CMV retinitis: Difference between revisions
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==Background== | ==Background== | ||
*Most frequent and serious ocular | *Most frequent and serious ocular opportunistic infection | ||
*Leading cause of blindness in [[AIDS]] patients | |||
*Typically occurs with CD4 less than 50 | |||
==Clinical Features== | ==Clinical Features== | ||
* | [[File:Fundus photograph-CMV retinitis EDA07.jpg|thumb|Fundus photograph of CMV retinitis]] | ||
**Change in visual acuity | *Variable, but may include: | ||
**Visual field cuts | **Change in visual acuity, [[visual loss]] | ||
**[[visual field defects|Visual field cuts]] (Scotomas, loss of central vision) | |||
**[[Floaters]], flashing lights | |||
**Photophobia | **Photophobia | ||
** | *[[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== | |||
*[[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== | |||
*[[HIV - AIDS (Main)]] | |||
*[[Cytomegalovirus (CMV) infection]] | |||
==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:Ophthalmology]] | |||
Latest revision as of 17:18, 25 January 2023
Background
- Most frequent and serious ocular opportunistic infection
- Leading cause of blindness in AIDS patients
- Typically occurs with CD4 less than 50
Clinical Features
- Variable, but may include:
- Change in visual acuity, visual loss
- Visual field cuts (Scotomas, loss of central vision)
- Floaters, flashing lights
- Photophobia
- Fundoscopy:
- Fluffy white perivascular lesions
- Dirty white granular retinal necrosis
- Adjacent hemorrhage - "Pizza pie" appearance
Differential Diagnosis
Acute onset flashers and floaters
- Ocular causes
- Floaters and/or flashes
- Posterior vitreous detachment
- Retinal tear or retinal detachment
- Posterior uveitis
- Predominantly floaters
- Vitreous hemorrhage secondary to proliferative retinopathy
- Sympathetic ophthalmia
- Predominantly flashes
- Oculodigital stimulation
- Rapid eye movements
- Neovascular age-related macular degeneration
- Floaters and/or flashes
- Non-ocular causes
- Intraocular foreign body
- Migraine aura (classic)
- Migraine aura (acephalgicmigraine)
- Occipital lobe disorders
- Postural hypotension
HIV associated conditions
- HIV neurologic complications
- HIV pulmonary complications
- Ophthalmologic complications
- Other
- HAART medication side effects[1]
- HAART-induced lactic acidosis
- Neuropyschiatric effects
- Hepatic toxicity
- Renal toxicity
- Steven-Johnson's
- Cytopenias
- GI symptoms
- Endocrine abnormalities
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
- ↑ 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.