Grand ward round
1 / 20

Grand Ward Round - PowerPoint PPT Presentation

  • Uploaded on

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.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Grand Ward Round' - holt

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Grand ward round l.jpg

Grand Ward Round

Tan Tock Seng Hospital

The Eye Institute


History l.jpg

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

History3 l.jpg

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 l.jpg

  • 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



Differential diagnosis l.jpg
Differential diagnosis

  • Posterior uveitis ? Cause

    - CMV retinitis

    - toxoplasmosis/ TB/ sarcoidosis/ syphilis

  • Acute retinal necrosis

  • SLE related retinal occlusive vasculopathy

  • Masquerade syndromes

Retinal vasculitis l.jpg




Pars planitis

Sickle cell retinopathy

Behcet disease


Giant cell arteritis

Polyarthritis nodosum



Behcet disease

Retinal Vasculitis

Investigation l.jpg

  • 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 l.jpg

  • Working diagnosis at this point in times likely CMV retinitis


  • 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

Progress l.jpg

  • 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


    - Intravitreal ganciclovir 2mg/0.04ml given BE on


  • VA remains fairly similar in both eyes with no worsening.

Progress13 l.jpg

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 l.jpg
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 review15 l.jpg
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 review17 l.jpg
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 review19 l.jpg
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 l.jpg

  • 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.