TREATMENT OF CYTOMEGALOVIRUS RETINITIS -
AN UNUSUAL CHALLENGE
Melinder K. Bhupinder, Siva K. Sundralingam, Fazilawati Q, Shelina OM
Objective :
To report a case of recurrence of Cytomegalovirus
Retinitis despite treatment with systemic antiviral agents
Method : Case Report
Introduction
Human Cytomegalovirus a Herpesviridae, is known to
manifest in immunocompromised patients.¹ The risk of
Cytomegalovirus disease was related to the severity and
duration of immunosuppression with a probability of
Cytomegalovirus disease at 2 years is 21.4% for patients
with a CD4 of <50/mm³. Retinitis is the most frequent
visceral localization, occuring in 60-70% of patients
infected with Cytomegalovirus² . Cytomegalovirus retinitis
is a necrotizing retinitis, which, if untreated, will spread
throughout the retina over a period of months and result
in total retinal destruction and blindness. Hence,
treatment of Cytomegalovirus retinitis is critical in
preserving vision and the quality of life.
Case Presentation
History
A 66-year-old gentleman diagnosed with non-Hodgkin’s
lymphoma of base of tongue whom had completed
chemotherapy and radiotherapy presented with three
months history of bilateral blurring of vision. Best
corrected vision was 6/36 and 6/9 for right and left eye
respectively. Anterior segments were normal. Both eye
fundus assessment showed zone one retinitis features
with flame shaped haemorrhages along the vascular
arcades with hyperaemic optic discs changes.(Figure 1)
Vitreous tap was positive for Cytomegalovirus.
Management and progression
Treatment was initiated with intravitreal and systemic
ganciclovir. However, patient had subsequently patient
developed neutropenic sepsis from systemic ganciclovir
toxicity. Patient was then converted to intravenous foscarnet
induction followed by maintenance dose for six weeks with
weekly intravitreal ganciclovir. Two weeks upon completion of
anti-viral treatment, he developed recurrent retinitis lesions
bilaterally. The lesions regressed with biweekly maintenance of
intravitreal ganciclovir with no further recurrence. (Figure 2)
Conclusion
Figure 1 Cytomegalovirus retinitis is an oppurtunistic infection that
occurs in immunocompromised patients infected with Human
Immunodeficiency Virus.² It can also occur in patients on
chemotherapy. Ganciclovir and foscarnet, both being virustatic
agents, has been proven to be equally effective in treating this
condition. However, due to the high tendency of
Cytomegalovirus retinitis to progress, treatment may need to be
effective and prolonged .² Langner-Wegscheider et al in 2009
reported patients with Cytomegalovirus retinitis who were
unable to stop systemic ganciclovir therapy were however
successfully tapered with either intravitreal injections of
ganciclovir or an intravitreal ganciclovir implant.¹ Hence,
prolonged and gradual tapering of intravitreal ganciclovir was
successful in controlling and managing the infection in this
patient.
Figure 2 ¹Intravitreal Ganciclovir in the management of non-AIDS related human
cytomegalovirus retinitis Can J Ophthalmol 2010;vol 45 No 2
² Management of CMV Retinitis in the era of highly active antiretroviral therapy Marc
Jouan, Christine Katlama International Journal of Antimicrobial Agents 13(1999)
³Cytomegalovirus Retinitis in HIV negative patients: A Practical Management Approach
Opthalmology Volume 122, Number 4, April 2015