Japanese Journal of Ophthalmology

https://doi.org/10.1007/s10384-018-0574-9

CLINICAL INVESTIGATION

Spectral domain optical coherence tomography and fundus

autofluorescence findings in cytomegalovirus retinitis in HIV‑infected
patients
Shigeko Yashiro1 · Takeshi Nishijima2 · Yuuka Yamamoto1 · Yumi Sekine1 · Natsuyo Yoshida‑Hata1 · Tomohiro Iida3 ·
Shinichi Oka2

Received: 28 June 2017 / Accepted: 21 January 2018

© Japanese Ophthalmological Society 2018

Abstract
Purpose  To assess the usefulness of spectral domain optical coherence tomography (SD-OCT) and fundus autofluorescence
(FAF) findings in cytomegalovirus (CMV) retinitis.
Study design  Observational case series.
Methods  Thirteen eyes of 11 human immunodeficiency virus (HIV)-positive patients with CMV retinitis underwent full
ophthalmologic examinations, SD-OCT, and 4 eyes of 4 patients underwent FAF. FAF images included short-wavelength
autofluorescence (SW-AF) and near-infrared autofluorescence (IR-AF). CMV retinitis was classified into proposed catego-
ries of acute, subacute, remission, and recurrent; the acute stage was further subdivided into initial, early, and late stages.
Results  In the initial stage, vertical structural disruption of all retinal layers was observed by SD-OCT, and FAF showed
hyperautofluorescence on SW-AF and hypoautofluorescence on IR-AF. In the early stage, SD-OCT showed significant retinal
thickening; cells and debris from the retinal surface to the vitreous; enlarged vessels with/without thickened vessel walls;
and highly complicated serous retinal detachment. In the late to subacute stage, features observed included rhegmatogenous
retinal detachment with shrinking posterior hyaloid membrane and waving from the ellipsoid zone to the retinal pigment
epithelium. In remission, FAF findings were hypoautofluorescence on SW-AF and hyperautofluorescence on IR-AF.
Conclusion  Although the number of examined eyes was limited, SD-OCT and FAF provide new information in various
stages of CMV retinitis in patients with HIV infection that is not obtainable by conventional examination and which may be
of great benefit when screening for the initial stage of CMV retinitis.

Keywords  Cytomegalovirus retinitis · Fundus autofluorescence · Human Immunodeficiency Virus · Spectral domain
optical coherence tomography

Introduction

The number of new cases of cytomegalovirus (CMV) reti-

* Shigeko Yashiro
syashiro@hosp.ncgm.go.jp
1
Department of Ophthalmology, Center Hospital
of the National Center for Global Health and Medicine,
1‑21‑1 Toyama Shinjyuku‑ku, Tokyo 162‑8655, Japan
2
AIDS Clinical Center, the National Center for Global
Health and Medicine, 1‑21‑1 Toyama Shinjyuku‑ku,
Tokyo 162‑8655, Japan
3 and evaluation of therapeutic effects. Moreover, spectral
Department of Ophthalmology, Tokyo Women’s Medical
University, 8‑1 Kawada‑cho Shinjyuku‑ku, Tokyo 162‑8666,
Japan
nitis in human immunodeficiency virus (HIV)-positive
patients has declined since the introduction of antiretroviral
therapy (ART) in 1996 [1, 2]. Nevertheless, CMV retini-
tis remains a serious, sight-threatening disease, especially
when the focus exists within the retinal arcades and near
the optic disc area, referred to as zone 1 [3]. The advent of
optical coherence tomography (OCT) has made it possible to
evaluate the retinal structure repeatedly and non-invasively,
which helps in the diagnosis of posterior ocular diseases
domain OCT (SD-OCT) has led to substantial gains in image
acquisition speed without loss of sensitivity or resolution,

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a performance not possible with conventional time-domain
OCT [4–7]. Some case reports describe posterior segment
findings of CMV retinitis using OCT, including those pre-
sented as immune reconstitution inflammatory syndrome
(IRIS) after the introduction of ART [8–19]; they show
the existence of subretinal hemorrhage [8], retinal edema
and/or submacular detachment [9–12], subfoveal choroidal
neovascularization [13], frosted retinal branch angiitis [14],
epiretinal membrane (ERM) [15], and atrophy of the retina
[16, 17]. Kurup et al. [18] report a case series of SD-OCT
images ranging from full-thickness disruption of the reti-
nal architecture in the active phase, to retinal thinning after
treatment. Brar et al. [19] report the pathologically changed
vitreoretinal interface in healed CMV retinitis using SD-
OCT, and the presence of ERM, vitreoretinal gliosis, and
traction which may relate to retinal elevation, retinal breaks,
and retinal detachment. However, details of the time course
of SD-OCT images, especially during the initial stage, have
not been reported.
Fundus autofluorescence (FAF) is a non-invasive tech-
nique that utilizes the fluorescent properties of lipofuscin
to evaluate functional changes in the retinal pigment epi-
thelium/photoreceptor complex. To our knowledge, there
is only one previous study of FAF images of active CMV
retinitis, which used a Topcon 50EX retinal camera with
excitation wavelength 585 nm and emission wavelength
695 nm, and reported hyperautofluorescence correlated
with the borders of active retinitis [20]. Near-infrared auto-
fluorescence (IR-AF) is a new technique that utilizes the
long-wavelength (780 nm) autofluorescence of melanin and
melanin-related compounds in the retinal pigment epithe-
lium (RPE) and choroid [21]. The advantage of IR-AF is
that it is 60-100 times less intense than the excitation level
of short-wavelength autofluorescence (SW-AF); however,
IR-AF imaging of CMV retinitis has not been reported. The
aim of this study was to examine the usefulness of SD-OCT
and combined SW/IR-AF findings of CMV retinitis in HIV-
infected patients.
Subjects and methods
This single-center observational case series was conducted
to demonstrate longitudinal SD-OCT and FAF images of
various stages of CMV retinitis in patients with HIV infec-
tion at the Department of Ophthalmology, National Center
for Global Health and Medicine (NCGM), Tokyo, Japan.
NCGM houses the AIDS Clinical Center, one of the largest
referral centers for HIV infection in Japan. The study proto-
col was approved by the Human Research Ethics Committee
of NCGM. Informed consent was waived because this study
solely used data obtained from clinical practice. The study
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S. Yashiro et al.
was conducted according to the principles expressed in the
Declaration of Helsinki.
HIV-infected patients with CMV retinitis that fulfilled the
standard AIDS Clinical Trials Group (ACTG) criteria for
“confirmed CMV retinitis” were included in the study, and
required diagnosis by an experienced ophthalmologist and
documentation of CMV retinitis by retinal photography [22].
Whenever a differential diagnosis of acute retinal necrosis
(ARN) was needed, virologic testing of aqueous fluid by
polymerase chain reaction (PCR) was conducted follow-
ing the new criteria advanced by the Japanese ARN Study
Group [23]. During the study period (April 2011 through
March 2015), CMV retinitis was diagnosed in 17 eyes of
15 patients; however, 4 eyes of 4 patients in which the focus
area was in the peripheral retina were excluded because of
difficulties in examinations with SD-OCT and FAF. Thus,
a total of 13 eyes in 11 patients were analyzed in this study.
Full ophthalmologic examinations were performed for
each study patient, including visual acuity, slit-lamp exami-
nation, indirect ophthalmoscopy, and retinal photography.
All patients underwent SD-OCT (Spectralis OCT; Heidel-
berg Engineering) and 4 eyes of 4 patients underwent FAF
(Spectralis HRA; Heidelberg Engineering). FAF images
included SW-AF using a blue laser (488 nm) and IR-AF
(815 nm).
Basic characteristics, including sex, age, nadir CD4-pos-
itive T lymphocyte count (CD4), CD4 at the first SD-OCT,
and CMV-DNA PCR at the first SD-OCT, as well as oph-
thalmologic parameters, such as the zone where the lesions
occurred, initial visual acuity, and visual acuity at the last
follow-up were collected from the medical charts. At our
hospital, plasma CMV-DNA PCR is routinely performed for
HIV-infected patients with CD4 < 200 /μL [24].
CMV retinitis was classified according to Standardization
of Uveitis Nomenclature working group descriptors [25];
uveitis activity was classified as acute (episode characterized
by sudden onset and limited duration of less than 3 months),
recurrent (repeated episodes separated by periods of inac-
tivity of more than 3 months’ duration without treatment),
chronic (persistent uveitis with relapse less than 3 months
after discontinuing treatment), and remission (inactive dis-
ease for more than 3 months after discontinuing all treat-
ments for eye disease). In addition, we divided acute into
three subcategories as follows: (1) initial stage (when the
focus is less than one disc diameter, observed approximately
less than one week after onset), (2) early stage (when the ini-
tial therapeutic dose of anti-CMV agents is used, observed
approximately less than 2 to 4 weeks after onset), and (3)
late-stage (when the chronic maintenance dose of anti-CMV
agents is used, observed approximately 1 to 3 months after
onset). Because more than 3 months of treatment with anti-
CMV agents is sometimes necessary for CMV retinitis in
patients with HIV infection until the CD4 count improves
 Table 1  Patient characteristics
Case Age Eye Observation Stage of CMV Zone Distinction of CD4 at OCT Nadir CMV-DNA Duration of ART Other complica- VA at first VA at last
(years) period for retinitis CMV retinitis (/μL) CD4 (/ PCR (copies/ at CMV-R diag- tions examina- follow-
CMV-R μL) mL) nosis tion up
(months) (months)

1 44 OD 2 Acute (initial) 1  NA 88 10 20000 4 DLBCL 1.2 1.2

2 41 OD 32 Acute (early/late) 1+2+3  NA 63 48 50000 0 PCP/syphilis 1.5 1.2
Remission
3 45 OD 1 Acute (early) 1+2  NA 31 22 700 2 DLBCL 1.2 1.2
4 37 OD 18 Acute (early) 2 IRIS 113 45 3000 3 PCP/KS/ 1.2 1.2
OS Acute (early) 1+2 IRIS syphilis 1.0 1.2
5 45 OS 10 Acute (early) 1+2  NA 81 22 10000 7 DLBCL 1.0 0.3
6 52 OD 18 Acute (early/late) 1+2 Post-vitrectomy 29 12 700 0 PCP CF 0.02
OS Acute (early/late) 1+2 NA　 0.03 0.5
7 37 OD 33 Subacute/Remis- 1+2 Diagnosed 20 6 <200 0 MAC 1.2 0.3
Spectral domain optical coherence tomography and fundus autofluorescence findings in…

sion
8 35 OS 9 Subacute 1+2 Diagnosed 61 7 <200 4 Syphilis 1.2 0.6
9 37 OD 48 Remission 2  NA 815 59 NA 36 1.2 1.2
10 46 OD 48 Remission 2  NA 686 44 NA 46 DLBCL 1.2 1.0
DM/syphilis
11 56 OS 7 Recurrence 2 Diagnosed 160 98 20000 9 DLBCL 1.2 1.2

ART​ antiretroviral therapy, CMV-R cytomegalovirus retinitis, CF counting finger, DLBCL diffuse large B-cell lymphoma, DM diabetes mellitus, IRIS immune reconstitution inflammatory syn-
drome, KS Kaposi sarcoma, MAC Mycobacterium avium complex, OCT optical coherence tomography, OD oculus dexter, OS oculus sinister, PCP pneumocystis pneumonia, PCR polymerase
chain reaction, VA visual acuity

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 S. Yashiro et al.

Table 2  Summary of SD-OCT Disease stage SD-OCT

Acute Initial Enlarged vessel in INL

Concavity of RNFL toward RPE
Structural disruption of all retinal layers vertically, then spread horizontally
Complete loss of retinal structure under OPL
Early Significant retinal thickening
Enlarged vessels without thickened vessel walls in exudate area
Enlarged vessels with thickened vessel walls in frosted branch angiitis
Numerous dot reflections and debris on surface of RNFL up to the vitreous
SRD adjacent to exudate and inferior area of exudate
Late Thinned retinal layer with undetectable structure
Dot reflections in vitreous disappeared
Normalized vessel wall thickness in area of frosted angiitis
Waving of ellipsoid zone to RPE
SRD disappeared
Subacute RRD with shrinkage of posterior hyaloid membrane
Remission No RRD
Variable presence of hyperreflective retinal tissue and/or posterior hyaloid membrane
Recurrent Hyperreflective tissue replaces thinned retina with ERM

CMV cytomegalovirus, ERM epiretinal membrane, INL inner nuclear layer, SD-OCT spectral domain opti-
cal coherence tomography, FAF fundus autofluorescence findings, OPL outer plexiform layer, RNFL retinal
nerve fiber layer, RPE retinal pigment epithelium, SRD serous retinal detachment, RRD rhegmatogenous
retinal detachment

Fig. 1  Fundus photography and optical coherence tomography
images. a Initial stage of cytomegalovirus retinitis (Case 1) show-
ing a small cyst-like enlarged vessel (white arrow) in the center of
the inner nuclear layer and concavity of the retinal nerve fiber layer
(RNFL) toward the retinal pigment epithelium; there is destruction
of all retinal layers vertically. b HIV retinopathy (unaffected eye of
Case 3). Cotton wool spot with elevation of the RNFL and concavity
of the outer plexiform layer but no destruction of the retinal structure.
Graphics program used: Adobe Photoshop

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Spectral domain optical coherence tomography and fundus autofluorescence findings in…

Fig. 2  Time course of optical coherence tomography images corre-
sponding to the fundus photograph of the initial stage of cytomegalo-
virus retinitis in Case 1. a First visit: destruction of retinal structure
in all layers. b One week: focus of retinitis is slightly bigger and has
spread horizontally. c Two weeks: focus seems to be disappearing on
fundus photograph, and destruction under the outer plexiform layer
(OPL) to the ellipsoid zone has progressed. d One month: focus has
disappeared on fundus photograph, but the retinal nerve fiber layer
(RNFL) has become thinner and complete loss of retinal structure
under the OPL is seen. e Two months: focus has spread, with thick-
ening of the RNFL and widespread destruction of all retinal layers
Graphics program used: Adobe Photoshop

13
 S. Yashiro et al.

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 Spectral domain optical coherence tomography and fundus autofluorescence findings in…
◂Fig. 3  Time course of Case 2 (a: early stage of onset, b: late stage of
2 months later, c: remission of 6 months later). a Significant retinal
thickening, dot reflections in the vitreous, enlarged vessels without
thickening of vessel walls in the exudate area (arrows), and thick-
ening of vessel walls in the frosted retinal branch vasculitis (arrow
heads). b Thinned structureless retina without dot reflections, unde-
tectable vessel walls in the exudate area, and waving of the retinal
pigment epithelium with normalized vessel wall thickness in the
area of frosted branch angiitis (arrow heads). c Hyperreflective tissue
replaces the thinned retina by proliferation, and the shrinking poste-
rior hyaloid membrane was irregularly attached to the healed retina
(arrows: upper and middle). Waving of the ellipsoid zone to the RPE
is more significant (lower). Graphics program used: Adobe Photoshop
to some degree, and such cases cannot be categorized as
either acute or chronic, we defined a new category of suba-
cute disease for uveitis characterized by sudden onset and
persisting for more than 3 months without discontinuation
of treatment. Lesions were assigned to retinal zones from 1
to 3 using the standardized system described by the UCLA
CMV Retinopathy Study Group [26].
Results
Patient characteristics (Table 1)
All study patients were men, with a mean age ± standard
deviation of 43.2 years ± 6.66 (range 35 to 56). One patient
(Case 6) was Filipino and the others were Japanese. The
mean observation period for CMV retinitis was 20.5 ± 17.2
months (range 1 to 48). At the first visit 8 eyes were classi-
fied as acute, 2 as subacute, 2 as remission, and 1 as recur-
rent. No eyes were classified as chronic. Nine eyes had a
zone 1 lesion. Three eyes of 3 patients (Cases 7, 8, and 11)
had CMV retinitis that had been diagnosed at a previous
hospital, 1 eye (the right eye of Case 6) had a history of
vitrectomy and silicone oil tamponade, and 2 eyes of Case
4 developed CMV retinitis as IRIS within 4 months after
introduction of ART. CD4 count and CMV-DNA level on
the day of the first SD-OCT examination ranged from 20
to 815 per μL, and from undetectable to 50,000 copies/
mL, respectively. Nadir CD4 ranged from 6 to 98 per μL.
Three patients (Cases 2, 6, and 7) had not started ART at
the time of the first SD-OCT examination. Five cases had
diffuse large B-cell lymphoma (DLBCL), 4 had syphilis, 3
had pneumocystis pneumonia, and 1 case each had Kaposi
sarcoma, Mycobacterium avium intracellulare complex, and
diabetes mellitus. Best corrected visual acuity on the first
SD-OCT examination day compared with the last follow-up
day decreased 2 or more lines for 3 eyes (Cases 5, 7, and 8);
others stayed the same or improved.
SD‑OCT findings (Table 2)
CMV retinitis and cotton wool spot due to HIV retinopathy
were difficult to distinguish in the fundus photographs of
the initial stage. The SD-OCT image of Case 1 showed a
very small cyst-like enlarged vessel in the center of the inner
nuclear layer (INL) and concavity of the retinal nerve fiber
layer (RNFL) toward the RPE, with structural disruption of
all retinal layers vertically (Fig. 1a). On the other hand, the
SD-OCT image of a similarly sized cotton wool spot in the
unaffected eye of Case 3 showed elevation of the RNFL only
and concavity of the outer plexiform layer (OPL) without
destruction of retinal structure (Fig. 1b). This lesion disap-
peared in a week, confirming that the cotton wool spot was
due to HIV retinopathy.
The time course of SD-OCT images corresponding to the
fundus photograph of Case 1 is shown in Fig. 2. The focus
was very small, but at the first visit it was apparent that all
layers of the retinal structure had been destroyed (Fig. 2a).
One week after the first visit and start of anti-CMV therapy,
the exudate was slightly bigger and had spread horizontally
(Fig. 2b). Two weeks later, fundus photograph seemed to
indicate that the exudate was disappearing, and destruc-
tion under the OPL to the ellipsoid zone had progressed
(Fig. 2c). One month later, fundus photograph indicated
that the focus had completely disappeared; however, the
RNFL had become thinner compared with a normal retina,
and complete loss of retinal structure under the OPL was
detected (Fig. 2d). In general, after 2 to 3 weeks of anti-
CMV therapy with induction dosing, the maintenance dose
of anti-CMV therapy is continued until recovery of the CD4
count. However, after anti-CMV therapy was discontinued
for Case 1 because of complications from DLBCL, the for-
merly resolved focus reappeared and spread, with thicken-
ing of the RNFL and wide destruction of all retinal layers
(Fig. 2e).
SD-OCT images of early stage CMV retinitis were
obtained in 7 eyes of 5 patients (Cases 2-6). Significant reti-
nal thickening including the RNFL was seen (Figs. 3a, 4a,
b). Shadowing made it difficult to assess the layer under
the ganglion cell layer. Cyst-like enlarged vessels without
thickened vessel walls were observed in the exudate area
(Figs. 3a, 4a, b). Frosted branch angiitis was identified in 4
cases (Cases 2, 3, 4, and 6), which had thickened vessel walls
without structural changes (Figs. 3a, 5a). A large number of
dot reflections, likely representing inflammatory cells, was
observed between the surface of the RNFL and the vitreous
in the region of the exudate (Figs. 4a, b, 5a). Inflamma-
tory cells sometimes gather and form debris in the vitreous.
Debris on the surface of the unaffected macula was identi-
fied by SD-OCT (Fig. 5b), and had been released from the
surface of retina into the vitreous by the next week (Fig. 5c).
Serous retinal detachment (SRD) was observed in 4 eyes
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Fig. 4  Early stage in Case 3 (a: onset, b: 1 week later). a Significant
retinal thickening, large number of dot reflections extending from
the surface of the retinal nerve fiber layer to the vitreous in the exu-
date area. Retinal structure clearly identifiable over the serous retinal
(Case 3: Fig. 4a, b; Case 5: Fig. 6a, b; Case 6: Fig. 7a, c).
Case 3 showed SRD adjacent to the border of the thickened
focus, with the retinal structure clearly identifiable over the
SRD (Fig. 4a). Retinal thickness and SRD decreased 1 week
immediately after starting the induction dose of anti-CMV
therapy; however, the retinal structure became irregular from
the optic disc side (Fig. 4b). Case 5 showed a small SRD
under the thickened RNFL, and enlarged vessels (Fig. 6a).
One month later, the exudate had expanded and because the
difficulty of anti-CMV therapy complicated DLBCL, accu-
mulation of SRD was identified under the expanded exudate
extending to the macula (Fig. 6b). The right eye of Case 6
had a history of vitrectomy 9 months before the first visit
to our hospital. SRD was seen after incomplete vitrectomy
with silicone oil tamponade OD (Fig. 7a) and in the inferior
area of the exudate with clearly identifiable retinal structure
OS (Fig. 7c).
In Case 2, dot reflections in the vitreous had disappeared
1 month after the first visit, and thinned, structureless ret-
ina was observed (Fig. 3b) in the late stage. Vessel wall
13
S. Yashiro et al.
detachment (SRD) near the optic disc (arrow). b Slightly thinned ret-
ina in the exudate area. Decreasing SRD with irregularly structured
retina near the optic disc (arrow). Graphics program used: Adobe
Photoshop
thickness in the area of frosted branch angiitis was nor-
malized after anti-CMV therapy; however, waving of the
ellipsoid zone to the RPE had appeared (Fig. 3b). After the
remaining SRD had completely disappeared in the re-oper-
ated right eye of Case 6, the structure under the ellipsoid
zone was not observed (Fig. 7b). SRD in the inferior area of
the exudate in the left eye had also disappeared 1 month after
maintenance dose of anti-CMV therapy (Fig. 7d).
Cases 7 and 8 were categorized as subacute, because a
maintenance dose of anti-CMV therapy had been used for
more than 3 months at a previous hospital. In Case 7mild
SRD remained adjacent to the thinned retina, and shrink-
ing of the posterior hyaloid membrane was seen over the
remaining granular border and bleeding area at the first
visit (Fig. 8a). Three months later, rhegmatogenous retinal
detachment (RRD)involving the macula started from the
upper side of the thinned atrophic retina (Fig. 8b). Shrinking
of the posterior hyaloid membrane on the thinned atrophic
retina seen in Case 8 at the first visit (Fig. 9a), and 5 days
Spectral domain optical coherence tomography and fundus autofluorescence findings in…
Fig. 5  Early stage in Case 4 (a: right eye onset, b: left eye onset, c:
left eye 1 week later). a Graphics program used: photoshop. (arrows).
Destruction of all retinal layers and dot reflections in the vitreous over
later bullous retinal detachment occurred by retinal holes on
the upper peripheral thinned retina (Fig. 9b).
In the remission stage of Case 2, hyperreflective tissue
replaced thinned retina without severe retinal pigmentation
but with proliferation, and the shrinking posterior hyaloid
membrane was irregularly attached to the healed retina
(Fig. 3c; upper and middle). Retinal detachment had not
occurred in this patient; however, waving of the ellipsoid
zone to the RPE was more significant (Fig. 3c; lower part).
Case 7　showed disappearance of the ellipsoid zone of
the reattached retina after vitrectomy (Fig. 8c). Six months
after vitrectomy of Case 8 for RRD, the retina had reat-
tached, hyperreflective tissue was evident, and the ellip-
soid zone was not clearly observable (Fig. 9c). In Case 9,
retinal detachment did not occur despite the presence of
thinned, atrophic retina. There was no vitreous traction,
the exudate. b Debris on the surface of unaffected macula. c Debris
released from the surface of the retina into the vitreous. Graphics pro-
gram used: Adobe Photoshop
hyperreflective retinal tissue, or posterior hyaloid membrane
present (Fig. 10a). In contrast, both hyperreflective retinal
tissue and posterior hyaloid membrane with an edge of vit-
reoretinal gliosis were seen in Case 10 (Fig. 10b), which did
not progress to RRD either.
In Case 11, complicated by DLBCL, recurrent CMV reti-
nitis evidenced by white exudates in zone 2 was revealed
by screening because of increased serum CMV-DNA level,
although CD4 was more than 200/μL. One week after treat-
ment with the induction dose of anti-CMV therapy, SD-
OCT already showed thinning and destruction of the retina
with an epiretinal membrane (arrow) on the granular bor-
der without dot reflections in the vitreous (Fig. 11a). One
month later, the granular border had disappeared and thinned
hyperreflective membrane-like tissue replaced the affected
retina. (Fig. 11b).
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Fig. 6  Early stage in Case 5 (a: onset, b: 1 month later). a Serous
retinal detachment (SRD) not identified on macula but present under
the exudate area of thickened retinal nerve fiber layer and enlarged
FAF findings
The time course of FAF images in the initial stage was seen
in Case 1 (Fig. 12a). At the first visit, the focus (arrowhead)
showed hyperautofluorescence on SW-AF and hypoautofluo-
rescence on IR-AF (upper). One week later, both images
were much clearer (middle). Two months later, the focus
had spread (dotted line); hyper- and hypoautofluorescence
were intermingled on SW-AF and hypoautofluorescence on
IR-AF were expanded (lower).
In images from Cases 2 (Fig. 12b) and 8 (Fig. 12c) in the
remission stage, the margin of the focus showed hypoauto-
fluorescence on SW-AF due to blocking of replaced prolif-
erative tissue, and showed hyperautofluorescence on IR-FA.
In images from Case 4 (Fig. 12d) in the remission stage,
SW-AF had normal autofluorescence; an area of hyperau-
tofluorescence was clearly evident in the IR-AF (Fig. 12d).
13
S. Yashiro et al.
vessels (arrows). b Accumulation of SRD on the macula under the
expanded exudate area. Graphics program used: Adobe Photoshop
Discussion
In this observational case series of CMV retinitis in HIV-
positive patients, 13 eyes of 11 patients underwent SD-OCT
and 4 eyes of 4 patients underwent FAF. Because CMV reti-
nitis requires long-term treatment until restoration of cel-
lular immunity by antiretroviral therapy, we proposed new
categories by subdividing the active stage into initial, early,
and late. Furthermore, we defined a new category of suba-
cute disease for uveitis characterized by sudden onset and
persisting for more than 3 months without discontinuation
of treatment. This is the first report to reveal findings from
the initial stage (when the focus is less than one disc diam-
eter), the vertical structural disruption of all retinal layers in
SD-OCT, and findings of hyperautofluorescence on SW-AF
and hypoautofluorescence on IR-AF. These findings might
help distinguish cotton wool spots due to HIV retinopathy
from a very small focus of CMV retinitis during the initial
stage. Furthermore, a substantial number of interesting new
Spectral domain optical coherence tomography and fundus autofluorescence findings in…
Fig. 7  Early to late stages in Case 6 (a: right eye, early stage at the
first visit b: right eye, late stage 1 month later, c: left eye, early stage
at the first visit d: left eye, late stage 1 month later). a Serous reti-
nal detachment (SRD) after incomplete vitrectomy with silicone oil
tamponade. b SRD disappeared after re-operation with the destroyed
SD-OCT findings that could not be detected by conventional
ophthalmic examination were observed in each stage.
Although the incidence of CMV retinitis has decreased
in the ART era, 17 eyes of 15 patients with CMV retinitis,
including 4 patients with zone 3 disease excluded from this
study, were diagnosed at NCGM during a 4-year period.
Eyes without zone 1 disease maintained good visual acu-
ity; however, 3 of 9 eyes with zone 1 disease had decreased
visual acuity despite intensive anti-CMV therapy, and 2 of
retina under the ellipsoid zone. c SRD on macula of interior area of
the exudate with clearly identifiable retinal structure. d Resolution of
SRD without retinal destruction. Graphics program used: Adobe Pho-
toshop
these developed RRD. Thus, good visual prognosis requires
early detection and treatment of zone 1 disease in the initial
stage, and appropriate timing of vitrectomy so as to prevent
RRD.
Early diagnosis of CMV retinitis during the initial stage is
very important because severe CMV retinitis is an indication
for delayed initiation of ART and could lead to blindness.
In Case 1, CMV retinitis was detected in the initial stage
because HIV-1-infected patients with CD4 < 200/μL and/
13

Fig. 8  Subacute to remission in Case 7 (a: subacute stage at the first
visit at 3 months after onset, b: subacute stage 3 months later, c:
remission stage 6 months later). a Mild Serous retinal detachment and
posterior hyaloid membrane over the remaining granular border and
area of hemorrhage. b Rhegmatogenous retinal detachment involving
or increasing plasma CMV-DNA by PCR routinely undergo
ophthalmologic screening at NCGM [27]. The standard
ACTG criteria of “confirmed CMV retinitis” require docu-
mentation of CMV retinitis by retinal photography [22], and
with this definition, it is difficult to distinguish the initial
stage of CMV retinitis from cotton wool spots due to HIV
retinopathy. Cotton wool spots also show a hyper-reflective
pattern on OCT [28, 29], and permanent retinal destruction
[30]. However, the destruction is limited to the outer plexi-
form layer [30]. Conversely, the full destruction of the entire
layer seen in this patient enabled a definitive diagnosis, and
early initiation of treatment. In Case 1, anti-CMV treatment
had to be discontinued later in the clinical course of DLBCL,
and retinal photography showed typical CMV retinitis, con-
firming our diagnosis.
SD-OCT showed the presence of an enlarged vessel in the
center of the INL in the initial stage of CMV retinitis, which
corresponds with a previous histological report suggesting
that CMV infects the inner retina via the retinal vessels [31].
13
S. Yashiro et al.
the macula arising from the upper side of the thinned atrophic retina.
c Reattached retina after vitrectomy with loss of the ellipsoid zone
around the macula (arrow). Graphics program used: Adobe Photo-
shop
Moreover, it is also reported that CMV retinitis extends
horizontally through the neurons and glial cells, and verti-
cally through the Müller cells [31]. Although it is difficult
to longitudinally examine pathological specimens for CMV
retinitis, SD-OCT showed the time course of CMV retini-
tis in vivo; the focus first expanded vertically with necrosis
around the outer retinal layer, and then spread horizontally.
When the focus seemed to have disappeared after treatment
on fundus photography, SD-OCT revealed that necrosis of
the outer retinal layer remained, although the inner retinal
layer, including the RNFL, seemed to have recovered.
In the early stage, significant retinal thickening and
many inflammatory cells and debris in the vitreous were
observed by SD-OCT, which is consistent with the find-
ings of a previous report [18]. A unique finding of thick-
ened vessel walls was also observed at this stage. Vessel
wall thickening, first reported by Giani et al. [14], was also
identified in an area of frosted retinal branch angiitis with-
out destruction of the retina. In contrast, vessel walls in the
Spectral domain optical coherence tomography and fundus autofluorescence findings in…
Fig. 9  Subacute to remission in Case 8 (a: subacute stage at the first
visit 3 months after onset, b: subacute stage 5 days later, c: remission
stage 6 months after vitrectomy). a Shrinkage of the posterior hya-
loid membrane extending from the thinned atrophic retina to the nor-
exudate area were enlarged but not thickened, and retinal
structure was not marked by shadowing due to edema and
eventually exhibited atrophy. The mechanism of frosted
retinal branch angiitis is unknown; however, these SD-
OCT findings support the hypothesis that the vessel walls
become thickened to prevent the infiltration of CMV from
the vessels to the adjacent inner retina.
SRD during the early stage was difficult to detect by
indirect ophthalmoscopy, but was clearly observed by SD-
OCT. All SRD had disappeared after anti-CMV therapy,
with the exception of Case 6 in which vitrectomy had been
performed on the right eye, probably the reason SRD had
not resolved. SRD disappeared after a repeat vitrectomy
on that eye; however, best corrected visual acuity remained
impaired. This case suggests that in CMV retinitis a well-
performed first vitrectomy is important for quality of
vision.
SD-OCT findings in the late stage included decreased
retinal thickness tending toward atrophy, disappearance
of vitreous inflammatory cells, and normal vessel wall
mal peripheral retina b Bullous retinal detachment caused by retinal
holes on the upper peripheral thinned retina. c Hyperreflective tissue
replaced on thinned retina (arrow). Obscuring of the ellipsoid zone.
Graphics program used: Adobe Photoshop
thickness in frosted retinal angiitis. Brar et al. [19] assumed
that gliotic bands may be a source of vitreoretinal traction
leading to retinal breaks or retinal detachment. In the pre-
sent study, RRD occurred in thinned retinas of 2 eyes at the
subacute stage, and both of these eyes showed shrinking of
the posterior hyaloid membrane. These findings suggest that
frequent observation is important for early detection of reti-
nal traction caused by RRD when shrinking of the posterior
hyaloid membrane adjacent to the healing retina is present in
the late stage. Gliotic bands with shrinking of the posterior
hyaloid membrane were seen in 2 out of 3 eyes in remission;
however, these eyes did not develop RRD, and the thinned
retina was replaced by hyperreflective retinal tissue, suggest-
ing proliferative change. Although the causal relationship
between proliferative retinal tissue and vitreous traction is
uncertain, the presence of proliferative retinal tissue might
play a part in preventing progression of RRD.
The root cause of choroidal infection is thought to be
different from that of retinal infection [31–34]. Minor wav-
ing from the RPE to the ellipsoid zone without remarkable
13

Fig. 10  Remission stage in Cases 9 and 10 (a: Case 9, b: Case 10). a
Neither hyperreflective retinal tissue nor posterior hyaloid membrane
is seen. b Hyperreflective retinal tissue (arrow) and posterior hyaloid
Fig. 11  Recurrence in Case 11 (a: 1 week after detection; b: 1 month
later). a Thinning and destruction of the retina is already present with
an epiretinal membrane (arrow) on the granular border. No dot reflec-
inner retinal change was shown by SD-OCT in 1 eye in
the late stage, and became more significant in remission.
Because this case was complicated by syphilis, the possi-
bility that this finding was due to acute syphilitic posterior
placoid choroiditis cannot be excluded; however, because
treatment for syphilis had been completed, CMV choroidal
infection remains a possibility. Further research is needed
13
S. Yashiro et al.
membrane with an edge of vitreoretinal gliosis (arrowhead) are seen.
Graphics program used: Adobe Photoshop
tions can be identified in the vitreous. b Disappearance of the granu-
lar border and thin hyperreflective membrane-like tissue has replaced
the affected retina. Graphics program used: Adobe Photoshop
to assess this finding, which was not observed in any other
patients in this study.
One eye was categorized as recurrent and was identified
by screening because of increased serum CMV-DNA level.
As early as 1 week after starting anti-CMV therapy, SD-
OCT showed thinning and destruction of the retina without
vitreous inflammation suggesting that this was not a fresh
Spectral domain optical coherence tomography and fundus autofluorescence findings in…
Fig. 12  FAF images (left: short-wavelength autofluorescence (SW-
AF); right: near-infrared autofluorescence (IR-AF). a: Case 1; b: Case
2; c: Case 8; d: Case 4). a At the first visit in the initial stage, the
focus (arrowhead) shows hyperautofluorescence on SW-AF and hypo-
autofluorescence on IR-AF (upper). One week later, both images are
much clearer (middle). Two months later, the focus has spread (dotted
focus but was due to prolonged inflammation. In this study,
5 of the 11 cases, including this recurrent case, were com-
plicated by DLBCL. Aqueous fluid or vitreous CMV-DNA
PCR was not performed for all cases, and thus it is difficult
to completely exclude the possibility of intraocular lym-
phoma (IOL) in cases complicated by DLBCL. However,
all cases showed typical characteristics of CMV retinitis;
for example, SD-OCT findings of IOL are reported to be
hyperreflective nodules in the outer retina and disruption
of ellipsoid zone without destruction of the inner retina
[35]. However, all layers of the retinal structure had been
destroyed even in the initial stage for all CMV retinitis
cases in this study. It is important to note that SD-OCT
findings are of a great help in differentiating between a
diagnosis of CMV retinitis and IOL.
One eye in the initial stage and 3 in remission were
examined by FAF. Yeh et al. [20] report FAF findings in
CMV retinitis, describing hyperautofluorescence at the
advancing border of active CMV retinitis. The 1 eye in
line); hyper- and hypoautofluorescence on SW-AF, and hypoautofluo-
rescence on IR-AF are expanded (lower). b, c The margin of the focus
shows hypoautofluorescence on SW-AF and hyperautofluorescence
on IR-FA in remission. d Normal autofluorescence is seen on SW-AF,
but an area of hyperautofluorescence is seen on IR-AF in remission.
Graphics program used: Adobe Photoshop
the initial stage showed not only hyperautofluorescence
on SW-AF but also hypoautofluorescence on IR-AF. In
remission, 2 eyes showed hypoautofluorescence on SW-AF
due to blocking by replaced proliferative tissue, and 1 eye
showed normal autofluorescence, but all 3 eyes showed
hyperautofluorescence on IR-AF. IR-AF shows hyperauto-
fluorescence which occurs in various diseases by pooling
of lipofuscin in RPE, because it is difficult to detect CMV
retinitis only on IR-AF. However, combined SD-OCT,
SW-AF, and IR-AF examination may become a helpful
tool to screen for the initial stage and to investigate the
possibility of past CMV retinitis in areas thought to be
unaffected as judged by indirect ophthalmoscopy.
Limitations of this study include the small number of
patients and the retrospective case series. However, to
our knowledge, this case series is the largest to date to
report longitudinal findings of SD-OCT for CMV retini-
tis in patients with HIV infection. It is also regrettable
that we had FAF findings for only 4 eyes of 4 patients. It
13

is very difficult to conduct a longitudinal study because
cases of HIV-associated CMV retinitis are now rare due
to the widespread use of ART, and thus only 1 example of
CMV retinitis in the initial stage was observed. Another
shortcoming is the retrospective study design with differ-
ent time points of examination and some missing images.
We also had some patients with short follow-up.
In conclusion, SD-OCT and FAF provide many new
findings not detectable by conventional examination in
various stages of CMV retinitis in patients with HIV infec-
tion, and particularly which may be of great help in screen-
ing for the initial stage of CMV retinitis in zone 1.
Acknowledgements  This work was supported in part by a Grants-
in-Aid for Research from the National Center for Global Health and
Medicine (26A201). Professional medical English editing was provided
by ThinkSCIENCE Inc., Tokyo, Japan.
Conflicts of Interest  S. Yashiro, None; T. Nishijima, None; Y. Yama-
moto, Grant (Santen Pharmaceutical’s Founder); Y. Sekine, None;
N. Y. -Hata, None; T. Iida, Grant (Bayer Yakuhin, Canon, Kowa,
Nidek, Novartis Pharma, Santen Pharmaceutical), Lecture fees (Bayer
Yakuhin, Novartis Pharma, Santen Pharmaceutical); S. Oka, None.
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