Grand Ward Round

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Grand Ward Round

• Tan Tock Seng Hospital
• The Eye Institute
• 05/07/07

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History

• 66 year old Indian Female
• Past medical hx
• SLE dx 2000
• - f/u TTSH RAI.
• - Had recent IV cyclophosphamide 800mg x 6 doses
  last 6 months.
• - Also on oral prednisolone previously on 30 mg
  bd, reduced to 40 mg om in feb 07 in view of
  CMV gastritis.
• Type II diabetes on OHGA
• Hypertension
• Hyperlipidaemia

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History

• Was seen in eye clinic for on 22/06/07 for
  follow-up on
• Left BRVO s/p sectoral laser in NUH 3-4 yrs ago
• 2) SLE not on plaquenil, on steroids
• Right Phaco/IOL in Mar 06
• Left macular scar

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Examination

• Visual acuity
• Right eye 6/12
• Left eye CF 1 feet.
• GAT
• Anterior segment examination
• Right eye PCIOL, cornea clear, AC deep quiet,
  retrolental vitreal cells
• Left eye NS 2, AC and retrolental quiet

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Differential diagnosis

• Posterior uveitis ? Cause
• - CMV retinitis
• - toxoplasmosis/ TB/ sarcoidosis/ syphilis
• Acute retinal necrosis
• SLE related retinal occlusive vasculopathy
• Masquerade syndromes

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Retinal Vasculitis

• Periphlebitis
• Sarcoidosis
• Syphilis
• Pars planitis
• Sickle cell retinopathy
• Behcet disease

• Arteritis
• Giant cell arteritis
• Polyarthritis nodosum
• SLE
• ARN
• Behcet disease

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Investigation

• Full blood counts, renal panel, liver function
  tests normal
• ESR 52
• CD4/ CD8 Panel
• - CD 4 count 22 (25-50)
• - CD4/ CD8 Ratio 0.46 (0.50 2.50)
• Vitreous tap for TB negative, for tetraplex
  unfortunately insufficient specimen.

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Treatment

• Working diagnosis at this point in times likely
  CMV retinitis
• Treatment
• Retinal laser barrier to right eye on day of
  admission.
• Intravitreal Ganciclovir 2mg/0.04 ml was given
  post vitreous tap.
• Sytemic IV ganciclovir 350mg bd
• G. PF Q1H RE
• G homatropine 2 bd RE

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Post Barrier Laser treatement
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Progress

• Referred to RAI
• - suggest reduce prednisolone to 15 mg om.
• Patient had involvement of left eye on day 2 of
  admission.
• - 2 isolated areas of retinitis in the
  supero-temporal
• region.
• - Intravitreal ganciclovir 2mg/0.04ml given BE
  on
• 25/06/07.
• VA remains fairly similar in both eyes with no
  worsening.

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Progress

• ID suggests
• If cost is not an issue
• i) Induction therapy IV ganciclovir 5mg/kg bd
  followed by oral valganciclovir 900mg bd (21d) 72
  hrs after starting IV therapy.
• -gt cost 6000 per month!
• ii) Following induction, need maintenance therapy
  to prevent relapse. Dose valganciclovir at
  900mg/day.
• Decision to stop maintenance therapy will be
  dependent on clinical response.
• In HIV pts who cannot afford oral valganciclovir
  or IV ganciclovir, they will do well on
  intravitreal ganciclovir only for maintenance
  therapy i.e. until no evidence of active
  infection.
• Discussed with family, decision made for
  intravitreal ganciclovir only for maintenance
  therapy.

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Literature review

• Clinical Characteristics and Outcomes of
  Cytomegalovirus
• Retinitis in Persons without Human
  Immunodeficiency
• Virus infection
• Am J Ophthalmol. 2004 Sep138(3)338-46

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Literature review

• Aim To describe the characteristics and outcomes
  of patients with CMV retinitis in the absence of
  HIV infection
• Methods Retrospective cohort study of 18
  patients (30 eyes) between 1984 and 2003 in a
  tertiary centre

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Literature review

• 5/18 patients receiving immunosuppresive therapy
  for autoimmune disease
• 11/30 eyes (37) VA of 6/15 or worse
• 12 patients (67) had bilateral involvement, 10
  at initial presentation and develop on f/u.

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Literature review
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Literature review

• Results
• Clinical characteristic retinitis of CMV patients
  without HIV similar to those with HIV.
• -necrotizing retinitis, often with intraretinal
  haemorrhage, with either granular or oedematous
  borders
• Rates of visual loss to 20/50 (6/15) 17 per
  eye-year
• Rates of visual loss to 20/200 (6/60) 14 per
  eye-year
• Incidence of RD 3.7 per eye-year
• With reduction of immunosuppressives, 10 patients
  (56) who discontinued anti-CMV therapy remained
  free of retinitis progression.

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Conclusion

• CMV retinitis patients without HIV had a similar
  clinical course similar to that in patients with
  AIDS treated with HAART
• - except RD incidence lower
• Substantial number of patients no longer required
  long term anti-CVM therapy after adjustment of
  immunomodulatory therapy.