and parafoveal quadrants was present with a shift toward lower macular chorioretinal vasculature, decreased full choroidal thickness, and thicker retinal thickness in the active and inactive CMVR groups. The retinal nerve fiber layer (RNFL) and inner nuclear layer (INL) were significantly thicker in the active and inactive CMVR groups than in the control group (all p < 0.05). For photoreceptor-retinal pigment epithelium (PR-RPE) thickness, no significant differences were found in any quadrant between groups. Foveal avascular zone areas were not significantly different among the three groups (p = 0.053).

Conclusions: Subtle macular structure and microvasculature damage still existed in CMVR eyes without macular-involved necrotic lesions. The results of our study are helpful for a deep understanding of the damage caused by CMVR.

Role of multicolour imaging in post-fever retinitis involving posterior pole

PURPOSE

To describe composite multicolour (MC) imaging features along with the monocoloured fundus reflectance images in active and resolving stages of post-fever retinitis (PFR).

METHODS

Retrospective image analysis of cases of PFR who underwent dilated retinal clinical examination followed by optical coherence tomography and MC imaging.

RESULTS

Twenty-five eyes of 18 patients diagnosed with PFR were included. There were 11 males and 7 females. Mean age of patients was 30.63 years. The retinitis lesion appeared bright white on MC image and white mainly on blue and green reflectance images during the active stages of PFR. The lesion appeared dull-grey to greyish white during the resolving stages and as dull-green in resolved cases. The active stages showed the presence of intraretinal/subretinal fluid which appeared as green colour on MC images and less green to normal during resolving stages. Hard exudates were seen as bright yellow- or orange-coloured spots on MC image during the resolving stages of the disease.

CONCLUSION

The different stages of PFR show different colour on multicolour image and different reflectance patterns on individual colour reflectance channels. Hence, multimodal fundus imaging with different wavelength can be helpful for differentiation of activity in PFR.

Clinical Characteristics Associated with the Development of Cystoid Macular Edema in Patients with Cytomegalovirus Retinitis

We evaluated the incidence and characteristics of eyes with cytomegalovirus (CMV) retinitis according to the occurrence of cystoid macular edema (CME) and identified the risk factors of its occurrence. Patients diagnosed with CMV retinitis and examined using optical coherence tomography were classified according to the development of CME. The CME group was further divided according to the presence of active retinitis at the time of CME development. The demographics, serologic findings, ophthalmic presentations, ocular treatments, and visual prognosis were compared. CME was identified in 25 eyes (17 eyes with active retinitis and 8 eyes with inactive retinitis) out of the 67 eyes with CMV retinitis. Visual acuity was worse in the CME group than in the non-CME group. The CME group had longer CMV viremia duration, zone 1 involvement, and larger extent of CMV retinitis. While CME with concurrent active retinitis developed in eyes with direct foveal involvement of retinitis in the acute phase and required more ganciclovir injections after CME development, CME without active retinitis developed in eyes with larger extents of involvement and more intravitreal ganciclovir injections before CME development. Zone 1 involvement and longer CMV viremia duration were independently associated with the occurrence of CME. CME, which caused visual deterioration, developed in considerable patients with CMV retinitis and had different characteristics according to the presence of active retinitis.

A novel OCT signature in leukemic papillopathy masquerading as autoimmune or infectious uveitis

PURPOSE

With therapeutic advances, central nervous system (CNS) involvement in leukemia has become more common. Leukemic optic disc infiltration, often a clinical diagnosis, can present as an isolated finding in primary or relapsed CNS disease and therefore requires early recognition. Not previously well appreciated, we report here signs of intraocular inflammation accompanying leukemic optic disc infiltration, suggesting infectious or non-infectious uveitis as an alternative diagnosis. We describe a novel optical coherence tomography (OCT) sign favoring leukemic infiltration.

METHODS

Retrospective consecutive case series of all leukemic patients with disc edema (5 patients, 6 eyes) presenting to the University of Michigan's Ocular Oncology Clinic between October 2019 and March 2020.

RESULTS

We report five leukemic patients (6 eyes) who were evaluated for disc edema and vitritis and eventually diagnosed with leukemic papillopathy. All five patients initially had a bland lumbar puncture (LP), and all four patients who underwent magnetic resonance imaging (MRI) had no retrobulbar nerve involvement. Clinical findings included preserved visual acuity (n = 5 eyes, 83%), anterior chamber (AC) cell (n = 3 eyes, 50%), vitreous cell (n = 6 eyes, 100%), and retinal whitening (n = 4 eyes, 66%). In five eyes (83%), a diagnosis of infectious or non-infectious uveitis was initially considered. The OCT finding of inner retinal thickening and loss of inner retinal lamination with largely preserved outer retinal architecture helped point towards a leukemic infiltrative process emanating from the disc and spreading retrograde through the nerve fiber layer.

CONCLUSIONS

These cases highlight the difficulty of distinguishing intraocular inflammation associated with leukemic papillopathy from infectious or non-infectious uveitis, especially considering bland LP and negative retrobulbar MRI signal in all our patients. We propose juxtapapillary inner retinal infiltration with the loss of inner retinal lamination and relative preservation of outer retinal architecture on OCT imaging as a finding that supports the diagnosis of leukemic papillopathy.

Extralesional microvascular and structural macular abnormalities in cytomegalovirus retinitis

To evaluate extralesional microvascular and structural changes of the macula using optical coherence tomography angiography (OCTA) and structural OCT in cytomegalovirus retinitis (CMVR). An observational study of CMVR patients were performed. Complete ophthalmic examination, serial color fundus photography, structural OCT and OCTA were performed at baseline and follow-up visits for up to 12 months. The structural OCT was analyzed to evaluate macular areas within, bordering and beyond the CMVR lesions. Extralesional retinal capillary plexus of the macula were evaluated by OCT angiography and compared with the unaffected fellow eyes. Thirteen eyes from 13 patients were enrolled. At baseline, macular areas without CMVR lesions showed decreased vessel density (VD) of both the superficial (P = 0.0002) and deep (P < 0.0001) retinal capillary plexus in eyes with CMVR as compared with the corresponding macular areas of the unaffected fellow eyes. The decrease of VD persisted through the follow-up period for up to 12 months after adjusting for degree of vitreous haze. Structural macular OCT characteristics at the borders and beyond the lesions included intraretinal hyperreflective dots, cystoid macular edema, subretinal fluid and selective ellipsoid zone (EZ) loss. The selective EZ loss found in 6 of 12 eyes showed recovery in 4 eyes after receiving anti-viral treatment. In CMVR eyes, there were microvascular and microstructural abnormalities in the macular area without clinically visible CMVR lesions. Our results provided interesting insights into CMV infection of the retina.

Spectral-domain optical coherence tomography finding in cytomegalovirus retinitis in AIDS patients

AIM

To observe the findings of spectral domain optical coherence tomography (SD-OCT) scan in cytomegalovirus retinitis (CMVR).

METHODS

Forty-six eyes of 33 patients with acquired immunodeficiency syndrome and CMVR were enrolled in the study. Complete ophthalmologic examinations, color fundus photography, SD-OCT and fundus autofluorescence (FAF) were performed for all patients at the first visit and each follow-up visit. Retinal necrosis in CMVR was analyzed on SD-OCT and classified into two types, the typical type and the atypical type.

RESULTS

Forty-one eyes of active CMVR and 4 eyes of recurrent CMVR were classified into typical type, and 4 eyes with graying retinal lesion without hemorrhage or only punctate hemorrhage were classified into atypical type. In active stage of CMVR, the retina in typical type was significant thickened with hyperreflective lesion and full-thickness disruption of retinal architecture with enlarged vessel; while in atypical type, the retina was also destroyed in all layers but without thickening or slightly thinned. The choroid, vitreous and retinal vessels were not significantly involved. In healed stage, the retina was thin with destroyed layers in both types. In typical type, FAF showed mottled hypofluorescence mixed with punctuate hyperfluorescence. In atypical type, the retina showed some "cavity" in outer nuclear layer, and FAF showed mild hyperfluorescence.

CONCLUSION

SD-OCT show different changes in the retina in typical type and atypical type of CMVR, which should be useful in assisting diagnosis and follow-up management of the disease.

Comparison of Optical Coherence Tomography With Fundus Photographs, Fluorescein Angiography, and Histopathologic Analysis in Assessing Coats Disease

Importance

Coats disease is a rare pediatric vitreoretinopathy that can cause devastating visual and anatomic outcomes.

Objective

To compare optical coherence tomography (OCT) with fundus photographs, fluorescein angiography (FA), and histopathologic findings in Coats disease.

Design, Setting, and Participants

This retrospective cohort study was conducted in a single tertiary institution (Duke Eye Center) and identified 28 children with Coats disease through a review of medical records from December 2002 to January 2018. Four eyes were obtained from a biorepository for histopathologic analysis.

Main Outcomes and Measures

Macular OCT, fundus photographs, and FA results were reviewed and compared for morphological changes. These were compared with retinal histopathological findings.

Results

The mean (SD) age was 9.5 (5.5) years for the 28 children (and 29 eyes) with clinical imaging results, and 24 (86%) were boys. A comparison between imaging modalities revealed OCT features that were not visible in photographs or FA, including exudates in multiple retinal layers (23 [82.1%]), small pockets of subretinal fluid (4 [14.3%]), an outer retinal atrophy overlying fibrotic nodules (7 [25.0%]), and small preretinal hyperreflective OCT dots (25 [89.3%]). Next, a comparison with light micrographs introduced an association of OCT findings with possible pathological features, including hyperreflective linear structures on OCT that appeared consistent with cholesterol crystals, small hyperreflective dots with macrophages, outer retinal tubulations with rosettes, and analogous OCT histopathology features such as intraretinal vessels entering fibrotic nodules and retinal pigment epithelium excrescences under the subretinal fluid. An OCT analysis revealed intraretinal cystoid spaces in 19 eyes, but in 9 of 19 (47.4) this was not associated with cystoid macular leakage; rather, fluorescein leakage was observed from peripheral telangiectatic vessels. Additionally, exudates were intraretinal only (6 [21.4%]) or both intraretinal and subretinal (17 [60.7%]); none were subretinal only. In eyes with follow-up results, new fibrosis developed in 8 of 17 eyes (47.1%). Fibrosis developed in 5 of 5 eyes (100%) with baseline subretinal fluid vs 3 of 12 without (25%; 95% CI, 22%-92%) and in 7 of 9 eyes (77.8%) with subretinal exudates vs 1 of 8 (12.5%) without (95% CI, 16%-89%).

Conclusions and Relevance

Optical coherence tomography may show the transient and permanent effects of Coats disease on the retina. These results suggest that exudates and fluid in the macular subretinal space appear later in the disease and may result in fibrosis formation. Further studies are needed to confirm if early treatment could prevent vision-threatening macular fibrosis.

A comparative study on retinal thickness of the macular region among AIDS patients with normal ocular fundus, HIV-related microvascular retinopathy patients, and cytomegalovirus retinitis patients

The present study aims to measure the retinal thickness of the macular region of AIDS patients with normal ocular fundus, HIV-related microvascular retinopathy patients and cytomegalovirus retinitis (CMVR) patients by optical coherence tomography, and generalize the characteristics of retinal thickness of these 3 groups of patients.In this retrospective case series, the study object comprised of 111 AIDS patients who received diagnosis and treatment in the Ophthalmology Department of Beijing Youan Hospital. There are 33 patients in the AIDS normal ocular fundus group, 47 patients in the HIV-related microvascular retinopathy group, and 31 patients in the CMVR group. The retinal thickness of the macular region of these above patients was measured. The main indicators were retinal thickness of 9 macular partitions, best corrected visual acuity, CD4+ T lymphocyte count, and the start of highly active antiretroviral therapy.In the CMVR group, except for the nasal-outer and temporal-outer sectors, the thickness of the affected eye of the rest of the regions was greater than that of healthy eye (P < .05). Furthermore, there was a difference in thickness of the superior-outer and inferior-outer sectors between the AIDS normal ocular fundus group and HIV-related microvascular retinopathy group. The difference in thickness of the superior-inner sector between patients in the AIDS normal ocular fundus group and CMVR group was not statistically significant, while the difference in thickness of the rest of the regions was statistically significant. The difference in thickness of various regions between patients in the HIV-related microvascular retinopathy group and CMVR group was statistically significant.The retinal thickness of patients in the CMVR group generally increased, the retinal thickness of superior-outer and inferior-outer sections of patients in the HIV-related microvascular retinopathy group increased, when compared to the AIDS normal ocular fundus group. These optical coherence tomography (OCT) examination results present its own characteristics in different eye diseases in AIDS patients, and different stages of eye disease.

Abnormal levels of aqueous humor trace elements in patients with cytomegalovirus retinitis

PURPOSE

To investigate the alterations of trace elements levels in aqueous humor of patients with cytomegalovirus retinitis (CMVR).

METHODS

A total of 15 eyes of 11 patients with CMVR and 24 eyes of 24 patients with senile cataract as control group were enrolled. Aqueous humor samples were assessed for calcium (Ca), potassium (K), magnesium (Mg), sodium (Na), phosphorus (P), titanium (Ti), vanadium (V), chromium (Cr), manganese (Mn), iron (Fe), nickel (Ni), copper (Cu), zinc (Zn), selenium (Se), strontium (Sr), and lead (Pb) by using inductively coupled-plasma-mass-spectrometry. Meanwhile, we examined the concentration of the CMV DNA load by using PCR and the concentration of interleukin (IL)-8 by using a cytometric bead array.

RESULTS

In patients with CMVR, the aqueous humor levels of P and Cu were significantly higher than those of controls (p < 0.001, p < 0.001, respectively). However, levels of K and Mg were significantly lower in patients with CMVR (p < 0.001, p < 0.001, respectively). The Spearman correlation test showed that the concentration of IL-8 in the aqueous humor was significantly associated with the aqueous level of Cu (p = 0.009, r = 0.646) and Se (p = 0.031, r = 0.558). In addition, the concentration of CMV DNA load in the aqueous humor was significantly associated with the aqueous level of Ca (p = 0.027, r = -0.568), Mn (p = 0.020, r = 0.593), and Cu (p = 0.043, r = 0.527).

CONCLUSIONS

Our preliminary results demonstrated that the abnormal aqueous levels of trace elements (P and Cu) in CMVR patients. Thus, the roles of trace element changes in the development of CMVR and the influence of intraocular trace element for the prognosis of CMVR warrant further investigations.

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.