CMV retinitis: Difference between revisions

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==Background==
==Background==
*Most frequent and serious ocular OI
*Most frequent and serious ocular opportunistic infection
*Leading cause of blindness in AIDS pts
*Leading cause of blindness in [[AIDS]] patients
*Typically occurs with CD4 less than 50
*Typically occurs with CD4 less than 50


==Diagnosis==
[[File:Fundus photograph-CMV retinitis EDA07.jpg|thumb|Fundus photograph of CMV retinitis]]
*Signs/symptoms are variable; may include:
 
**Change in visual acuity
==Clinical Features==
**Visual field cuts (Scotomas, loss of central vision)
*Variable, but may include:
**Floaters, flashing lights
**Change in visual acuity, [[visual loss]]
**[[visual field defects|Visual field cuts]] (Scotomas, loss of central vision)
**[[Floaters]], flashing lights
**Photophobia
**Photophobia
**Eye redness/pain
*[[Fundoscopy]]:
**Fluffy white perivascular lesions
**Dirty white granular retinal necrosis
**Adjacent hemorrhage - "Pizza pie" appearance
 
**[[Eye pain]]/[[red eye|redness]]
 
==Differential Diagnosis==
{{Acute onset flashers and floaters DDX}}
 
{{HIV associated conditions}}
 
==Evaluation==
*CD4 typically < 50 cells/mm³
 
==Management==
===Antivirals===
{{CMV retinitis treatment}}


==Complications==
==Complications==
*Retinal detachment
*[[Retinal detachment]]
*Complete Vision loss
*Complete [[vision loss]]
**Despite treatment, 10% lose vision
*CMV Immune Recovery Uveitis (IRU)
*CMV Immune Recovery Uveitis (IRU)
**Patients with retinitis who develop blurry vision after starting HART need ophtho eval to assess for CMV progression, relapse, or IRU
**Patients with retinitis who develop blurry vision after starting HAART need ophtho eval to assess for CMV progression, relapse, or IRU
**Possible cause -  T-cell mediated immune reconstitution to latent CMV intraocular antigens
**Possible cause -  T-cell mediated immune reconstitution to latent CMV intraocular antigens
**Symptoms - Floaters, photophobia, blurred vision
**Symptoms - Floaters, photophobia, blurred vision
**Occurs median 20 weeks after starting HART
**Occurs median 20 weeks after starting HAART
**Urgent ophtho eval
**Urgent ophtho eval


==Treatment==
==Disposition==
*Ganciclovir implant and ganciclovir 1–1.5gm PO TID


==See Also==
==See Also==
*[[HIV - AIDS (Main)]]
*[[HIV - AIDS (Main)]]
*[[HIV (Overview)]]
*[[Cytomegalovirus (CMV) infection]]
 
==Source==
Tintinalli


==References==
<References/>
*Rothmans RE, Marco CA, Yang S. Human immunodeficiency virus infection and acquired immunodeficiency syndrome, in Tintinalli JE, Stapczynski JS, Ma OJ, et al (eds): Tintinalli’s Emergency Medicine, ed 7. New York, The McGraw-Hill Companies Inc., 2011.
[[Category:ID]]
[[Category:ID]]
[[Category:Ophtho]]
[[Category:Ophthalmology]]

Revision as of 21:46, 6 October 2019

Background

  • Most frequent and serious ocular opportunistic infection
  • Leading cause of blindness in AIDS patients
  • Typically occurs with CD4 less than 50
Fundus photograph of CMV retinitis

Clinical Features

  • Variable, but may include:
  • Fundoscopy:
    • Fluffy white perivascular lesions
    • Dirty white granular retinal necrosis
    • Adjacent hemorrhage - "Pizza pie" appearance

Differential Diagnosis

Acute onset flashers and floaters

HIV associated conditions

Evaluation

  • CD4 typically < 50 cells/mm³

Management

Antivirals

Severe Vision Threatening

  • Ganciclovir intraocular implant for 8 months AND
    • Valganciclovir 900mg PO q12hrs x 14 days FOLLOWED BY 900mg PO q24hrs x 7 days

Peripheral lesions

  • Valganciclovir 900mg PO q12hrs x 21 days FOLLOWED BY 900mg PO q24hrs x 7 days

Complications

  • Retinal detachment
  • Complete vision loss
    • Despite treatment, 10% lose vision
  • CMV Immune Recovery Uveitis (IRU)
    • Patients with retinitis who develop blurry vision after starting HAART need ophtho eval to assess for CMV progression, relapse, or IRU
    • Possible cause - T-cell mediated immune reconstitution to latent CMV intraocular antigens
    • Symptoms - Floaters, photophobia, blurred vision
    • Occurs median 20 weeks after starting HAART
    • Urgent ophtho eval

Disposition

See Also

References

  1. Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.
  • Rothmans RE, Marco CA, Yang S. Human immunodeficiency virus infection and acquired immunodeficiency syndrome, in Tintinalli JE, Stapczynski JS, Ma OJ, et al (eds): Tintinalli’s Emergency Medicine, ed 7. New York, The McGraw-Hill Companies Inc., 2011.