NEOVASCULAR COMPLICATIONS FROM CYTOMEGALOVIRUS NECROTIZING RETINOPATHY IN PATIENTS AFTER HAPLOIDENTICAL HEMATOPOIETIC STEM CELL TRANSPLANTATION

PURPOSE

To report the incidence and clinical features of neovascular complications from cytomegalovirus (CMV) necrotizing retinopathy in patients after haploidentical hematopoietic stem cell transplantation.

METHODS

Thirty-nine patients (58 eyes) of CMV necrotizing retinopathy after haploidentical hematopoietic stem cell transplantation in our institute between January 2018 and June 2020 were retrospectively reviewed, and cases that developed neovascular complications during follow-up were identified and described.

RESULTS

Two (2 eyes) cases that developed neovascular glaucoma from CMV necrotizing retinopathy were identified. Both of them manifested as granular peripheral retinitis, panretinal occlusive vasculitis, and some degree of intraocular inflammation, which were consistent with chronic retinal necrosis. Insidious progression of isolated immune-mediated occlusive vasculitis that could only be observed on fundus fluorescein angiography without active retinitis or intraocular inflammation was recognized to be the cause in one of two cases.

CONCLUSION

Neovascular glaucoma developed in 5.1%/cases and 3.4%/eyes complicated by CMV chronic retinal necrosis and vasculitis in patients after haploidentical hematopoietic stem cell transplantation, which warrants the needs for long-term follow-up. Immune-mediated CMV vasculitis could be an isolated manifestation in patients with a minimal immune deviation and may only be found on fundus fluorescein angiography, which emphasizes the importance of fundus fluorescein angiography on a regular basis during follow-up.

Treatment of cytomegalovirus retinitis with cytomegalovirus-specific T-lymphocyte infusion

Cytomegalovirus (CMV) retinitis is a potentially blinding infection that affects immunocompromised patients who are unable to generate a T-cell response against the organism. Infusion of CMV-specific leukocytes has been shown to be effective in patients with systemic CMV infection, especially those resistant to standard therapies. The authors report a case of a patient with CMV viremia with progressive retinitis in whom infusion of third-party donor-derived CMV pp65-specific T cells alone prompted resolution of CMV retinitis. This case suggests a potential role for CMV-specific leukocyte infusion in the treatment of CMV retinitis, especially in cases resistant or refractory to antiviral therapies.

[Retinal detachment in HIV-infected patients with cytomegalovirus retinitis]

The authors present their own clinical experience in three HIV-infected patients with cytomegalovirus retinitis aged from 8 to 36 years. Detailed analysis of the results of physical and laboratory examinations is provided. Given short life expectancy for these patients, the authors pose a deontological question as to whether or not active treatment of retinal detachment in patients with AIDS and CMV retinitis is reasonable.

[Clinical characteristic and treatment of cytomegalovirus retinitis in 80 patients with acquired immunodeficiency syndrome]

OBJECTIVE

To investigate the clinical characteristics of cytomegalovirus retinitis (CMVR) in acquired immunodeficiency syndrome (AIDS) patients.

METHODS

Retrospective case-series study. The clinical and laboratory data of 80 AIDS patients (118 eyes) with findings of CMVR were collected from Shanghai Public Health Clinical Center from December 2006 to December 2011. The relationship between CMVR and cellular immunity, the high risk factor, clinical characteristics, treatment and prognosis of CMVR were analyzed in this study. χ(2) test was used to check the incidence of CMVR in different CD4(+) T lymphocyte count groups.

RESULTS

There was 80 AIDS patients (118 eyes) totally, 71 males and 9 females. Their age was from 18 to 60 years old, which mean value was (38 ± 10) years old. The incidence in the group of CD4(+) T lymphocyte count over 100 cells/µl was lower than the two groups of CD4(+) T lymphocyte count less than 100 cells/µl (χ(2) = 15.567, 32.469; P = 0.00,0.00). CD4(+) T lymphocyte count was always ranged from 0 to 141 cells/µl in CMVR patients. It was less than 50 cells/µl in 81.3% cases. In 10.0% AIDS patients, CMVR was the first manifestation. In 25% AIDS patients(26 eyes), lesions in retina was found by routine eye examination. In 54.2% patients, the best corrected visual acuity was less than 0.3. Retinal necrosis was involvement near the posterior pole in 62.5% CMVR patients. The visual acuity of 51 eyes was improved after treatment within 94.1% cases which were treated within 3 months. However, BCVA of 35 eyes decreased or with less change within 42.9% cases which were treated after symptoms appeared 3 months. The anti-CMV treatment included induction and maintenance of ganciclovir or foscarnet stopped when the CD4(+)T lymphocyte count was more than 150 cells/µl in 3 continuous months. 86.9% eyes were cured clinically. Retinal detachment, immune reconstitution uveitis and complicated cataract was found in 13.1%, 12.1% and 20.5% cases respectively. Optic atrophy occurred in 6 eyes. The visual acuity of 28.9% eyes was 0.05 or less, 71.3% of that caused by retinal detachment, cataract and optic atrophy.

CONCLUSIONS

CD4(+) T lymphocyte count reduction is the risk factor for CMVR. HAART and anti-CMV therapy will cure the CMVR clinically.Routine eye examinations should be performed in all AIDS patients to get early diagnosis of CMVR or other opportunistic infections to avoid vision loss, especially in those CD4(+) T lymphocyte count lower than 100 cells/µl.

Causes of visual acuity loss among HIV-infected patients with cytomegalovirus retinitis in the era of highly active antiretroviral therapy in Chiang Mai University Hospital

OBJECTIVE

To quantify the frequencies of the common causes of visual acuity loss for HIV-infected patients with cytomegalovirus retinitis (CMVR) in the era of highly active antiretroviral therapy(HAART).

MATERIAL AND METHOD

The present prospective observational study comprised 113 patients (184 eyes) with newly diagnosed CMVR, from May 2008-March 2010. Each patient was followed-up every 3 months with medical history and ophthalmologic examination. Patients were divided as visual impairment and legal blindness.

RESULTS

The majority of the patients were native Thai (91%), while the rest was of hill tribe origin. 55% were females with age ranged between 14-57 years (average of 39). The main cause of HIV infection was heterosexual contact (90%), followed by homosexual contact (7%). It was found that 68% had CD4 T-cell count less than 50 cells/microl and that 46% had bilateral CMVR. Major causes of visual impairment were CMVR zone 2&3, CMVR zone 1 and cataract, respectively. Major causes of legal blindness were CMVR zone 2&3, CMVR zone 1 and retinal detachment, respectively Retinal detachment was a major risk factor in both groups. Even when surgery was successful, the visual acuity was not significantly improved, indicating a permanent loss of vision.

CONCLUSION

In the HAART era, immune recovery of HIV patients also helps restoring specific anti-CMVimmunity. HAART reduces occurrence of visual impairment to 0.10/eye-year (EY) and legal blindness to 0.15/EY, compared to the pre-HAART figures of 0.94-0.98/EY and 0.47-0.49/EY respectively. However, it did not completely eliminate the occurrence. CMVR and cataract remain the most common causes of visual acuity loss followed by retinitis-related retinal detachment, and optic nerve atrophy respectively.

Metastatic endophthalmitis

Endophthalmitis carries a poor visual prognosis for patients and can be a potentially blinding condition that may result in loss of the eye. Early diagnosis and prompt treatment are imperative to save the eye. Delay in diagnosis affects visual prognosis and therefore doctors should be aware of the presenting features of endophthalmitis. Urgent ophthalmic referral is advised as soon as a diagnosis is suspected.

A case of immune recovery vitritis induced by donor leukocyte infusion for the treatment of cytomegalovirus retinitis

Donor leukocyte infusion (DLI) has been successfully used for some life-threatening viral infections after stem cell transplantation (SCT). We describe here the first case of DLI treatment for cytomegalovirus (CMV) retinitis. A 49-year-old female patient with AML, M1 underwent SCT with a reduced-intensity conditioning regimen from HLA-haploidentical son. On day +140, the patient developed CMV retinitis of her left eye despite the continuing antiviral therapy. DLI at a dose of 1 x 10(5) CD3+ cells/kg was added to ganciclovir and foscarnet therapy. Eighteen days after the DLI, the funduscopic findings revealed improvement of the retinitis and the development of vitreous inflammation. Simultaneously, the number of CD4+ cells in the peripheral blood rapidly increased. Thus, we consider it likely that DLI induced a local immune response against CMV antigens, which resulted in the immune recovery vitritis. This case suggested the potentiality of DLI for the treatment of CMV retinitis.

Interleukin-2 immunotherapy and AIDS-related cytomegalovirus retinitis

Cytokines are small proteins produced by T lymphocytes that mediate immune responses. Those produced by the CD4+ Th1 subset induce cell-mediated immunity, whereas those produced by the CD4+ Th2 subset are more efficient at stimulating immunoglobulin production. The goal of cytokine immunotherapy is prevention or reduction of disease progression through stimulation of cell-mediated immunity (i.e., immune reconstitution) by administration of an exogenous Th1 cytokine such as interleukin-2 (IL-2). Cytokine immunotherapy has its origins in cancer immunobiology where IL-2 has been used successfully to manage several human cancers (metastatic melanoma, acute myelogenous leukemia, and metastatic renal cell carcinoma). More recent work has demonstrated cytokine immunotherapy to be effective at improving immune responses in patients with HIV-1 disease. To explore cytokine immunotherapy for sight-threatening AIDS-related human cytomegalovirus (HCMV) retinitis, we developed a mouse model of experimental murine cytomegalovirus (MCMV) retinitis that employs mice with MAIDS, a retrovirus-induced immunodeficiency syndrome. Systemic cytokine immunotherapy with IL-2, but not with interleukin-12 (IL-12), provides absolute protection against MAIDS-related MCMV retinitis by stimulation of the perforin-mediated pathway of cytotoxicity used by natural killer cells and cytotoxic CD8+ T cells to kill virus-infected cells. Our findings warrant additional studies on the use of cytokine immunotherapy for management of HCMV retinitis (and possibly other opportunistic infections) during HIV-1-induced immunodeficiency. We envision systemic cytokine immunotherapy as an altemative or adjunct to traditional antiviral chemotherapy for optimal management of AIDS-related HCMV retinitis.

A phase II, double-masked, randomized, placebo-controlled evaluation of a human monoclonal anti-Cytomegalovirus antibody (MSL-109) in combination with standard therapy versus standard therapy alone in the treatment of AIDS patients with Cytomegalovirus retinitis

ACTG 266 was designed as a randomized study to evaluate two doses of the human monoclonal antibody directed against CMV gH (MSL-109) versus placebo, each in combination with standard antiviral therapy for the treatment of newly diagnosed Cytomegalovirus (CMV) retinitis in AIDS patients. A total of 82 subjects were enrolled and received either placebo (n = 28), or MSL-109 at 15 mg (n = 26) or 60 mg (n = 28) every 2 weeks until disease progression was diagnosed. The primary endpoint, disease progression, was determined by masked reading of retinal photographs taken every 4 weeks read by a single investigator. The median time to progression was 8.0, 8.3, and 12.1 weeks in the placebo, MSL-109 15mg and MSL-109 60 mg cohorts, respectively (P = 0.087, placebo versus 60 mg cohort). There were 22 deaths during the study period (9, 9, and 4 in the placebo, MSL-109 15 mg and MSL-109 60 mg cohorts, respectively (P = 0.0058, placebo versus 60 mg cohort)). MSL-109 was well tolerated with no significant adverse events attributable to study medication. The unexplained survival advantage in the higher dose cohort was discordant with the findings of the parallel Studies of Ocular Complications of AIDS Research Group (SOCA)-Monoclonal Anti-CMV Retinitis Trial (MACRT), which was prematurely halted because of increased mortality in subjects treated with high-dose MSL-109, recognizing that A266 enrolled subjects with newly diagnosed, whereas the MACRT enrolled subjects with relapsed, CMV retinitis.

Retinal and choroidal biopsies are helpful in unclear uveitis of suspected infectious or malignant origin

OBJECTIVES

To assess the clinical value of retinal or choroidal biopsy in establishing a definitive diagnosis directing subsequent management and to assess the risk involved in such surgery.

DESIGN

Retrospective noncomparative interventional case series.

PARTICIPANTS

Thirteen patients with uveitis of suspected malignant or infectious origin. One patient had 2 consecutive biopsies on the same eye.

METHODS

A retrospective review of a 4-year period was undertaken of all those cases in which the biopsy was taken for diagnostic purposes at a single institution.

MAIN OUTCOME MEASURES

Ability of biopsy to establish a pathologic diagnosis and guide treatment and surgical complications.

RESULTS

A transscleral approach was used in 4 and a pars plana vitrectomy approach in 10 of the biopsies. The only operative complication was a retinal break in 1 case. Postoperative events that might be related to the surgery included 1 localized retinal detachment, 2 cataracts, and 1 phthisical eye. The pathologic diagnosis differed from the initial clinical diagnosis in 5 of the 13 cases. The biopsy result directed specific appropriate treatment in 7 of the 13 cases. In the 6 remaining cases, no specific diagnosis was confirmed, but the results of the biopsy were useful in excluding malignancy and in some cases allowing a therapeutic trial.

CONCLUSIONS

Retinal or choroidal biopsy is a valuable investigation that often changes clinical management when carried out for specific indications in patients with uveitis of suspected malignant or infectious origin. Although it is likely to remain an investigation of last resort, it should be considered at an earlier stage when there is diagnostic uncertainty if severe visual loss is to be prevented.

Interleukin-2 immunotherapy of murine cytomegalovirus retinitis during MAIDS correlates with increased intraocular CD8+ T-cell infiltration

AIDS-related human cytomegalovirus retinitis continues to be an important sight-threatening disease in AIDS patients who do not respond to highly active antiretroviral therapy. We have shown previously that systemic cytokine immunotherapy with interleukin-2 (IL-2) will protect against experimental murine cytomegalovirus (MCMV) in mice with a murine retrovirus-induced immunodeficiency syndrome (MAIDS). Since IL-2 serves as a Th1 immunoregulatory cytokine, we hypothesized that IL-2-induced protection against MCMV retinitis during MAIDS would correlate with a measurable increase in the number of natural killer (NK) cells and/or CD8+ T cells that infiltrate the eye in response to MCMV infection of the retina. We therefore performed a study to quantify and compare the number of NK cells and CD8+ T cells that infiltrate MCMV-infected eyes in untreated and IL-2-treated mice with MAIDS at 3 days and 5 days after subretinal MCMV inoculation. Double-label flow cytometric analysis revealed the detection of measurable numbers of both NK cells and CD8+ T cells in MCMV-infected eyes of untreated MAIDS mice destined to develop retinitis. In contrast, IL-2 immunotherapy during MAIDS correlated with a 10-fold increase by day 5 after inoculation in the number of CD8+ T cells in MCMV-infected eyes destined to be resistant to retinitis. However, IL-2 immunotherapy during MAIDS had no appreciable effect on the number of NK cells that infiltrated MCMV-infected eyes. Taken together, our findings suggest that function of cytotoxic lymphocytes that infiltrate the eye may be more important than absolute numbers of cytotoxic lymphocytes that infiltrate the eye when assessing the protective effects of IL-2 immunotherapy on MCMV retinitis during MAIDS.

[Progress in the studies on cytomegalovirus retinitis]

Cytomegalovirus retinitis (CMVR) is the commonest opportunistic ocular infection in patients with human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS), typically occurs when CD4+ T cell counts fall below 50/mm3. CMVR accounts for the majority of the vision loss associated with HIV-related eye diseases. However progress in the studies on CMVR, including the prevalence, clinical features, differential diagnosis and recent advances in the management of CMVR is reviewed.

Cytomegalovirus

Cytomegalovirus (CMV) is a prevalent viral pathogen. The majority of persons with acute CMV will experience an inapparent infection. Primary CMV infection will cause up to 7 percent of cases of mononucleosis syndrome and will manifest symptoms almost indistinguishable from those of Epstein-Barr virus-induced mononucleosis. CMV, or heterophil-negative mononucleosis, is best diagnosed using a positive IgM serology. Complications of acute CMV infection in immunocompetent persons are rare, except in newborns. The virus usually is spread through close personal contact; transmission risk can be reduced by following simple hygienic and handwashing techniques. Severe illness can occur after reactivation of the latent virus in immunosuppressed persons. The retina is the most common site of CMV-induced pathology in persons with human immunodeficiency virus infection. Advances in the treatment of human immunodeficiency virus infection with highly active antiretroviral therapy (HAART) have decreased the incidence of CMV retinitis but have resulted in a new set of ophthalmologic complications induced by restoration of immune competency and the pro-inflammatory response of the patient to CMV. If HAART restores the patient's CD4 cell count to above 100 to 150 per mm3 (100 to 150 x 10(6) per L), it may preclude lifelong treatment for CMV retinitis.

Data and safety monitoring board deliberations resulting in the early termination of the Monoclonal Antibody Cytomegalovirus Retinitis Trial

We report on two features of the early termination of the studies of ocular complications of AIDS monoclonal antibody cytomegalovirus retinitis trial: one related to the deliberative process of the treatment effects monitoring body (the policy and data monitoring board [PDMB]) and the other related to the relationships among the PDMB, the investigators, and the joint sponsors (the National Institutes of Health and a pharmaceutical company). The PDMB was challenged with reconciling internally inconsistent safety and mortality data and determining the weight to give mortality data from other concurrently running trials. The coordinating center faced a challenge in negotiating how to communicate results from a jointly sponsored trial. Early resolution of certain organizational and procedural issues, such as rules regarding absentee voting, to which body the monitoring committee should report officially, and the timing and general content of dissemination of different kinds of results, would make jointly sponsored trials more robust to difficulties at the final hour.

Clinical profile and immunological status of cytomegalovirus retinitis in organ transplant recipients

PURPOSE

Cytomegalovirus retinitis (CMV) is the most common ocular opportunistic infection in transplant recipients. This retrospective study attempts to report the differences in occurrence of cytomegalovirus retinetis in transplant recipients from those reported in patients with acquired immunodeficiency syndrome (AIDS).

METHODS

25 eyes of 15 transplant recipients (14 renal and one cardiac) with cytomegalovirus retinitis were retrospectively reviewed. Immunological profile included CD4+ and CD8+ T lymphocyte counts, CD4+/CD8+ cell ratio (5 cases) and serology for the viral antibodies (8 cases).

RESULTS

A predominantly bilateral presentation (60%) was noted. Active cytomegalovirus retinitis (72%) in zone 2 (92%) of the inferotemporal quadrant (68%) was noted. The average cell counts were within normal limits (mean CD4 cell count-711/microliter), unlike in late stages of AIDS with cytomegalovirus retinitis (CD4 count < 50/microliter). Serology revealed an IgM positivity of 53%. Retinal detachment (52%) was the most common complication occurring after an average of 5.4 months.

CONCLUSION

CMV retinitis in organ transplant recipients appears to differ from that in AIDS patients. CMV retinitis presents early and has different immunological profile, probably owing to differences in pathogenesis.

HIV and cytomegalovirus viral load and clinical outcomes in AIDS and cytomegalovirus retinitis patients: Monoclonal Antibody Cytomegalovirus Retinitis Trial

OBJECTIVE

To determine the association of cytomegalovirus (CMV) viremia with mortality and CMV retinitis progression in newly diagnosed and relapsed CMV retinitis.

DESIGN

Ancillary study of a randomized, placebo-controlled, phase III clinical trial.

PATIENTS

A total of 83 patients with AIDS and CMV retinitis, enrolled during the first phase of the Monoclonal Antibody Cytomegalovirus Retinitis Trial, were administered MSL-109 or placebo as adjuvant therapy for CMV retinitis.

MAIN OUTCOME MEASURE(S)

Mortality and CMV retinitis progression.

RESULTS

Treatment with MSL-109 did not predict either progression of CMV retinitis or mortality. Detection in plasma CMV DNA at baseline predicted mortality, but CMV antigenemia did not. CMV DNA was a better predictor of mortality than a high HIV viral load. Neither CMV DNA nor antigenemia predicted the progression of CMV retinitis. Among newly diagnosed patients, there was a decline in the proportion with detectable CMV viral load and CMV antigenemia in response to anti-CMV therapy. However, there was a rebound in CMV viral load to 25% and CMV antigenemia to 54.6% at 6 months. In relapsed patients, anti-CMV therapy was not associated with a change in the percentage with detectable CMV-DNA or CMV antigenemia over time.

CONCLUSION

In patients with AIDS and CMV retinitis, the detection of plasma CMV DNA was associated with a higher risk of mortality than was a high HIV viral load. Anti-CMV therapy provided a transient reduction in CMV viremia in newly diagnosed but not relapsed patients with CMV retinitis. Adjuvant therapy with MSL-109 was ineffective in clearing CMV-DNA and CMV antigen from the plasma.

Foscarnet therapy for ganciclovir-resistant cytomegalovirus retinitis after stem cell transplantation: effective monitoring of CMV infection by quantitative analysis of CMV mRNA

We report three pediatric patients with ganciclovir-resistant cytomegalovirus (CMV) retinitis who were successfully treated with foscarnet. The patients were recipients of hematopoietic stem cell transplantation (SCT) from HLA-mismatched donors. Because these patients had developed or experienced progressive CMV retinitis during ganciclovir therapy, they received foscarnet therapy at 60 mg/kg every 8 h. Their retinitis resolved promptly after initiating foscarnet therapy, suggesting foscarnet's effectiveness in treating ganciclovir-resistant CMV infection. The amount of CMV mRNA was quantitatively measured using an NASBA technique, which amplified the beta2.7 transcripts specific for CMV replication. This technique was useful for monitoring disease activity in a more rapid and sensitive manner than the PCR assay for CMV DNA.

Ophthalmic manifestations of HIV: an update

A variety of ocular disease processes have been identified in HIV-antibody positive persons, especially in people with AIDS. The most common sight-threatening disease in this population is cytomegalovirus (CMV) retinitis. Effective therapies are available to treat CMV retinitis. However, such therapies carry potentially challenging toxicities. Highly active antiretroviral therapy (HAART) has improved immune system functioning in many of its adherents, decreasing the incidence and improving the clinical course of CMV retinitis. However, a recent phenomenon associated with HAART, immune recovery uveitis (IRU), has been noted with additional, often problematic ocular manifestations in many persons with CMV retinitis. Periodic ophthalmic examination is prudent for all persons with HIV and especially for people with AIDS.

[Herpetic retinal necrosis]

Update on herpetic retinal necrosis, including cytomegalovirus retinitis.

[Ocular damage during HIV infection at the University Hospital Center of Casablanca. (Apropos of 400 cases)]

The objective of this study was to report ocular manifestations in Moroccan patients infected with HIV/AIDS. 400 patients were surveyed retrospectively from 1993 to 1998 as part of a co-operative study undertaken by the departments of infectious diseases and ophtalmology of the Casablanca Teaching Hospital. Of the 400 patients, 127 had an infection of the posterior segment and 7 showed signs of a palpebral infection. We also found 44 cases of opportunist retinal infections, dominated by the Cytomegalovirus (CMV) (18 cases). Our sample study indicates an intermediary position between western countries where the widespread use of the tritherapy has increased the life expectancy of patients and sub-Saharan Africa where epidemiological data are still characterised by high mortality and increasing endemic disease.

[CMV retinitis--"the lightning that announces a storm"]

After a theoretic presentation, the authors show the results of a study on 11 patients with cytomegalovirus retinitis. We observed the slowing of the evolution of the retinal lesions. Of 11 patients, 8 comes the first time to the physician for ocular symptoms. The CMV retinitis may predict the presence of HIV infection.

MR imaging of intraventricular silicone: case report

A 42-year-old man with human immunodeficiency viral infection developed cytomegaloviral retinitis that was complicated by retinal detachment and was treated with an intravitreous injection of silicone. Fifteen months later, magnetic resonance imaging revealed intraocular and intraventricular silicone. Signal intensity characteristics and chemical shifts of silicone in the two locations were identical.

[Features of the course and treatment of several eye diseases in Eastern Africa]

Ophthalmologist with a 4-year history (1993-1997) of practice at the Russian Red Cross Hospital in Addis Ababa (Ethiopia) shares his experience. More than 30,000 patients were examined and treated. Interesting cases are described: cytomegalovirus retinitis in the presence of AIDS, AIDS-associated involvement of the eyes (uveitis, keratitis, Kaposi's sarcoma), herpes zoster involvement of the eyes, phlyctenar keratoconjunctivitis, vernal conjunctivitis, trachoma, diseases of the eyes concomitant with syphilis, a case with Vogt-Koyanagi-Harada. Clinical course and therapy of these diseases under local conditions are described.

[Cytomegalovirus retinitis in patients with human immunodeficiency virus infection]

Cytomegalovirus retinitis (CMVR) is a common opportunistic infection and a major cause of blindness in patients with AIDS. The aim of this study was to determine the frequency, clinical course and outcome of CMVR in patients treated at the University Hospital of Infectious Diseases "Dr. Fran Mihaljević" in Zagreb in the period from January 1995 to April 1996. CMVR was diagnosed in 8 (27.5%) of 29 patients with AIDS. The median CD4 lymphocyte count in patients with CMVR was 44 per mm3, six patients had less than 50 per mm3. Five patients died during the study period, the mean survival being 5.5 months. CMVR was present in both eyes in 5 (62.5%) patients at the time of diagnosis. Blindness in both eyes developed in 3 (37.5%) patients. In order to recognize and promptly treat CMVR frequent ophthalmologic examinations should be performed in patients with advanced HIV disease.

MSL-109 adjuvant therapy for cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome: the Monoclonal Antibody Cytomegalovirus Retinitis Trial. The Studies of Ocular Complications of AIDS Research Group. AIDS Clinical Trials Group

OBJECTIVE

To evaluate the efficacy and safety of an intravenous human monoclonal antibody to cytomegalovirus (CMV), MSL-109, as adjuvant treatment for CMV retinitis.

METHODS

Two hundred nine patients with acquired immunodeficiency syndrome and active CMV retinitis were enrolled in a multicenter, phase 2/3, randomized, placebo-controlled clinical trial. Patients received adjuvant treatment with MSL-109, 60 mg intravenously every 2 weeks, or placebo. Randomization was stratified on the basis of whether patients had untreated or relapsed retinitis. Primary drug therapy for CMV retinitis was determined by the treating physician.

RESULTS

The rates of retinitis progression, as evaluated in a masked fashion, were 3.04/person-year in the MSL-109-treated group and 3.05/person-year in the placebo-treated group (P=.98; Wald test); the median times to progression were 67 days in the MSL-109-treated group and 65 days in the placebo-treated group. No differences between the 2 groups were noted in the rates of increase in retinal area involved by CMV, visual field loss, or visual acuity outcomes. The mortality rate in the MSL-109-treated group was 0.68/person-year, and in the placebo-treated group, 0.31/person-year (P=.01). The mortality difference was not explained by differences in baseline variables or in concurrent antiretroviral therapy. Among patients with newly diagnosed retinitis, mortality rates were similar (MSL-109, 0.41/person-year; placebo, 0.42/person-year; P=.95), whereas among patients with relapsed retinitis the MSL-109-treated group had a greater mortality rate (MSL-109, 0.83/person-year; placebo, 0.24/person-year; P=.003). However, the mortality rate in the placebo-treated patients with relapsed CMV retinitis was lower than that in the placebo-treated patients with newly diagnosed CMV retinitis and lower than that in other trials of patients with relapsed CMV retinitis.

CONCLUSIONS

Intravenous MSL-109, 60 mg every 2 weeks, appeared to be ineffective adjuvant therapy for CMV retinitis. The mortality rate was higher in the MSL-109-treated group, but the reasons for this difference remain uncertain.

German health economic cost evaluation on oral ganciclovir in treating cytomegalovirus retinitis

The purpose of this study was to discuss the cost of oral ganciclovir in comparison with its intravenous formulation in treating CMV retinitis. A cost-cost evaluation was carried out to compare the costs of oral and intravenous treatment with ganciclovir. Costs were calculated by employing the usual prices charged to sickness funds (German social health insurers). The costs of induction and maintenance therapy depend on the period of time the therapy takes, the site of administration (e.g. hospital, physician's office, patient's home) and the charges for the services. Different treatment scenarios were created in order to calculate the costs of the treatment alternatives and in a sensitivity analysis the robustness of the results was tested. Different probabilities for adverse effects were used. The study results showed that total costs of treating CMV retinitis with oral ganciclovir were substantially lower than the costs of intravenous treatment.

[Retinal manifestations of AIDS]

Cytomegalovirus (CMV) retinitis is the most common retinal opportunistic infection in AIDS patients and is the main cause of blindness. It is generally associated with a CD4+ lymphocyte count below 50/microL. CMV retinitis is often asymptomatic (54% of the cases), frequent ophtalmoscopic screening is very important. Two virostatic drugs (Cymevan and Foscavir) have been approved for the treatment of CMV retinitis. Both are effective in preventing the progression of the lesion within 3 weeks of induction therapy. Long-term use of virostatic maintenance therapy delays the onset of relapses. The differential diagnosis of CMV retinitis are: human immunodeficiency virus retinopathy, varicella-zoster virus retinitis, ocular toxoplasmosis, syphilis, candida endophthalmitis in intravenous drug users, and unfrequently, tuberculosis, choroidal pneumocystosis, intraocular lymphoma.

The eye in AIDS

The most common ocular problem arising in patients with acquired immunodeficiency syndrome (AIDS) is opportunistic infection of the retina by cytomegalovirus. There are, however, other causes of retinitis and unusual ocular diseases associated with AIDS, the diagnosis and management of which are reviewed in this article.

Retinal vascular nonperfusion and retinal neovascularization as a consequence of cytomegalovirus retinitis and cryptococcal choroiditis

BACKGROUND

Cytomegalovirus retinitis and cryptococcal choroiditis are opportunistic infections in patients with acquired immune deficiency syndrome. These infections are associated with a retinal vasculitis and vascular attenuation.

METHODS

We present a case of retinal vascular nonperfusion and retinal neovascularization in a patient with acquired immune deficiency syndrome.

RESULTS

Retinal vascular nonperfusion and retinal neovascularization were confirmed by fluorescein angiography.

CONCLUSIONS

This is the first reported case of retinal neovascularization in a patient with acquired immune deficiency syndrome, ocular cytomegalovirus retinitis, and cryptococcal infection.

[AIDS: infections of the retina and choroid]

Various viral, bacterial, parasitic and fungal agents have been found to cause infections of retina and choroidea in HIV-infected patients. Usually these infections are opportunistic infections caused by the profound immunodeficiency, which is a result of the decay of lymphocytes by HIV. Before the HIV epidemic only rare cases of cytomegalovirus (CMV) retinitis were known in the literature. Now CMV retinitis has become the most common infection of the eye in AIDS patients. Ocular toxoplasmosis in HIV-infected patients can have a severe clinical appearance without treatment. Spontaneous recovery, as it usually occurs in otherwise healthy patients, does not take place in HIV-infected patients, so that a lifelong maintenance therapy is mandatory. Pneumocystis carinii chorioiditis was unknown before the HIV epidemic. In 1987 Pneumocystis carinii were found in the choroidea and two years later the clinical appearance could be described. Infections of choroidea and retina associated with AIDS may not be seen as isolated diseases. Commonly other organs are infected by the same or another organism. In case of AIDS-associated eye infections other organs should be checked for opportunistic disease. Diagnosis can be difficult. Because most of all intraocular infections associated with AIDS are CMV retinitis, an effective therapy can be initiated in most cases and in the follow-up a diagnosis can finally be made. Serological testing may be inconclusive because of occasional false-negative findings. Treatment often only suppresses the infections and so ongoing maintenance therapy may be necessary, as in the cases of CMV retinitis and Toxoplasma retinochorioiditis. A variety of different diseases, which can be treated by a multitude of different substances with a lot of adverse effects and contraindications, can complicate the therapeutic modalities used for the management of each individual disorder. Additionally HIV-infected patients suffer from at least two or three different diseases and must be treated lifelong with plenty of substances, which often are given with higher doses than usual. Only by cooperation of HIV-experienced doctors of different specialities in hospitals and offices the complex subject of HIV infection can be managed.

[Retinitis due to cytomegalovirus in AIDS]

Clinical course of 4 AIDS patients suffering from CMV retinitis is presented. Two patients were treated with ganciclovir, one died before starting the treatment and one was vitrectomized with silicone oil injection. Of the two patients treated with ganciclovir one improved significantly when the other continued to deteriorate and died after 8 months of follow-up. Early diagnosis and treatment of patients with zone I involvement gives the best chances for improvement. Mean life expectancy in aids patients after diagnosis of CMV retinitis is 7-10 months.

Branch retinal artery occlusion (BRAO) combined with branch retinal vein occlusion (BRVO) and optic disc neovascularization associated with HIV and CMV retinitis

Two vaso-occlusive events, branch retinal artery occlusion (BRAO) and branch retinal vein occlusion (BRVO), were observed in the retina of an HIV-infected patient with cytomegalovirus (CMV) retinitis who developed neovascularization of the disc (NVD). Although BRVO and reversible NVD have been reported in association with CMV retinitis, we have seen no reports of concomitant BRAO. CMV damages endothelial cells and causes an occlusive vasculitis. In HIV-infected individuals, damaged endothelial cells and rheologic problems result in increased blood viscosity. HIV infection has also been associated systemically with elevated levels of cytokines, including tumor necrosis factor alpha (TNF-alpha). In vitro, TNF-alpha exerts effects that decrease fibrinolytic potential; this activity in the circulation of a patient with AIDS may lead to vascular occlusive events. In the patient reported here, the retinal changes were not reversed by induction therapy with ganciclovir and the NVD did not regress.

Cytomegalovirus

CMV is a common opportunistic pathogen in patients with AIDS and is a major source of morbidity in this population. CMV has been unequivocally implicated as a cause of increased mortality in immunosuppressed patients who do not have AIDS. Whether CMV directly causes higher mortality in the AIDS population, however, remains controversial. This review focuses on the major clinical syndromes caused by CMV infection. Studies are ongoing with regard to optimal dosing schedules using combination antiviral regimens. In addition, new drugs and vaccines are being investigated in an effort to better control, if not eliminate, CMV infection in AIDS patients.