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Rodrigues Alves N, Barão C, Mota C, Costa L, Proença RP. Immune recovery uveitis: a focus review. Graefes Arch Clin Exp Ophthalmol 2024; 262:2703-2712. [PMID: 38381160 PMCID: PMC11271330 DOI: 10.1007/s00417-024-06415-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 12/23/2023] [Accepted: 02/11/2024] [Indexed: 02/22/2024] Open
Abstract
Immune recovery uveitis (IRU) is an intraocular inflammation that typically occurs as part of immune reconstitution inflammatory syndrome (IRIS) in the eye. Typically, it affects human immunodeficiency virus (HIV)-infected patients with recognized or unrecognized cytomegalovirus (CMV) retinitis who are receiving highly active antiretroviral therapy (HAART). IRU is a common cause of new vision loss in these patients, and it manifests with a wide range of symptoms and an increased risk of inflammatory complications, such as macular edema. Recently, similar IRU-like responses have been observed in non-HIV individuals with immune reconstitution following immunosuppression of diverse etiologies, posing challenges in diagnosis and treatment. This review provides an updated overview of the current literature on the epidemiology, pathophysiology, biomarkers, clinical manifestations, diagnosis, differential diagnosis, and treatment strategies for IRU.
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Affiliation(s)
- Nuno Rodrigues Alves
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal.
| | - Catarina Barão
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
| | - Catarina Mota
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
| | - Lívio Costa
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Rita Pinto Proença
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
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Arevalo JF, Beatson B. Surgery for Infectious Retinitis - When Medical Therapy Is Not Sufficient: The Moacyr E. Alvaro Pan-American Lecture 2023. Ocul Immunol Inflamm 2024; 32:541-549. [PMID: 36758250 DOI: 10.1080/09273948.2023.2174883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 01/05/2023] [Accepted: 01/26/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Viral retinitis composes a group of infectious ocular diseases with poor prognoses. With the advent of antivirals and HAART, the treatment of these diseases has evolved and ocular outcomes have improved. However, even with prompt medical treatment, a significant number of patients will experience complications that require surgical intervention. While there has been an abundance of research examining the medical treatment of CMV retinitis and acute retinal necrosis, the research examining surgical outcomes of complications such as retinitis-associated retinal detachment is comparatively limited. METHODS Literature review. RESULTS In this review, we discuss the current literature examining treatment of CMV retinitis and acute retinal necrosis, with a focus on surgical management of complications such as retinal detachment. CONCLUSIONS Despite significant improvements in the medical treatment of CMV retinitis and ARN over the last three decades, vision-threatening complications such as retinal detachment are relatively common and require surgical management via PPV, laser photocoagulation, and intraocular gas or silicone oil tamponade.
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Affiliation(s)
- J Fernando Arevalo
- Johns Hopkins University School of Medicine, Wilmer Eye Institute, Baltimore, Maryland, USA
| | - Bradley Beatson
- Johns Hopkins University School of Medicine, Wilmer Eye Institute, Baltimore, Maryland, USA
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Akhavanrezayat A, Uludag Kirimli G, Matsumiya W, Khojasteh H, Or C, Karaca I, Pham B, Ongpalakorn P, Lajevardi S, Lam B, Hwang JJ, Than NTT, Park S, Yavari N, Bazojoo V, Mobasserian A, Khatri A, Halim MS, Thng ZX, Ghoraba H, Do DV, Tugal-Tutkun I, Gupta V, de Smet M, Nguyen QD. The Role of Corticosteroids and Immunomodulatory Therapy in the Management of Infectious Uveitis. Ocul Immunol Inflamm 2024:1-12. [PMID: 38330155 DOI: 10.1080/09273948.2023.2296032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/11/2023] [Indexed: 02/10/2024]
Abstract
PURPOSE The index review aims to provide an update on the role of corticosteroids and steroid-sparing immunomodulatory therapy (IMT) in managing patients with infectious uveitis. METHOD Narrative literature review. RESULTS Corticosteroids and immunomodulatory therapy (IMT) focus on the host defense system instead of the pathogen, adjusting exaggerated inflammatory reactions to reduce potential harm to ocular tissues. Systemic or local corticosteroids are primarily selected as adjunctive medication for infectious uveitis. Concomitant corticosteroids have also been used in cases of paradoxical worsening in ocular tuberculosis and immune recovery uveitis in cytomegalovirus (CMV) retinitis. While there is no well-established evidence to support the use of IMT in infectious uveitis, it is occasionally used in clinical settings to treat persistent inflammation following resolution of infection such as cases of ocular tuberculosis and ocular syphilis where an insufficient response is observed with corticosteroids. CONCLUSION There is no consensus on the position of immunomodulatory therapy in the management of infectious uveitis with different etiologies. The index review provides an overview of available adjunctive corticosteroids and IMT options to assist clinicians in managing such disease entities more efficiently.
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Affiliation(s)
- Amir Akhavanrezayat
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Gunay Uludag Kirimli
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Wataru Matsumiya
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hassan Khojasteh
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Christopher Or
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Irmak Karaca
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Brandon Pham
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Sherin Lajevardi
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Brandon Lam
- Department of Ophthalmology, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Jaclyn Joyce Hwang
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ngoc Trong Tuong Than
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - SungWho Park
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Negin Yavari
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vahid Bazojoo
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Azadeh Mobasserian
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Anadi Khatri
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Muhammad Sohail Halim
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Zheng Xian Thng
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Hashem Ghoraba
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Bayrampasa Eye Hospital, Eye Protection Foundation, Istanbul, Turkey
| | - Vishali Gupta
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Marc de Smet
- Department of Ophthalmology, MicroInvasive Ocular Surgery Clinic (MIOS), Lausanne, Switzerland
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
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Jayadev C, Sanjay S, Handa A, Agrawal S. Human immunodeficiency virus retinopathy with presumed cytomegalovirus retinitis with macular oedema in a diabetic. BMJ Case Rep 2023; 16:e252710. [PMID: 37024150 PMCID: PMC10083806 DOI: 10.1136/bcr-2022-252710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
A man in his early 50s on regular follow-up for a stable non-proliferative diabetic retinopathy (NPDR) presented with decreased vision, worsening of retinal pathology and macular oedema in both eyes. His corrected distance visual acuity (CDVA) was 6/9 in the right eye and 6/15 in the left eye and fundus examination showed multiple intraretinal haemorrhages in all quadrants. His systemic workup revealed a severe thrombocytopaenia, which prompted a further detailed systemic evaluation revealing him to be positive for HIV with retinopathy complicating the pre-existing NPDR. Given the significant inflammation and macular oedema, a cocktail of intravitreal bevacizumab, ganciclovir and dexamethasone was administered. The retinopathy and macular oedema resolved and the CDVA improved to 6/6 in both eyes over a 6-month follow-up period. Any sudden worsening of fundus findings in a patient with diabetes necessitates immediate and detailed ocular and systemic evaluation, especially when the immune status is unknown.
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Affiliation(s)
- Chaitra Jayadev
- Vitreoretina Department, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Srinivasan Sanjay
- Uveitis and Ocular Immunology, Narayana Nethralaya, Bangalore, Karnataka, India
| | - Ashit Handa
- Vitreoretina Department, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Sameeksha Agrawal
- Vitreoretina Department, Narayana Nethralaya, Bengaluru, Karnataka, India
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Cho YW, Hong CM, Choi YJ, Yoo WS, Chung IY. Cytomegalovirus Immune Recovery Retinitis with Similarity to Acute Retinal Necrosis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2022. [DOI: 10.3341/jkos.2022.63.5.484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose: To describe successful treatment of cytomegalovirus immune recovery retinitis, with similarity to acute retinal necrosis, in patients with acquired immunodeficiency syndrome (AIDS) in the immune recovery stage.Case summary: A 37-year-old man, diagnosed with AIDS 5 years prior, visited our clinic with a chief complaint of visual disturbance in his right eye for 1 week. Slit lamp examination revealed severe inflammation; a light gray retinal lesion with a clear border was present in the inferotemporal area of the peripheral retina. Antiviral (ganciclovir) and oral steroid treatments were initiated. Blood test results indicated that the CD4+ T-cell count was 222/μL. Polymerase chain reaction analysis of anterior puncture findings showed a positive result for cytomegalovirus. Clinical findings were suggestive of acute retinal necrosis, but the patient's condition and examination were also suggestive of cytomegalovirus retinitis in the immune recovery stage. One month after treatment, retinal detachment was observed; surgery was performed. There was no recurrence for 3 years after the second operation and the patient remained in stable condition.Conclusions: In the immune recovery stage, non-specific cytomegalovirus retinitis accompanied by inflammation may exhibit fundus findings similar to acute retinal necrosis. We report a rare case of cytomegalovirus immune recovery retinitis where normal vision was restored via systemic drug treatment and surgery.
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Qian Y, Wang L, Jiang J, Suo J, Weng H, Che X, Lu H, Wang Z. Cytomegalovirus-Immune Recovery Retinitis After Initiation of Highly Active Antiretroviral Therapy: A Case Series. Front Med (Lausanne) 2022; 9:807013. [PMID: 35573011 PMCID: PMC9091447 DOI: 10.3389/fmed.2022.807013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/14/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose To delineate the characteristics and treatment of cytomegalovirus-immune recovery retinitis (CMV-IRR) in human immunodeficiency virus (HIV) patients with immune recovery under effective highly active antiretroviral therapy (HAART) regimen. Methods We reported four patients with HIV who were diagnosed with CMV-IRR soon after effective HAART. Plasma levels of CD4 T cells, HAART regimen, and other clinical and laboratory characteristics of the four patients were described. Patients were monitored for ocular manifestations and clinical signs under effective ocular and systemic anti-cytomegalovirus (CMV) and corticosteroid treatment for 12 months. Results With HAART, plasma levels of CD4 T cell counts rose remarkably. The mean baseline CD4 count of the four patients was 14.5 (range from 7 to 33) cells/μl before HAART and 183.25 (range from 153 to 220) cells/μl when diagnosed with CMV-IRR. Ophthalmic examination demonstrated severe vitreous opacities and necrotizing retinitis, intraretinal hemorrhages, and vasculitis. A large number of CMV sequencing was detected by DNA sequencing of vitreous samples. All four patients were recovered from CMV-IRR with anti-CMV and corticosteroid treatment. Conclusions Cytomegalovirus-immune recovery retinitis is a new diagnosis of HIV-associated ocular complication under HAART. These findings suggest that the immunological effects of HAART may accelerate the CMV retinitis in patients with very low initial CD4 T cell counts. HIV patients are recommended to have a thorough fundus examination before HAART initiation and a close follow-up especially in those with low CD4 counts to avoid the progression of CMV retinitis.
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Affiliation(s)
- Yiwen Qian
- Department of Ophthalmology, Huashan Hospital of Fudan University, Shanghai, China
| | - Luoziyi Wang
- Department of Ophthalmology, Huashan Hospital of Fudan University, Shanghai, China
| | - Jing Jiang
- Department of Ophthalmology, Huashan Hospital of Fudan University, Shanghai, China
| | - Jinshan Suo
- Department of Ophthalmology, Huashan Hospital of Fudan University, Shanghai, China
| | - Huan Weng
- Department of Ophthalmology, Huashan Hospital of Fudan University, Shanghai, China
| | - Xin Che
- Department of Ophthalmology, Huashan Hospital of Fudan University, Shanghai, China
| | - Hongzhou Lu
- Department of Infectious Disease, Shenzhen Third People's Hospital, Shenzhen, China
- Hongzhou Lu
| | - Zhiliang Wang
- Department of Ophthalmology, Huashan Hospital of Fudan University, Shanghai, China
- *Correspondence: Zhiliang Wang
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Jain S, Bajgai P, Tigari B, Sharma K, Sharma A, Gupta V, Singh R. Bevacizumab for paradoxical worsening treatment adjunct in HIV patient with choroidal tuberculoma. J Ophthalmic Inflamm Infect 2016; 6:42. [PMID: 27822744 PMCID: PMC5099299 DOI: 10.1186/s12348-016-0112-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/28/2016] [Indexed: 12/05/2022] Open
Abstract
The use of anti-tubercular therapy (ATT) along with anti-retroviral therapy (ART) in human immunodeficiency virus-tuberculosis (HIV-TB) co-infected individuals could at times lead to paradoxical worsening due to an increase in the inflammatory activity due to immune reconstitution inflammatory syndrome (IRIS) in the eye. This is characterized by anterior and posterior segment inflammatory reactions which may occur in the form of serous retinal detachment. We describe a case where the use of intravitreal anti-vascular endothelial growth factor (anti-VEGF) agent led to resolution of the serous retinal detachment, which had failed to respond to other common modalities of treatment. An HIV-TB co-infected 18-year-old, male patient, who was started on ART and ATT developed IRIS in the form of worsening of serous retinal detachment around a pre-existent asymptomatic tuberculoma. The patient was initially treated with oral and topical steroids without a satisfactory response. Intravitreal bevacizumab was then tried for this patient. Serial fundus photos and optical coherence tomography (OCT) taken before and after treatment showed complete resolution of the serous retinal detachment with two doses of intravitreal bevacizumab. Intravitreal anti-VEGF agents may have a role in the reversal of serous retinal detachment, which occurs as a part of IRIS in HIV-tuberculosis co-infected individuals who have been started on anti-tubercular and anti-retroviral therapies.
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Affiliation(s)
- Sahil Jain
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Priya Bajgai
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Basavaraj Tigari
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Kusum Sharma
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Aman Sharma
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Vishali Gupta
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Ramandeep Singh
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India.
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Yeo TH, Yeo TK, Wong EP, Agrawal R, Teoh SC. Immune recovery uveitis in HIV patients with cytomegalovirus retinitis in the era of HAART therapy-a 5-year study from Singapore. J Ophthalmic Inflamm Infect 2016; 6:41. [PMID: 27822743 PMCID: PMC5099291 DOI: 10.1186/s12348-016-0110-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/27/2016] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study is to analyse the clinical features of HIV patients with cytomegalovirus retinitis (CMVR) developing immune recovery uveitis (IRU) while on highly active antiretroviral therapy (HAART) and to identify the risk factors, visual outcomes and complications of IRU. Results Majority (n = 26, 86.7 %) of patients were male, with 76.7 % (n = 23) of patients having bilateral disease. Twenty-seven eyes (50.9 %) had both anterior uveitis and vitritis. The median CD4 at IRU was 210 cells/μL (IQR 140–279), with 86.7 % having CD4 >100 cells/μL. The median duration from initiation of HAART to IRU was significantly different between those <50 years old (median 763 days, IQR 174–1872 days) and those ≥50 years old (median 161 days, IQR 84.5–278 days). Fourteen eyes (26.4 %) had loss of one or more Snellen lines visual acuity at 6 months while the rest maintained or improved vision. Complications developed in 21 eyes, with cataract (66.7 %), glaucoma and ocular hypertension (33.3 %) being the most common. The risk of complications was associated with the absolute difference in CD4 counts at IRU and at HAART commencement (p = 0.041). Age was also negatively associated with the duration from HAART to IRU (p = 0.005, Spearman’s rho coefficient = −0.503). Conclusions It is common to have both anterior uveitis and vitritis in IRU. There was a positive association between the increase in CD4 from HIV to IRU diagnoses and the risk of developing complications. Younger patients appeared to develop IRU later than older patients after HAART, suggesting that long-term follow-ups are essential for these patients.
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Affiliation(s)
- Tun Hang Yeo
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, 308433, Singapore.
| | - Tun Kuan Yeo
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, 308433, Singapore
| | - Elizabeth P Wong
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, 308433, Singapore
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, 308433, Singapore
| | - Stephen C Teoh
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, 308433, Singapore.,Eagle Eye Centre, Singapore, Singapore
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Schaftenaar E, van Gorp ECM, Meenken C, Osterhaus ADME, Remeijer L, Struthers HE, McIntyre JA, Baarsma GS, Verjans GMGM, Peters RPH. Ocular infections in sub-Saharan Africa in the context of high HIV prevalence. Trop Med Int Health 2014; 19:1003-14. [PMID: 25039335 DOI: 10.1111/tmi.12350] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Healthy eyes and good vision are important determinants of populations' health across the globe. Sub-Saharan Africa is affected by simultaneous epidemics of ocular infections and human immunodeficiency virus (HIV). Ocular infection and its complications, along with cataract and ocular trauma, are common conditions in this region with great impact on daily life. In this review, we discuss the epidemiology, clinical manifestations and microbial aetiology of the most important infectious ocular conditions in sub-Saharan Africa: conjunctivitis, keratitis and uveitis. We focus specifically on the potential association of these infections with HIV infection, including immune recovery uveitis. Finally, challenges and opportunities for clinical management are discussed, and recommendations made to improve care in this neglected but very important clinical field.
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Affiliation(s)
- Erik Schaftenaar
- Department of Viroscience, Erasmus MC, Rotterdam, the Netherlands; Anova Health Institute, Johannesburg, Tzaneen, South Africa; Rotterdam Eye Hospital, Rotterdam, The Netherlands
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Immune recovery uveitis: pathogenesis, clinical symptoms, and treatment. Mediators Inflamm 2014; 2014:971417. [PMID: 25089078 PMCID: PMC4096001 DOI: 10.1155/2014/971417] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 06/10/2014] [Indexed: 12/13/2022] Open
Abstract
IRU is the most common form of immune reconstitution inflammatory syndrome in HIV-infected patients with cytomegalovirus retinitis who are receiving highly active antiretroviral therapy (HAART). Among patients with CMV in the HAART era, immune recovery may be associated with a greater number of inflammatory complications, including macular edema and epiretinal membrane formation. Given the range of ocular manifestations of HIV, routine ocular examinations and screening for visual loss are recommended in patients with CD4 counts <50 cells/μL. With the increasing longevity of these patients due to the use of HAART, treatment of IRU may become an issue in the future. The aim of this paper is to review the current literature concerning immune recovery uveitis. The definition, epidemiology, pathophysiology, clinical findings, complications, diagnosis, and treatment are presented.
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Hiwarkar P, Gajdosova E, Qasim W, Worth A, Breuer J, Chiesa R, Ridout D, Edelsten C, Moore A, Amrolia P, Veys P, Rao K. Frequent Occurrence of Cytomegalovirus Retinitis During Immune Reconstitution Warrants Regular Ophthalmic Screening in High-Risk Pediatric Allogeneic Hematopoietic Stem Cell Transplant Recipients. Clin Infect Dis 2014; 58:1700-6. [DOI: 10.1093/cid/ciu201] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Eid AJ, Razonable RR. Valganciclovir for the treatment of cytomegalovirus retinitis in patients with AIDS. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2.3.351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tan DHS, Walmsley SL. Management of persons infected with human immunodeficiency virus requiring admission to the intensive care unit. Crit Care Clin 2013; 29:603-20. [PMID: 23830655 DOI: 10.1016/j.ccc.2013.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Rates of admission to the intensive care unit (ICU) for persons infected with human immunodeficiency virus (HIV) remain relatively unchanged in the modern era despite advances in antiretroviral therapy (ART) and improvements in ICU survival. Critical care may be required for patients with HIV because of severe opportunistic infections or malignancy, antiretroviral drug toxicity, or critical illness seemingly unrelated to HIV, and each of these scenarios may present different management challenges. In this article, the epidemiology of HIV-related ICU admission is reviewed and key management issues are discussed.
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Affiliation(s)
- Darrell H S Tan
- Division of Infectious Diseases, University Health Network, Faculty of Medicine, University of Toronto, 585 University Avenue, 13 N, Toronto, Ontario M5G 2N2, Canada.
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Meintjes G, Scriven J, Marais S. Management of the immune reconstitution inflammatory syndrome. Curr HIV/AIDS Rep 2012; 9:238-50. [PMID: 22752438 DOI: 10.1007/s11904-012-0129-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) is a frequent early complication of antiretroviral therapy (ART) in patients with advanced HIV. Because there is no confirmatory diagnostic test, the diagnosis is based on clinical presentation and exclusion of alternative causes for deterioration, such as antimicrobial drug resistance. Opportunistic infection treatment should be optimized. Mild cases may require symptomatic therapy alone or nonsteroidal anti-inflammatory drugs. Corticosteroids have been used to treat more severe cases of IRIS associated with mycobacterial and fungal infections. There is evidence from a randomized controlled trial that prednisone reduces morbidity and improves symptoms in paradoxical tuberculosis (TB)-IRIS. Neurological TB-IRIS is potentially life-threatening; high-dose corticosteroids are indicated and ART interruption should be considered if level of consciousness is depressed. When considering corticosteroid treatment clinicians should be aware of their side effects and only use them when the diagnosis of IRIS is certain. In viral forms of IRIS corticosteroids are generally avoided.
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Affiliation(s)
- Graeme Meintjes
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Mitchell SM, Shiew MMF, Nelson M. 5 Ocular infections. HIV Med 2011. [DOI: 10.1111/j.1468-1293.2011.00944_6.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Yoganathan K. Cystoid macular edema secondary to immune recovery uveitis in a man with cytomegalovirus retinitis and AIDS. Clin Ophthalmol 2010; 4:1065-7. [PMID: 20957141 PMCID: PMC2952605 DOI: 10.2147/opth.s12049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Cytomegalovirus (CMV) is the most common intraocular opportunistic infection in profoundly immunocompromised patients with AIDS. It is characterized by an acute, progressive, necrotizing retinitis in patients with a CD4 count of <50 cells/μL. Although the incidence of CMV retinitis has declined because of the introduction of antiretroviral therapy (ART), a new syndrome of intraocular inflammation has emerged in patients with rising CD4 lymphocyte counts following ART. This is called immune recovery uveitis (IRU). It is thought to occur as a result of restored immunity to various infectious agents, commonly mycobacterial, Cryptococcus, and herpes virus infections. We report a man who was treated for CMV retinitis and later developed IRU in the form of cystoid macular edema (CMO) even though his CMV retinitis remained inactive. His CMO resolved and visual acuity improved 2 years after the onset of CMO without any treatment interventions.
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Affiliation(s)
- Kathir Yoganathan
- HIV/Genito-Urinary Medicine, Abertawe Bro Morgannwg University Health Board, Singleton hospital, Swansea, UK.
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Phospholipases A2 in ocular homeostasis and diseases. Biochimie 2010; 92:611-9. [DOI: 10.1016/j.biochi.2010.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Accepted: 04/15/2010] [Indexed: 02/02/2023]
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Abstract
Cytomegalovirus (CMV) retinitis is the most common cause of vision loss in patients with acquired immunodeficiency syndrome (AIDS). CMV retinitis afflicted 25% to 42% of AIDS patients in the pre-highly active antiretroviral therapy (HAART) era, with most vision loss due to macula-involving retinitis or retinal detachment. The introduction of HAART significantly decreased the incidence and severity of CMV retinitis. Optimal treatment of CMV retinitis requires a thorough evaluation of the patient's immune status and an accurate classification of the retinal lesions. When retinitis is diagnosed, HAART therapy should be started or improved, and anti-CMV therapy with oral valganciclovir, intravenous ganciclovir, foscarnet, or cidofovir should be administered. Selected patients, especially those with zone 1 retinitis, may receive intravitreal drug injections or surgical implantation of a sustained-release ganciclovir reservoir. Effective anti-CMV therapy coupled with HAART significantly decreases the incidence of vision loss and improves patient survival. Immune recovery uveitis and retinal detachments are important causes of moderate to severe loss of vision. Compared with the early years of the AIDS epidemic, the treatment emphasis in the post- HAART era has changed from short-term control of retinitis to long-term preservation of vision. Developing countries face shortages of health care professionals and inadequate supplies of anti-CMV and anti-HIV medications. Intravitreal ganciclovir injections may be the most cost effective strategy to treat CMV retinitis in these areas.
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Affiliation(s)
- Michael W Stewart
- Department of Ophthalmology, Mayo School of Medicine, Jacksonville, FL, USA.
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Affiliation(s)
- Aliza Jap
- Division of Ophthalmology, Changi General Hospital, 2 Simei Street 3, Singapore
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Abstract
PURPOSE OF REVIEW The aim of this article is to review the current literature concerning immune reconstitution inflammatory syndrome in relation to the eye. The definition, epidemiology, pathophysiology, risk factors, clinical features, diagnosis and treatment are discussed. RECENT FINDINGS Immune reconstitution inflammatory syndrome affecting the eye has been documented in association with cytomegalovirus retinitis following the introduction of highly active antiretroviral therapy in a large number of patients. This syndrome is referred to as immune recovery uveitis, which is presumed to be mediated by recovery of immune responses specific to residual cytomegalovirus antigen located in the eye. In addition to improved immunity itself, risk factors include a low CD4 T count at the time of initiation of highly active antiretroviral therapy and involvement of a larger proportion of retina. Immune recovery uveitis is a major cause of visual loss and morbidity among patients with AIDS who are receiving highly active antiretroviral therapy. SUMMARY Immune recovery uveitis is the most common form of immune reconstitution inflammatory syndrome in HIV-infected patients with cytomegalovirus retinitis who are receiving highly active antiretroviral therapy. Clear clinical definitions are required for ocular immune reconstitution inflammatory syndromes to avoid misclassification of other inflammatory conditions. A multidisciplinary approach is important in the diagnosis and management of immune recovery uveitis.
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Marais S, Wilkinson RJ, Pepper DJ, Meintjes G. Management of patients with the immune reconstitution inflammatory syndrome. Curr HIV/AIDS Rep 2009; 6:162-71. [PMID: 19589302 DOI: 10.1007/s11904-009-0022-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A significant proportion of patients present with the immune reconstitution inflammatory syndrome (IRIS) after commencing antiretroviral therapy (ART). This syndrome is most frequently associated with infective causes. The lack of evidence-based treatment guidelines poses challenges in the management of these patients. Alternative causes for deterioration should be excluded, and optimization of treatment for the underlying opportunistic infection is essential. In addition, anti-inflammatory or immunomodulatory therapy may be considered, particularly in severe cases. Corticosteroids, the only treatment for which clinical trial data exist (for treating paradoxical tuberculosis-associated IRIS), are the treatment most frequently used in IRIS. Limited anecdotal reports of benefit exist for other agents, including NSAIDs, pentoxifylline, montelukast, thalidomide, and hydroxychloroquine. Therapeutic procedures (eg, aspiration of pus collections) play an important role in some patients. Interruption of ART may be considered in life-threatening forms of IRIS.
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Affiliation(s)
- Suzaan Marais
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
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Waib LF, Bonon SHA, Salles AC, Benard G, de Oliveira ACP, Pannuti CS, Pedro RDJ, Costa SCB. Withdrawal of maintenance therapy for cytomegalovirus retinitis in AIDS patients exhibiting immunological response to HAART. Rev Inst Med Trop Sao Paulo 2007; 49:215-9. [PMID: 17823749 DOI: 10.1590/s0036-46652007000400004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Accepted: 01/15/2007] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND: Before the introduction of highly active antiretroviral therapy (HAART), CMV retinitis was a common complication in patients with advanced HIV disease and the therapy was well established; it consisted of an induction phase to control the infection with ganciclovir, followed by a lifelong maintenance phase to avoid or delay relapses. METHODS: To determine the safety of CMV maintenance therapy withdrawal in patients with immune recovery after HAART, 35 patients with treated CMV retinitis, on maintenance therapy, with CD4+ cell count greater than 100 cells/mm³ for at least three months, but almost all patients presented these values for more than six months and viral load < 30000 copies/mL, were prospectively evaluated for the recurrence of CMV disease. Maintenance therapy was withdrawal at inclusion, and patients were monitored for at least 48 weeks by clinical and ophthalmologic evaluations, and by determination of CMV viremia markers (antigenemia-pp65), CD4+/CD8+ counts and plasma HIV RNA levels. Lymphoproliferative assays were performed on 26/35 patients. RESULTS: From 35 patients included, only one had confirmed reactivation of CMV retinitis, at day 120 of follow-up. No patient returned positive antigenemia tests. No correlation between lymphoproliferative assays and CD4+ counts was observed. CONCLUSION: CMV retinitis maintenance therapy discontinuation is safe for those patients with quantitative immune recovery after HAART.
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Affiliation(s)
- Luis Fernando Waib
- Department of Internal Medicine, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
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Murdoch DM, Venter WDF, Van Rie A, Feldman C. Immune reconstitution inflammatory syndrome (IRIS): review of common infectious manifestations and treatment options. AIDS Res Ther 2007; 4:9. [PMID: 17488505 PMCID: PMC1871602 DOI: 10.1186/1742-6405-4-9] [Citation(s) in RCA: 175] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Accepted: 05/08/2007] [Indexed: 11/24/2022] Open
Abstract
The immune reconstitution inflammatory syndrome (IRIS) in HIV-infected patients initiating antiretroviral therapy (ART) results from restored immunity to specific infectious or non-infectious antigens. A paradoxical clinical worsening of a known condition or the appearance of a new condition after initiating therapy characterizes the syndrome. Potential mechanisms for the syndrome include a partial recovery of the immune system or exuberant host immunological responses to antigenic stimuli. The overall incidence of IRIS is unknown, but is dependent on the population studied and its underlying opportunistic infectious burden. The infectious pathogens most frequently implicated in the syndrome are mycobacteria, varicella zoster, herpesviruses, and cytomegalovirus (CMV). No single treatment option exists and depends on the underlying infectious agent and its clinical presentation. Prospective cohort studies addressing the optimal screening and treatment of opportunistic infections in patients eligible for ART are currently being conducted. These studies will provide evidence for the development of treatment guidelines in order to reduce the burden of IRIS. We review the available literature on the pathogenesis and epidemiology of IRIS, and present treatment options for the more common infectious manifestations of this diverse syndrome and for manifestations associated with a high morbidity.
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Affiliation(s)
- David M Murdoch
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham North Carolina, USA
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- CB#7435, 2104-H McGavran-Greenberg Hall, University of North Carolina, School of Public Health, Chapel Hill, NC 27599-7435, USA
| | - Willem DF Venter
- Reproductive Health & HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Annelies Van Rie
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Charles Feldman
- Division of Pulmonology, Department of Medicine, Johannesburg Hospital and University of the Witwatersrand, Johannesburg, South Africa
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Morrison VL, Kozak I, LaBree LD, Azen SP, Kayicioglu OO, Freeman WR. Intravitreal triamcinolone acetonide for the treatment of immune recovery uveitis macular edema. Ophthalmology 2007; 114:334-9. [PMID: 17270681 DOI: 10.1016/j.ophtha.2006.07.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Revised: 07/13/2006] [Accepted: 07/13/2006] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To evaluate the use of intravitreal triamcinolone (IVTA) for the treatment of macular edema secondary to immune recovery uveitis (IRU) in patients with AIDS. DESIGN Prospective, consecutive, interventional case series. PARTICIPANTS Eight eyes of 7 patients receiving 13 injections. METHODS Prospective, consecutive, interventional case series of 13 injections involving 8 eyes in 7 patients who underwent an intravitreal injection of 20 mg decanted triamcinolone acetate for fluorescein angiographically proven IRU-related macular edema. MAIN OUTCOME MEASURES The primary outcome measure was vision (using the Early Treatment Diabetic Retinopathy Study chart). Other outcome measures included fluorescein angiography and optical coherence tomography. RESULTS Visual acuity improved at all time points and was statistically significant at the 1-month and 3-month follow-up examinations. The average visual improvement was 3 lines at 3 months. Retinal volume and thickness improvement were statistically significant at all time points. All patients had a minimum follow-up of 9 months, and there were no cases of cytomegalovirus reactivation. CONCLUSIONS Previous studies showed that treatment with sub-Tenon repository steroids for the treatment of macular edema of IRU was only marginally effective. However, the current study shows that IVTA can be an effective short-term treatment for macular edema secondary to IRU in patients with AIDS. Longer follow-up is needed to assess the durability of the effect and to monitor for longer-term complications and outcomes.
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Affiliation(s)
- Victoria L Morrison
- Jacobs Retina Center, Department of Ophthalmology, University of California, San Diego, La Jolla, California 92093, USA
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Riedel DJ, Pardo CA, McArthur J, Nath A. Therapy Insight: CNS manifestations of HIV-associated immune reconstitution inflammatory syndrome. ACTA ACUST UNITED AC 2006; 2:557-65. [PMID: 16990829 DOI: 10.1038/ncpneuro0303] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Accepted: 08/03/2006] [Indexed: 11/09/2022]
Abstract
The introduction of combination antiretroviral therapy for HIV infection has prolonged the lives of patients with AIDS. It is increasingly being recognized, however, that following initiation of this therapy some patients can develop a paradoxical neurological deterioration, despite dramatic improvements in HIV viral load and CD4+ T-cell counts. This immune reconstitution inflammatory syndrome (IRIS) in the CNS is emerging as an important neurological complication, particularly as antiretroviral therapy is now becoming readily available worldwide. Currently, there are no guidelines for prevention, diagnosis or treatment of the CNS manifestations of IRIS. Even in patients with an acute presentation, the diagnosis can be challenging. Furthermore, it is possible that more-chronic forms of the syndrome exist but remain unrecognized. Here, we review the various clinical presentations of CNS IRIS, and discuss options for their management.
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Sendi P, Sachers F, Drechsler H, Graber P. Immune recovery vitritis in an HIV patient with isolated toxoplasmic retinochoroiditis. AIDS 2006; 20:2237-8. [PMID: 17086067 DOI: 10.1097/01.aids.0000252056.53062.c8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kempen JH, Min YI, Freeman WR, Holland GN, Friedberg DN, Dieterich DT, Jabs DA. Risk of Immune Recovery Uveitis in Patients with AIDS and Cytomegalovirus Retinitis. Ophthalmology 2006; 113:684-94. [PMID: 16581429 DOI: 10.1016/j.ophtha.2005.10.067] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Revised: 10/29/2005] [Accepted: 10/31/2005] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To evaluate the prevalence of and risk factors for immune recovery uveitis (IRU) in eyes of patients with AIDS and cytomegalovirus (CMV) retinitis. DESIGN Enrollment data from a 19-clinical center cohort study. PARTICIPANTS Three hundred seventy-four patients with AIDS and CMV retinitis affecting 539 eyes. METHODS Patients with AIDS were enrolled at 19 United States AIDS ophthalmology clinics. Data were collected by interview, review of medical records, ophthalmic examination, and phlebotomy. MAIN OUTCOME MEASURE Immune recovery uveitis. RESULTS Thirty-six patients (9.6%) were diagnosed with IRU involving 50 eyes. The CD4+ T-cell count of 31 of these had risen by > or =50 cells per microliter above nadir to a level > or = 100 cells per microliter (immune recovery), making up 17.6% of the patients known to have immune recovery after diagnosis of CMV retinitis (95% confidence interval, 12.3%-24.1%). No patients with IRU were observed to have active retinitis or detectable CMV DNA in peripheral blood (P<0.001 and P<0.001 with respect to patients without IRU). Other factors associated with IRU were > or =25% retinal area (odds ratio [OR], 2.72; P = 0.014) or posterior pole involvement with CMV retinitis (odds ratio, 0.43; P = 0.039), treatment with intravitreous injection of cidofovir (OR, 10.6 with respect to eyes never exposed to intravitreous or IV cidofovir; P<0.001), and male gender (OR, 0.26; P = 0.012). More eyes with IRU had visual acuity (VA) of 20/50 or worse (38.0% vs. 26.3%, P = 0.077) relative to eyes without IRU, but the proportions with VA of 20/200 or worse were similar (14.0% vs. 13.8%, P = 0.96). Eyes with IRU more commonly had cystoid macular edema (CME) (45.5% vs. 3.7%, P<0.001) and epiretinal membrane (48.9% vs. 13.3%, P<0.001) than eyes without IRU. CONCLUSIONS Among eyes of patients with immune recovery, the prevalence of IRU is substantial. Eyes with IRU have a high risk of additional morbidity over and above that seen with CMV retinitis, with several-fold higher risk of CME and epiretinal membrane. Large CMV lesions and use of intravitreous cidofovir are risk factors for IRU.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe the epidemiology, clinical features, putative immune mechanisms and management of immune reconstitution inflammatory syndrome (IRIS) using data published in the last 2 years. RECENT FINDINGS Ever more conditions are reported as IRIS events. These most frequently occur with mycobacterial (tuberculosis or Mycobacterium avium complex infection) or cryptococcal disease (each in approximately 30% of cases). Definitions have been proposed for its clinical diagnosis. These suffer from a lack of prospective studies to support their predictive value. The immunopathogenesis of IRIS appears to be related to the interaction between HAART-induced changes in host immune response and the presence of (usually microbial) antigen. Increasing evidence exists that this might be an anatomically compartmentalized phenomenon, such that immune responses may be localized to specific tissue sites such as the brain. This has implications for the use of simple blood tests, such as CD4 count or change in viral load, when assessing risk of IRIS. Treatment options include immune modulation, though supportive care is typically all that is required, unless symptoms are prolonged, significant or life-threatening. SUMMARY IRIS is common and will become more so as HAART is rolled out worldwide. Clear clinical definitions are required to avoid its over-diagnosis due to misclassification of other conditions.
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Affiliation(s)
- Marc Lipman
- Department of HIV and Respiratory Medicine, Royal Free Hospital, London, UK.
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Goldberg DE, Smithen LM, Angelilli A, Freeman WR. HIV-associated retinopathy in the HAART era. Retina 2005; 25:633-49; quiz 682-3. [PMID: 16077362 DOI: 10.1097/00006982-200507000-00015] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The effectiveness of highly active antiretroviral therapy (HAART) in restoring immune function in patients with acquired immunodeficiency syndrome (AIDS) has led to changes in the incidence, natural history, management, and sequelae of human immunodeficiency virus (HIV)-associated retinopathies, especially cytomegalovirus (CMV) retinitis. METHODS The medical literature pertaining to HIV-associated retinopathies was reviewed with special attention to the differences in incidence, management strategies, and complications of these conditions in the eras both before and after the widespread use of HAART. RESULTS In the pre-HAART era, CMV retinitis was the most common HIV-associated retinopathy, occurring in 20%-40% of patients. Median time to progression was 47 to 104 days, mean survival after diagnosis was 6 to 10 months, and indefinite intravenous maintenance therapy was mandatory. Retinal detachment occurred in 24%-50% of patients annually. Herpetic retinopathy and toxoplasmosis retinochoroiditis occurred in 1%-3% of patients and Pneumocystis carinii choroiditis, syphilitic retinitis, tuberculous choroiditis, cryptococcal choroiditis, and intraocular lymphoma occurred infrequently. In the HAART era the incidence of CMV retinitis has declined 80% and survival after diagnosis has increased to over 1 year. Immune recovery in patients on HAART has allowed safe discontinuation of maintenance therapy in patients with regressed CMV retinitis and other HIV-associated retinopathies. Immune recovery uveitis (IRU) is a HAART dependent inflammatory response that may occur in up to 63% of patients with regressed CMV retinitis and elevated CD4 counts and is associated with vision loss from epiretinal membrane, cataract, and cystoid macular edema. CONCLUSIONS The incidence, visual morbidity, and mortality of CMV retinitis and other HIV-associated retinopathies have decreased in the era of HAART and lifelong maintenance therapy may safely be discontinued in patients with restored immune function. Patients with regressed CMV retinitis, however, may still lose vision from epiretinal membrane, cystoid macular edema, and cataract secondary to IRU.
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Affiliation(s)
- Daniel E Goldberg
- Vitreous, Retina, Macula Consultants of New York, LuEsther T. Mertz Retinal Research Laboratory, Manhattan Eye, Ear and Throat Hospital, New York, New York 10022, USA.
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Ng WT, Versace P. Ocular association of HIV infection in the era of highly active antiretroviral therapy and the global perspective. Clin Exp Ophthalmol 2005; 33:317-29. [PMID: 15932540 DOI: 10.1111/j.1442-9071.2005.01001.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Ocular involvement is a common complication of HIV infection. Since the late 1990s, widespread use of highly active antiretroviral therapy (HAART) has altered the spectrum, and reduced the incidence of ocular involvement in developed countries. The incidence of the most common ocular opportunistic infection, cytomegalovirus retinitis, has decreased tremendously. However, immune recovery uveitis secondary to HAART has emerged as a frequent visually threatening condition. Early diagnosis and treatment with periocular steroids is helpful in minimizing visual loss. Clinicians should also be aware that certain antimicrobial agents used to treat opportunistic infections in HIV-positive patients are associated with potentially serious ocular side effects. In developing countries, where most of the world's 40 million HIV-positive patients live, the spectrum and incidence of ocular involvement differ from those in developed countries. The lack of HAART availability is among the many causes of these differences, which may include nutritional factors, basic medical care availability and the levels of exposure to different infectious agents. These factors add to the already challenging task of treating ocular complications and preventing blindness in HIV-positive patients in developing countries.
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Affiliation(s)
- Weng T Ng
- Department of Ophthalmology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
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Roels P. Ocular manifestations of AIDS: new considerations for patients using highly active anti-retroviral therapy (HAART). ACTA ACUST UNITED AC 2004; 75:624-8. [PMID: 15508863 DOI: 10.1016/s1529-1839(04)70209-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Highly active anti-retroviral therapy (HAART) effectively restores the immune system and lowers the viral load in patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Since widespread use of HAART drugs began in 1996, many AIDS patients are living longer and enjoying a higher quality of life. The incidence of AIDS-related ophthalmic infections, such as cytomegalovirus (CMV) retinitis, have declined sharply. AIDS patients with CMV are less likely to experience necrotizing retinitis and retinal detachment, once the major causes of vision loss. HAART and immune recovery is now considered the preferred treatment for CMV retinitis. The role of immune recovery vitritis (IRV), a new manifestation of CMV retinitis, is now understood. In patients with pre-existing CMV retinitis who begin HAART the manifestations of an active immune system are seen, as the body is now able to fight the CMV infection. Incidence of Kaposi's sarcoma has declined by an estimated 87% and molluscum contagiosum is seen less frequently in those using HAART. With the clinical picture of ocular AIDS changing, the role of optometry in the management of AIDS patients is also changing.
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Affiliation(s)
- Philip Roels
- Eye/VICTORS Clinic, VA Medical Center, Kansas City, Missouri 64128, USA.
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Kuo IC, Kempen JH, Dunn JP, Vogelsang G, Jabs DA. Clinical characteristics and outcomes of cytomegalovirus retinitis in persons without human immunodeficiency virus infection. Am J Ophthalmol 2004; 138:338-46. [PMID: 15364214 DOI: 10.1016/j.ajo.2004.04.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2004] [Accepted: 04/12/2004] [Indexed: 11/23/2022]
Abstract
PURPOSE To describe the characteristics and outcomes of patients with cytomegalovirus (CMV) retinitis in the absence of human immunodeficiency virus (HIV) infection. DESIGN Retrospective cohort study. METHODS Consecutive patients with CMV retinitis in the absence of HIV infection were identified at a university hospital. Demographic and clinical characteristics were noted at the time of CMV retinitis. Outcomes were determined retrospectively. Main outcome measures were rates of second eye involvement, vision loss, rhegmatogenous retinal detachment (RD), immune recovery uveitis, progression of retinitis, and mortality. RESULTS The clinical characteristics of CMV retinitis in 18 patients (30 eyes) without HIV infection diagnosed between January 1, 1984, and April 13, 2003, were similar to those of patients with HIV infection. The incidences of visual loss to the levels of 20/50 or worse and of 20/200 or worse were 17% per eye-year and 14% per eye-year, respectively. The observed incidence of RD was 3.7% per eye-year, and the mortality rate was 23% per person-year. Following reduction of immunosuppression, 10 patients (56%) who discontinued anti-CMV therapy remained free of retinitis progression. The incidence of immune recovery uveitis was 13% per person-year. CONCLUSIONS In our series, CMV retinitis in patients without HIV infection had a clinical course similar to that in patients with AIDS treated with highly active antiretroviral therapy (HAART), except the incidence of RD was lower for patients without AIDS. A substantial number of patients no longer required long-term anti-CMV therapy after adjustment of immunomodulatory therapy.
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Affiliation(s)
- Irene C Kuo
- Department of Ophthalmology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
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Meenken C, van Agtmael MA, Ten Kate RW, van den Horn GJ. Fulminant ocular leishmaniasis in an HIV-1-positive patient. AIDS 2004; 18:1485-6. [PMID: 15199333 DOI: 10.1097/01.aids.0000131348.83913.72] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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El-Bradey MH, Cheng L, Song MK, Torriani FJ, Freeman WR. LONG-TERM RESULTS OF TREATMENT OF MACULAR COMPLICATIONS IN EYES WITH IMMUNE RECOVERY UVEITIS USING A GRADED TREATMENT APPROACH. Retina 2004; 24:376-82. [PMID: 15187659 PMCID: PMC1378115 DOI: 10.1097/00006982-200406000-00007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the results of a graded treatment approach in a cohort of eyes with macular complications of immune recovery uveitis. METHODS A cohort of 18 eyes of 13 patients representing all eyes with these complications at the University of California, San Diego AIDS Ocular Treatment Unit was studied. Eyes were classified into three groups and treated according to a graded protocol. RESULTS Eyes with mild disease (macular edema and vision of 20/30 or better) were observed. These six eyes maintained good vision with only one dropping to 20/40. In eyes with worse macular edema and vision of 20/30 or worse (10 eyes of 9 patients), repository sub-Tenon steroid injections were used repeatedly. There were no complications of steroid use but visual improvement occurred in only 40% of eyes. Macular edema persisted. In eyes with structural macular changes, such as epiretinal membrane, vitrectomy resulted in vision improvement in three of four eyes. The cystoid macular edema persisted despite surgery. CONCLUSION Mild cases of immune recovery uveitis and macular edema may be observed. In eyes with reduction of vision due to cystoid macular edema, there was only a modest treatment effect using repository corticosteroids. Eyes with immune recovery uveitis that develop epiretinal membrane undergo some visual improvement after removal of the membrane. The macular edema of immune recovery uveitis is resistant to corticosteroid treatment.
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Reed JB, Briggs JW, McDonald JC, Freeman WR, Morse LS. Highly active antiretroviral therapy-associated regression of cytomegalovirus retinitis: long-Term results in a small case series. Retina 2002; 21:339-43. [PMID: 11508879 DOI: 10.1097/00006982-200108000-00007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To report the stability of acquired immunodeficiency syndrome (AIDS)-associated cytomegalovirus (CMV) retinitis lesions that have undergone regression in the absence of specific anti-CMV medications owing to highly active antiretroviral therapy (HAART)-generated immune recovery. METHODS The initial examination revealed HAART-associated regression of CMV retinitis lesions in eight subjects at two institutions. Patients were monitored for recurrences of CMV activity. CD4+ T-lymphocyte counts and human immunodeficiency virus (HIV) loads were measured. RESULTS All patients had positive initial responses to HAART with an average HIV load decrease of 2.26 log units (range 0.3-5.57). Mean CD4+ T-lymphocyte count at baseline was 45.6 (range 4-107) and increased by an average of 132.5 (range 7-266) within the first 2 to 4 months of HAART. Patients were observed for an average of 15.5 months (range 11-20 months). Six subjects had a vigorous and sustained response to therapy, achieving an average HIV load of 9,400 copies/mL (3.32 log10 decrease) and CD4+ T-lymphocyte count of 158.2 cells/microL. These patients had no CMV retinitis progression. By contrast, two others who attained an average log10 decrease of only 0.48 had modest and short-lived increases in the CD4+ T-lymphocyte count. These patients experienced reactivation of CMV retinitis after 5 and 7 months, respectively. CONCLUSIONS Regressed CMV retinitis may remain healed for long periods. However, failure of HAART to induce substantial decreases in HIV load may predict poor or unsustainable rises in the CD4+ T-lymphocyte count and presage recurrence of CMV retinitis. Vigilance in ophthalmic examinations is especially mandatory in these subjects.
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Affiliation(s)
- J B Reed
- Wilford Hall Medical Center, Lackland AFB, Texas 78236-5300, USA.
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Abstract
Ophthalmic abnormalities are common in HIV-infected patients. Serious ophthalmic diseases often result from opportunistic infections and can cause blindness in the absence of prompt diagnosis and therapy. We review recent advances in the diagnosis and management of HIV-associated ocular disease, including cytomegalovirus retinitis, the leading cause of vision loss in HIV-infected patients. The widespread use of highly active antiretroviral therapy (HAART) over the past 3 years has reduced the morbidity and mortality associated with HIV infection. HAART has dramatically altered the incidence and natural history of many opportunistic infections, and we discuss the impact of HAART on ophthalmic disease.
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Affiliation(s)
- M R Robinson
- National Institutes of Health, National Eye Institute, Bethesda, Maryland 20892-1863, USA.
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Ambati J, Wynne KB, Angerame MC, Robinson MR. Anterior uveitis associated with intravenous cidofovir use in patients with cytomegalovirus retinitis. Br J Ophthalmol 1999; 83:1153-8. [PMID: 10502577 PMCID: PMC1722828 DOI: 10.1136/bjo.83.10.1153] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM Intravenous cidofovir is used to treat cytomegalovirus (CMV) retinitis, and has been reported to cause anterior uveitis. Relations were sought between this complication and patient characteristics that might help predict its occurrence. METHODS 17 patients with AIDS and CMV retinitis who were treated with intravenous cidofovir were identified, and the following data collected in a retrospective chart review: demographic characteristics, duration of CMV retinitis, retinal lesion characteristics, dose and duration of cidofovir therapy, tests of renal function, CD4+ T lymphocyte counts, visual acuity, intraocular pressure, iris colour, history of diabetes mellitus, and use of concomitant medications. Case-control analyses were performed to determine risk factors for developing cidofovir associated uveitis. RESULTS Anterior uveitis characterised by pain, ciliary injection, and decreased visual acuity occurred in 10 patients (59%). Median interval to development of uveitis was 11 doses of cidofovir. Symptoms developed 4.4 (SD 2.5) days (median 3.5) after an infusion of cidofovir. Patients who developed uveitis had a significantly greater rise in CD4+ T lymphocyte count while receiving cidofovir (68.4 (75.7) x10(6)/l versus 5.0 (0.6) x10(6)/l, (p = 0.04)). By stepwise linear regression, this factor accounted for 33% (p = 0.03) of the effect of developing uveitis. Mean follow up time, intraocular pressure decline during cidofovir therapy, serum creatinine and urine protein concentrations, and rates of protease inhibitor use were not significantly different between patients who developed uveitis and those who did not. Uveitis responded to topical corticosteroids and cycloplegia. CONCLUSION Anterior uveitis in patients receiving intravenous cidofovir therapy may be related to improving immune function. The uveitis responds to treatment and may not preclude continuation of cidofovir.
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Affiliation(s)
- J Ambati
- Current address: Retina Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA
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