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Grand Ward Round. Tan Tock Seng Hospital The Eye Institute 05/07/07. 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.

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Grand Ward Round

Tan Tock Seng Hospital

The Eye Institute

05/07/07


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


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


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

19

18


Differential diagnosis

  • Posterior uveitis ? Cause

    - CMV retinitis

    - toxoplasmosis/ TB/ sarcoidosis/ syphilis

  • Acute retinal necrosis

  • SLE related retinal occlusive vasculopathy

  • Masquerade syndromes


Periphlebitis

Sarcoidosis

Syphilis

Pars planitis

Sickle cell retinopathy

Behcet disease

Arteritis

Giant cell arteritis

Polyarthritis nodosum

SLE

ARN

Behcet disease

Retinal Vasculitis


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.


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


Post Barrier Laser treatement


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.


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.

-> 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.


Literature review

Clinical Characteristics and Outcomes of Cytomegalovirus

Retinitis in Persons without Human Immunodeficiency

Virus infection

Am J Ophthalmol. 2004 Sep;138(3):338-46


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


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.


Literature review


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.


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.


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