CMV Retinitis
Necrotizing full thickness retinitis due to CMV, most common in HIV patients with CD4 count <50
Other causes- leukemia, lymphoma, on immunosuppressants, organ
transplant recipients
Pathogenesis:
CMV reaches the retina hematogenously and infects the vascular endothelium & spreads to retinal cells
Symptoms:
Asymptomatic, photopsia, visual loss, floaters, scotomas
Signs:
AC & vitreous reaction minimal
Irregular border of solitary yellow white active retinitis, small white satellite lesions
Centrifugal spread with central clearing
Prominent vasculitis resulting in ischemia and hemorrhages- Pizza pie/cottage cheese & ketchup appearance
Brushfire pattern of spread along vessels -Frosted branch appearance-
active border advances by 25-300 um/wk
ON involvement- concurrent CNS infection
RRD -1/3 patients when >25% of retina is involved
Types:
Fulminant-hemorrhagic necrosis on white/yellow cloudy retinal lesions, centered around vasculature
Granular-retinal periphery, with minimal necrosis/hemorrhage/vascular sheathing
Perivascular- Frosted branch angitis- white lesions around vessels
Zones:
1- 1DD (1500um) around disc & 2DD (3000um) around fovea:immediately sight threatening
2- Anterior to zone 1 & posterior to vortex vein ampullae
3- Peripheral to Zone 2
Visual loss:
Macula/ON involvement
Immune recovery uveitis-Rejuvenated immune response against residual viral antigen following immune constitution with HAART
Signs: Vitritis, Optic disc edema, CME, ERM, Cataract, Anterior uveitis etc.
RD
Diagnosis:
Clinical
PCR -aqueous/vitreous
DD: HIV Retinopathy, ARN, Toxo, Syphilis, TB, Behçet’s
CWS: Lesions condense, fade & disappear over 4-6 wks
CMV Retinitis: Lesions advance, at about 1/2DD in 2-3 wks
Rx:
HAART in AIDS patients
IV ganciclovir 5-7 mg/kg/day in 2 divided doses for 2 weeks -induction dose
Maintenance dose -OD till complete resolution of lesions & improvement of immune status
Oral valganciclovir 900mg BD as induction dose for 21 days, 900mg OD as maintenance dose
Other options: IV foscarnet/cidofovir, Intraocular ganciclovir device, Intravitreal ganciclovir, Oral leflunomide
www.ophthalmobytes.com
Image from Rajan Eye Care Hospital