Retinal Physician

JAN-FEB 2017

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54 R E T I N A L P H Y S I C I A N . C O M | J A N U A R Y / F E B R U A R Y 2 0 1 7 CMV Retinitis: Evidence-based Treatment ALAA E. RADWAN, MD, FRCS OPHTH • ROWAYDA M. AMIN, MD, FICO, FRCS OPHTH C ytomegalovirus (CMV ) retinitis is a disease characterized by progressive, necrotizing reti- nitis that can lead to blindness in patients with immunocompromised states. 1,2 Similar to other herpes viruses, CMV remains latent sup- pressed by cell-mediated immunity, unless the patient suf- fers from a significant local (regional corticosteroid therapy) or systemic immunodeficiency. 2-8 It is the most common intraocular infection in patients with acquired immunode- ficiency syndrome (AIDS) and, as such, many of the treat- ment approaches emanate from studies on cohorts of adult patients with AIDS-associated CMV retinitis. 3,9,10 Non– AIDS-related CMV retinitis cases with pharmacologic immunosuppression and cases in some healthy individuals or those immunosuppressed by other means have also been reported. 11,12-14 CMV retinitis affects AIDS patients as a rela- tively late-stage manifestation when CD4+ cell counts are profoundly suppressed (eg <50 cells/µL). 1, 2 Prior to the introduction of HAART, patients often expe- rienced a catastrophic loss of vision due to CMV retinopathy and other intraocular infections. 1,2,15,16 e development of HAART in 1996 dramatically changed the incidence rates of CMV retinitis and its attendant complications. 17-19 e four- year cumulative incidence of CMV retinitis in AIDS patients with lowered CD4 counts was 7%, a 72% reduction in the post-HAART era as determined in 2012 by the Longitudinal Study of Ocular Complications of AIDS (LSOCA) study research groups. 19 Consequently, the focus of anti-CMV treatment has shifted from short-term disease control to long- term maintenance of vision and quality of life considerations 10 for patients on HAART. To date, management of CMV retinitis has been influ- enced by the fact that all available treatments are virostatic. 3 A histopathologic study on autopsy eyes demonstrated the presence of viral protein at the border of treated CMV lesions. With cessation of therapy, viral assembly apparently resumes and the retinal lesions start to enlarge. 20, 21 erefore, unless immune recovery occurs, chronic lifelong therapy may be required. Clinicians must determine when it is safe to dis- continue anti-CMV drug treatment in patients who achieve immune recovery and how to best schedule follow-up visits or treat a CMV relapse. Since 1989, prospective randomized trials have compared different treatment strategies for different disease presenta- tions, while others compared drugs for efficacy, long-term effects on visual functions, morbidity, and mortality rates. AIDS, SOCA, AND OCULAR COMPLICATIONS SOCA were collaborative, randomized, prospective clinical NEI-funded trials designed to evaluate treatment options and long-term trends of ocular complications of AIDS. e study arms were designed to test emerging treatments for effectiveness in CMV retinitis with the propensity for pre- serving vision without decreasing survival or quality of life. e first SOCA study, completed in 1991, compared foscarnet and ganciclovir in controlling CMV retinitis. 22 Between 1989 and 1998, five clinical trials were completed, Alaa Radwan, MD, FRCS Ophth, is a uveitis consultant ophthalmologist at the International Eye Clinic in Egypt and a former uveitis and ocular immunology fellow at Massachuses Eye Research and Surgery Institu- tion (MERSI). Rowayda Amin, MD, FICO, FRCS Ophth, is an assistant lecturer of ophthalmology and uveitis specialist at the Division of Ocu- lar Immunology and Uveitis at Alexandria University. Neither author reports any financial interests in any of the products mentioned in this article. Dr. Radwan can be reached via e-mail at alaa1313@gmail.com. 54 R E T I N A L P H Y S I C I A N | J A N U A R Y / F E B R U A R Y 2 0 1 7 Figure 1. Fundus photographs of the right eye of a 38-year-old female HIV patient with cytomegalovirus retinitis and extensive "frosted branch angiitis" with a CD4 count of 50 cells/uL. Figure 2. Two weeks aer repeated intravitreal injections of ganciclovir alone; the patient later developed retinal detach- ment. e other eye developed CMV retinitis 6 months later.

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