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

Effect of Anti-CMV Therapy at Different Stages on Retinal Detachment in Patients with AIDS and CMVR

INTRODUCTION

The present study aimed to investigate the effect of anti-cytomegalovirus (anti-CMV) therapy at different stages on retinal detachment in patients with acquired immunodeficiency syndrome (AIDS) and cytomegalovirus retinitis (CMVR).

METHODS

Ninety-seven patients with AIDS and CMVR diagnosed and treated at the Ophthalmology and Infection Center of Beijing You'an Hospital, affiliated with Capital Medical University, from November 2017 to January 2020 were retrospectively analyzed. Of the 138 eyes included, 30 eyes with concomitant retinal detachment were enrolled as the study subjects. The eyes with retinal detachment were divided into a pre-induction group, an intra-induction group, and a post-induction group of anti-CMV therapy. The occurrence and characteristics of retinal detachment at different stages of anti-CMV therapy were observed.

RESULTS

Retinal detachment occurred in 30 of the 138 eyes of 97 patients, with an incidence of retinal detachment of 21.74%. Retinal detachment occurred in eight eyes in the pre-induction group, with an incidence of 26.67%, and in four eyes in the intra-induction group, with an incidence of 13.33%. The difference in incidence between the two groups was statistically significant (P = 0.000). Retinal detachment occurred in 18 eyes in the post-induction group, with an incidence of 60%. The difference in incidence between the intra-induction group and the post-induction group was statistically significant (P = 0.001).

CONCLUSION

The incidence of retinal detachment at the intra-induction stages of anti-CMV therapy was lower than that at the pre-induction stage, and retinal detachment during the anti-CMV therapy predominantly occurred after the end of the induction stage.

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.

Recent developments in the treatment of posterior uveitis

Uveitis is an intraocular inflammation that can be caused by infection, autoimmune disease, trauma or malignancy. It is a serious cause of visual handicap and therapy is targeted at: removal of possible infectious agents, the immunological processes that lead to or sustain the inflammation and finally to prevent or treat the destructive effects of the inflammation on the delicate ocular structures. In this review the latest developments concerning the treatment of posterior uveitis are illuminated, e. g., new approaches concerning the treatment of infectious uveitis including the therapy of herpes virus (VZV, HSV and CMV), bacterial and toxoplasma infections of the eye. Several new ways to influence the immune response and inflammation are described including the use of interferons, modulation of cytokines, soft steroids, other new immunosuppressive drugs and treatment of autoimmune uveitis by oral tolerization. An overview is given to illustrate new ways to administer drugs into eyes, such as intravitreal devices. Finally new developments in the field of the treatment of the various complications of uveitis (cystoid macular edema) are described.

Demarcation laser therapy in the management of macular-sparing persistent subretinal fluid after scleral buckling procedures

BACKGROUND

Persistent or recurrent macular-sparing subretinal fluid (SRF) can sometimes occur following scleral buckling procedures. Observation and reoperation have been used in the management of such cases. Demarcation laser therapy (DLT) has been used to treat macular-sparing retinal detachments in the context of cytomegalovirus retinitis and as primary treatment for selected rhegmatogenous retinal detachments. There are, however, scarce data in the literature regarding its use following primary scleral buckling procedures. The current study explores the use of DLT under the latter circumstances.

METHODS

The medical records of all consecutive patients with persistent SRF sparing the macula following primary rhegmatogenous retinal detachment repair using a scleral buckling procedure were retrospectively reviewed. Only those patients in whom the breaks were localised to the area of indentation and, thus, seemed to be well supported by the buckle were included. Demographics, clinical characteristics of the retinal detachment prior to scleral buckling, extension of the residual SRF observed postoperatively, details of the laser procedure, anatomical and functional outcomes and complications were evaluated.

RESULTS

Seven patients, all females, with a mean age of 47.9 years (range: 20-81) were included in the study. The retinal detachments were superior (n=3), inferior (n=3) and subtotal, affecting both superior and inferior retina (n=1). Scleral buckling procedures were used to treat the retinal detachments in all cases. Following demarcation laser therapy, the area of SRF remained stable in two patients, and flattened in four. In one patient, extension of SRF occurred requiring further surgery.

CONCLUSIONS

Demarcation laser therapy appears to be a reasonable option in the management of patients with persistent or recurrent SRF sparing the macula following scleral buckling surgery.

Laser therapy for rhegmatogenous retinal detachment

Traditional techniques for managing uncomplicated macula-sparing rhegmatogenous retinal detachments include scleral buckling and pneumatic retinopexy. Demarcation laser photocoagulation is associated with less morbidity than these techniques and may be equally as effective in stabilizing selected macula-sparing retinal detachments.

Outcomes of cytomegalovirus retinitis following the use of ganciclovir implants

PURPOSE

To determine the results and complications from the use of ganciclovir implants to treat patients with HIV infection and cytomegalovirus (CMV) retinitis.

METHODS

The present study was a retrospective review of 87 consecutive ganciclovir implant surgeries performed in 60 patients over a 3 year period.

RESULTS

Based on the results of the present study, ganciclovir implants are an efficacious therapy for CMV retinitis but are associated with significant postoperative complications, including retinal detachment (12.0%), vitreous haemorrhage (7.2%) and cataract formation (6.0%). In this series, all implanted eyes responded to treatment and the mean time to progression was 252 days. Only a small number of patients developed second eye involvement (n = 9) or clinically significant CMV infection of other organ systems (n = 5).

CONCLUSIONS

This small retrospective study provides additional data confirming the effectiveness of ganciclovir implants and the complications from their use.

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.

Ophthalmic complications of HIV infection

HIV retinopathy, a noninfectious microangiopathy, is the most common ocular manifestation of HIV infection. Opportunistic infections, neoplasms, neuro-ophthalmic lesions, and drug-induced lesions may also cause ocular problems. Opportunistic ocular infections, particularly CMV retinitis, are a major cause of morbidity in patients with AIDS. Because of the underlying chronic and progressive immune dysfunction, the ocular symptoms, signs, clinical course, and treatment are often atypical and severe, requiring protracted medical therapy.