Case 8

Cytomegalovirus retinitis (CMVR) is a slowly progressive necrotizing retinitis which will eventually lead to blindness without treatment. It occurs in 30 to 50 percent of AIDS patients and is associated with low CD4 counts (less than 50)--a late-stage manifestation. CMVR is the most common ocular opportunistic infection and is the major cause of morbidity and mortality.

Symptoms

• Floaters and flashes
• Progressive peripheral scotoma
• Blurred vision
• Decreased acuity
• One eye affected more than the other
• Redness
• Pain?

Eye findings

• Binocular presentation in 50%
• Perivascular, yellow-white, full-thickness, retinal, granular infiltrate associated with retinal hemorrhage which progresses leaving thin, atrophic retina behind
• "Pizza fundus"
  Posterior pole--65% or peripheral--35% retinal lesions
  • Hemorrhagic/fulminant
  • Granular/indolent type
• Usually mild vitritis and AC reaction
• Absolute field loss
• Reduced acuity from retinal and optic nerve involvement
• May resemble cotton wool spots
• At least 25% of patients will develop retinal detachments
  

  Higher risk with larger and peripheral lesions Vitrectomy with silicone oil tamponade

  Retinal detachment

Treatment options

• IV ganciclovir
• IV foscarnet
• IV ganciclovir + oral ganciclovir
• IV cidofovir
• Intravitreal injections
• Ganciclovir intraocular implant
  

  Ganciclovir intraocular implant

New treatment options Valganciclovir (Valcyte) a prodrug of ganciclovir 450mg, 2 tabs daily shown to be as effective as IV ganciclovir for induction therapy Ganciclovir implant + valganciclovir Prior trials prove that when oral ganciclovir is added to ganciclovir implant, the therapeutic effect increases substantially. Previously had to take 18 pills a day, but with valganciclovir, can achieve the same levels with 2 tabs of 450mg daily.

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