Current status of retinal detachment in AIDS patients

Cytomegalovirus retinitis is the most common opportunistic ocular infection in patients with AIDS affecting 30 to 40% of the patients. It usually occurs in patients in the terminal stage of the disease presenting with low CD4+ count (<50/mm(3)). Retinal detachment (RD) is a frequent complication of this disease, with an incidence varying from 18% to 29%. Risk factors for development of rhegmatogenous RD in patients with CMV retinitis were peripheral involvement greater than 25%, the presence of active retinitis, greater patient age and lower CD4+ cell counts. Multiple or single holes, as well as micro holes, were observed in areas of retinal necrosis leading to complex retinal detachments. Strong vitreoretinal adherences in these young patients, associated with chronic inflammation, were important elements in the pathophysiology of retinal detachment in AIDS patients. For localized RD, demarcating laser photocoagulation may delayed or avoided vitreoretinal surgery. For RD with macula off, good anatomical results have been obtained by repairing CMV retinitis-related retinal detachments using primary vitrectomy and instillation of silicone oil. Despite good anatomical results, poor long term functional results are related to optic atrophy. Since the introduction of highly active antiretroviral therapy (HAART), retinal detachment incidence has nevertheless dramatically decreased. Under HAART, CMV retinitis remains quiescent for long periods of time with a reduction of retinal detachment incidence of approximately 77%. For some patients on HAART, retinal reattachment can be obtained using vitrectomy, posterior hyaloid removal, and intraocular tamponade with SF-6 gas.     

Treating cytomegalovirus retinitis-related retinal detachment by combining silicone oil tamponade and ganciclovir implant

BACKGROUND AND OBJECTIVE: With the efficacy of pars plana vitrectomy and silicone oil infusion in treating cytomegalovirus (CMV) retinitis-related retinal detachment and the success of the ganciclovir implant in controlling CMV retinitis, we sought to evaluate the possible benefits of combining these two procedures in one surgical operation. PATIENTS AND METHODS: A retrospective review of 10 patients was conducted. Each patient was diagnosed with a CMV retinitis-related retinal detachment and treated with pars plana vitrectomy and silicone oil infusion, with simultaneous placement of a ganciclovir implant. Parameters evaluated included location of retinal detachment, reattachment rate, pre- and post-operative Snellen visual acuity, pre- and post-operative CMV retinitis activity and location, and complications of the combined procedure. RESULTS: Overall anatomic reattachment was achieved in all 10 patients. Four patients presented with macular involvement of their retinal detachments. Three of these patients experienced significant post-operative improvement in visual acuity. Surgery preserved visual acuity in the 6 patients who presented with macula attached. Best postoperative acuity was better than or equal to 20/100 in 7 (70%) patients. All 3 CMV retinitis patients with inactive retinitis preoperatively remained free of retinitis for the duration of follow up. At last follow up, 8/10 (80%) showed no active CMV retinitis and no patients experienced progression of their retinitis. CONCLUSIONS: Results of this series indicate that patients benefit from excellent anatomic reattachment rates, preservation or improvement of visual acuity in most cases, and extended control of their CMV retinitis. Combining the two procedures appears viable. Further study is warranted to assess definitive anatomic and functional outcomes resulting from this new technique.     

Results of silicone oil removal in patients with cytomegalovirus retinitis related retinal detachments

PURPOSE: To evaluate the percentage and risk indicators leading to retinal redetachment in HIV (human immunodeficiency virus) patients with CMV (cytomegalovirus) retinitis related retinal detachments that were repaired with silicone oil, and then subsequently underwent oil removal. DESIGN: Retrospective, noncomparative interventional case series. METHODS: The study cohort consisted of a series of 15 eyes in 14 patients with HIV and CMV retinitis with a retinal detachment (RD) repaired with silicone oil at a single center and followed from the time of the CMV retinitis diagnosis through the time of silicone oil removal. Patient- and eye-specific data regarding demographic and clinical characteristics were collected retrospectively and statistical analyses were performed to compare differences between the eyes that had retinal detachments versus the eyes that remained attached following removal of silicone oil. RESULTS: Eight eyes (53%) redetached after a median of 4.0 months following oil removal. Cataract surgery performed at the time of oil removal was a statistically significant risk factor for redetachment (P = .01). There was a trend for lower CD4 levels to be associated with a higher risk of retinal redetachment. The use of a scleral buckle at the time of surgery (initial RD repair or at the time of oil removal) did not reduce the risk of redetachment. CONCLUSIONS: Approximately half of the eyes with CMV related retinal detachment may safely undergo oil removal. The risk factor for redetachment was simultaneous cataract extraction at the time of silicone oil removal. There was also a trend for lower CD4 levels to be associated with a higher risk of retinal redetachment.     

Posterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome

Ocular manifestations can occur in up to 50% of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) patients and posterior segment involvement is the most common presentation. The posterior segment manifestations of AIDS can be divided into four categories: retinal vasculopathy, opportunistic infections, unusual malignancies and neuro-ophthalmologic abnormalities. Retinal microvasculopathy and cytomegalovirus (CMV) retinitis are the most common manifestations, even in the era of highly active anti-retroviral therapy (HAART). Highly active anti-retroviral therapy has been shown to cause regression of CMV retinitis, reduce the incidence of CMV-related retinal detachments, and prolong patient survival. Immune recovery uveitis is a new cause of vision loss in patients on HAART. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.     

Surgical repair of rhegmatogenous retinal detachment in immunosuppressed patients with cytomegalovirus retinitis.

The authors performed retinal reattachment surgery in 29 eyes of 24 patients with acquired immune deficiency syndrome virus with retinal detachment associated with cytomegalovirus (CMV) retinitis and documented the course of eight additional untreated eyes. Retinal detachment repair using vitrectomy, posterior hyaloid removal, and intraocular tamponade with silicone oil or SF-6 gas resulted in a total retinal reattachment rate of 76% and a macular attachment rate of 90% in one operation. The mean postoperative visual acuity (best corrected) was 20/60, but, in some patients, the visual acuity decreased because of progressive retinitis. Prophylactic laser photocoagulation of fellow eyes to surround CMV lesions did not appear to prevent retinal detachment. The mean postoperative survival was 37 weeks (range, 8 to 127 weeks). The surgical techniques used and pathophysiology of these retinal detachments are discussed.     

Prophylactic argon laser coagulation for rhegmatogenous retinal detachment in AIDS patients with cytomegalovirus retinitis

· Background: The incidence of cytomegalovirus (CMV) retinitis in patients with acquired immunodeficiency syndrome (AIDS) reaches 20–45%. Despite aggressive medical treatment, rhegmatogenous retinal detachments develop in up to 30% of the affected eyes. Surgical repair is often difficult due to multiple, large and hardly visible retinal holes with vitreal traction. Pars plana vitrectomy with instillation of silicone oil is the procedure of choice, giving limited functional results with anatomical reattachment. · Methods: We performed prophylactic laser coagulation in AIDS patients with medically treated CMV retinitis to prevent a progressive retinal detachment. Twenty-two quiescent CMV lesions in 22 eyes of 20 patients were treated with argon green laser coagulation. Each CMV lesion was completely surrounded with a double or triple row of laser spots (500–600 μm; 0.2 s; gray-white lesions). · Results: The duration of follow-up was 2–24 months. Histopathologic evaluation was possible in two eyes of one patient. Reactivated or smoldering CMV retinitis crossed the laser scars in 11 eyes, making additional laser coagulation necessary. In four eyes retinal holes in the CMV scar tissue led to retinal detachment, which stopped at the laser scar. In three eyes the detachment is still controlled by the laser scar. In one eye, the detachment stopped at the laser scar for 6.5 months and then slowly progressed across it. There were no complications associated with our laser treatment. · Conclusion: Prophylactic argon laser coagulation in quiescent CMV retinitis seems to reduce the rate of progressive retinal detachment with no need for vitrectomy and silicone oil tamponade. Received: 25 January 1997 Revised version received: 20 August 1997 Accepted: 1 October 1997     

Pharmacokinetics of the ganciclovir implant in the silicone-filled eye

PURPOSE: Ganciclovir (GCV) implants are highly effective in delaying the progression of cytomegalovirus (CMV) retinitis. Rhegmatogenous retinal detachments can occur in untreated eyes with CMV retinitis or in eyes treated with anti-CMV therapy, which may include placement of a GCV implant. The clinical management of CMV retinitis and associated retinal detachment often involves the concurrent use of silicone oil and GCV implants. The authors investigated the effect of silicone oil tamponade on intravitreal drug levels achieved with the GCV implant. METHODS: The authors performed gas compression vitrectomy in the right eyes of 29 New Zealand white rabbits. They then inserted a 5-mg GCV implant into the vitreous cavity through an inferotemporal sclerotomy. Saline (1 cc), silicone oil 0.5 cc, or silicone oil 1.0 cc was then injected into the midvitreous cavity of 9, 8, and 12 rabbits, respectively. On postoperative days 21, 42, and 70, the rabbits were killed and the right eyes were immediately collected and stored at -70 degrees C until all samples were obtained. Vitreous was then isolated and drug levels were determined by high-pressure liquid chromatography. RESULTS: Vitreous GCV levels at days 21 and 42 were similar in both the saline-filled and silicone oil-filled eyes. At day 70, GCV levels in both the saline- and silicone-filled eyes were statistically significantly lower than at day 21 (P < 0.05 for all groups). In addition, at day 70, GCV levels in the saline-filled eyes were significantly lower than in silicone-filled eyes (saline versus 0.5 cc oil, P = 0.01; saline versus 1 cc oil, P = 0.09). CONCLUSIONS: Effective GCV levels are maintained in the aqueous phase of the vitreous cavity of eyes with silicone oil tamponade. Ganciclovir levels may be maintained longer in eyes with silicone oil tamponade than in those without. These results support the use of combined GCV implants and silicone oil tamponade in patients with CMV retinitis and associated retinal detachment.     

Retinal pigment epithelial dysfunction in human immunodeficiency virus-infected patients with cytomegalovirus retinitis

OBJECTIVE: Prior clinical observations led the authors to examine electrophysiologic measures of retinal (electroretinogram [ERG]) and retinal pigment epithelial (electro-oculogram [EOG]) function in patients infected with human immunodeficiency virus (HIV) who either had or did not have cytomegalovirus (CMV) retinitis in order to determine if the ERG or EOG measures were differentially affected in CMV retinitis. DESIGN: Cross-sectional study. PARTICIPANTS: Forty-one HIV-infected patients (20 with and 21 without CMV retinopathy) were evaluated. INTERVENTION: ERGs and EOGs were recorded. Patients' fundi were evaluated by indirect ophthalmoscopy or fundus photography. MAIN OUTCOME MEASURES: The ERG a- and b-wave amplitudes and EOG light/dark amplitude ratio (L/D ratio) from the eyes of all patients were compared with values 2 standard deviations from the mean of a normal sample. The area of the retinal lesions was estimated from fundus photographs or from careful drawings made during indirect ophthalmoscopy. RESULTS: The majority of the eyes (64.5%) of the patients with CMV retinitis had subnormal L/D ratios, and most eyes (95%) of patients without CMV retinitis had normal L/D ratios. Only six eyes (four with and two without CMV retinopathy) had subnormal a-wave amplitudes, and there was no significant correlation between a-wave amplitude and the L/D ratio for patients with CMV retinitis. Most eyes (80.6%) of the patients with CMV retinitis had subnormal b-wave amplitudes, but there was no significant correlation between b-wave amplitude and L/D ratio in the patients with CMV retinitis. In three patients with CMV retinitis selected to exemplify the range of effects on the ERG and EOG, the b-wave amplitude loss was roughly proportional to the area of retina visibly affected in indirect ophthalmoscopy. One patient had a nonrhegmatogenous retinal detachment. CONCLUSIONS: Middle retinal function, as reflected in the b-wave amplitude, and retinal pigment epithelial function, as reflected in the L/D ratio, were both compromised in CMV retinitis, but the effect on function in the two layers of the retina appeared independent because there was no significant correlation between the L/D ratio and b-wave amplitude. The decrease in L/D ratio was not secondary to loss of photoreceptor function and probably represents a dysfunction of the retinal pigment epithelium because there was no significant correlation between a-wave amplitude, which was normal in most cases, and L/D ratio. The inner retinal pathology of CMV retinitis is visible clinically and was associated with decreases in b-wave amplitude in this and previous studies. The significant independent retinal pigment epithelial dysfunction demonstrated in this study may be an important predisposing factor to retinal detachment in CMV retinitis.     

Management of CMV retinal detachments in the new era of antiretroviral therapy

In the past, retinal detachment occurred at a rate of 38% after one year of cytomegalovirus retinitis (CMVR). The current rate of detachment may be reduced by improved therapies for CMVR. In addition, the number of new patients acquiring CMVR has fallen, resulting in a lower incidence of these detachments. Another important effect of the new era of antiviral therapy on CMVR-related detachments includes longer patient survival with a need to select surgical strategies that will provide the best long-term visual outcome while still recognizing the unique difficulties posed by detachments in necrotic retinas. Vitrectomy with planned removal of silicone oil, scleral buckle, vitrectomy with gas tamponade, and laser demarcation are strategies that may provide excellent visual and anatomic results for retinal detachments with various characteristics. The final selection of the surgical approach depends on the mechanical factors of the detachment and patient factors such as immune status, expected survival, control of retinitis, and visual needs.     

Management of CMV retinal detachments in the new era of antiretroviral therapy

In the past, retinal detachment occurred at a rate of 38% after one year of cytomegalovirus retinitis (CMVR). The current rate of detachment may be reduced by improved therapies for CMVR. In addition, the number of new patients acquiring CMVR has fallen, resulting in a lower incidence of these detachments. Another important effect of the new era of antiviral therapy on CMVR-related detachments includes longer patient survival with a need to select surgical strategies that will provide the best long-term visual outcome while still recognizing the unique difficulties posed by detachments in necrotic retinas. Vitrectomy with planned removal of silicone oil, scleral buckle, vitrectomy with gas tamponade, and laser demarcation are strategies that may provide excellent visual and anatomic results for retinal detachments with various characteristics. The final selection of the surgical approach depends on the mechanical factors of the detachment and patient factors such as immune status, expected survival, control of retinitis, and visual needs.     

Adult cytomegalovirus inclusion retino-uveitis.

A 27-year-old male renal transplant recipient acquired cytomegalovirus (CMV) infection of both eyes. This was characterized early by a distinctive necrotic retinitis with discrete advancing edges. A large exudative retinal detachment and hypopyon developed in one eye, and cultures from the anterior chamber aspirate grew CMV. Cytomegalovirus was also isolated from the urine and throat; after serial negative base-line titers, CMV antibody titer became positive. At autopsy CMV was isolated from lung, esophagus, and kidney tissue. Light and electron microscopic studies demonstrated extensive necrosis and disruption of the sensory retina and retinal pigment epithelium with exudative retinal detachments. The diseased retinal cells contained a multiplicity of viral particles in various stages of maturity. Cytomegalic inclusion-bearing cells were demonstrated in the choroid of the more severely affected eye.     

Antiviral therapy with ganciclovir for cytomegalovirus retinitis and bilateral exudative retinal detachments in an immunocompromised child

A child with bilateral cytomegalovirus (CMV) retinitis, vitritis, and exudative retinal detachments, who was in remission from stage IV neuroblastoma and status post-chemotherapy and autologous bone marrow transplantation, was treated with ganciclovir. The drug is a new acyclic nucleoside antiviral drug with potent antiCMV activity. There was bilateral retinal reattachment, clearing of vitritis and regression of retinal exudates and hemorrhages, with concomitant resolution of viral shedding in urine and blood, on ganciclovir 7.5 mg/kg per day. There was recurrence of exudative detachments, vitritis and retinitis when the dose was reduced to 2.5 mg/kg per day, and regression of these findings when the dose was again increased to 7.5 mg/kg per day. Despite continued therapy at this dose, a relapse occurred. When the dose of drug was doubled to 15 mg/kg per day, there initially was a partial therapeutic response, followed by a subsequent relapse. No further response was seen when the dose was increased to 19.5 mg/kg per day. This patient was treated with ganciclovir for a total of 192 days. No adverse reactions to ganciclovir were seen. On the last day of drug administration, there were persistent bilateral exudative retinal detachments and progressive optic nerve head involvement with optic disc pallor, despite quiescence of the retinitis.     

Retinal nerve fiber layer evaluation in human immunodeficiency virus-positive patients

PURPOSE: To determine the effect of human immunodeficiency virus (HIV) infection on topographic measures of the optic disk and the retinal nerve fiber layer. METHODS: A cross-sectional study at the Acquired Immunodeficiency Syndrome (AIDS) Ocular Research Unit at the University of California, San Diego. Retinal nerve fiber layer thickness at the optic nerve head was evaluated using the Heidelberg Retinal Tomograph, a confocal scanning laser tomograph in 38 HIV-positive and 24 age-matched HIV-negative subjects. RESULTS: HIV-positive patients without CMV retinitis showed significant differences from HIV-negative normal controls in a number of measures of the retinal nerve fiber layer. This indicated a loss of retinal ganglion cells in HIV-positive patients without retinitis. HIV-positive patients with CMV retinitis were worse in most measurements than both HIV-negative controls and HIV-positive patients without CMV. CONCLUSIONS: Significant thinning of the retinal nerve fiber layer occurs in HIV-positive patients without infectious retinopathy, and there are further changes in the optic disk associated with CMV retinitis. Confocal scanning laser tomography may be of use in the diagnosis of early HIV-associated visual function loss.     

巨细胞病毒性视网膜炎与获得性免疫缺陷综合征

目的 探讨巨细胞病毒性视网膜炎与获得性免疫缺陷综合征的关系、临床表现及诊断、治疗。 方法 观察分析56例巨细胞病毒(cytomeglovirus,CMV)性视网膜炎合并获得性免疫缺陷综合征(acquired immunodeficiency syndrome,AIDS)患者95只眼，对其眼底、视力、T辅助细胞的细胞受体4（CD4 ＋）计数及预后进行观察随访2周～18个月。 结果 56例患者在诊断为巨细胞病毒性视网膜炎之前AIDS病程为4～26个月。95只眼56例患者中，眼底病灶表现为颗粒型者55只眼，其中46只眼位于周边部；爆发型者25只眼，均位于后极部，视网膜坏死灶致密伴斑片状出血和血管炎；颗粒型与爆发型病灶混合存在者15只眼；其中7只眼合并有视神经乳头炎；患者就诊时视力为眼前数指至0.5，病变广泛者及病变位于后极部者视力下降尤为严重。30例患者CD4 ＋细胞计数为0～30 个/μl,平均(15±9) 个/μl。患者存活时间为3～18个月。接受更昔洛韦(ganciclovir)治疗组患者视力多数提高，CD4 ＋T细胞计数明显升高，未治疗组患者92%病变呈进行性发展，视力显著下降。 结论 CMV性视网膜炎是AIDS病的主要眼部并发症，临床上以坏死性视网膜炎伴出血及血管炎为特征，目前治疗主要用更昔洛韦。 (中华眼底病杂志, 2002, 18: 89-91)     

Retinitis in euthymic mice following inoculation of murine cytomegalovirus (MCMV) via the supraciliary route.

Cytomegalovirus (CMV) retinitis is the most frequent infectious ocular complication of the acquired immune deficiency syndrome (AIDS). Currently, there are few animal models to study the virologic and immunologic factors which contribute to the pathogenesis of CMV retinitis. In these experiments, 1-2 X 10(4) PFU of murine cytomegalovirus (MCMV) was inoculated into the supraciliary space of BALB/c mice. Within three days of inoculation, moderate iridocyclitis was observed which progressed to necrosis of the ciliary body by day 14. Approximately 60% of the mice developed typical retinitis characterized by virus-infected cytomegalic cells in the retina and retinal pigment epithelium, focal retinal infiltrates, transition zones between uninvolved and involved retina, and optic neuritis. The remaining animals exhibited atypical retinitis characterized by non-specific retinal inflammation in the absence of obvious viral infection. This murine model of CMV retinitis shares some features with retinitis observed in AIDS patients with CMV retinitis and may be useful to evaluate the efficacy of immunologic and/or pharmacologic treatment strategies for CMV retinitis.     

Cytomegalovirus retinitis and ocular complications in AIDS patients in Togo

BACKGROUND: Cytomegalovirus retinitis seems to be an uncommon complication in African AIDS patients. This study was conducted in 200 patients in order to evaluate AIDS eye related complications with specific focus to cytomegalovirus retinitis. MATERIAL AND METHODS: During a period of 20 months, 200 patients (83 men and 117 women) presenting WHO AIDS case definition diagnosis were enrolled for a complete ocular examination comprising external, anterior segment and retinal fundus and fluorescein angiographic examination. RESULTS: For the whole, 200 patients underwent ocular examinations; of them 121 (60.5%) developed ocular complications.The most frequent complications were cotton wool spots (25.5%), cytomegalovirus (CMV) retinitis (21.5%), retinal hemorrhage (6%), papilloedema (3%), chorioretinal toxoplasmosis (3%), peripheral retinal vascularitis (2. 5%), herpes zoster ophthalmicus (2%). Among those with CMV retinitis, bilateral lesions were found in 30 cases, and unilateral ones in 13 cases. Poor vision was associated with the presence of CMV retinitis in 88% of cases.Death occurred in a mean range of 22 days after the "presumed" diagnosis of CMV retinitis. CONCLUSION: Cytomegalovirus retinitis represents the second ocular complication in AIDS patients in this study. Poor visual outcome was associated in 88% of cases. These results demonstrate that in some west African countries, CMV retinitis may be a common complication in AIDS patients.     

Noncytomegalovirus-related chorio-retinal manifestations of the acquired immunodeficiency syndrome

The diagnosis of the ocular manifestations of AIDS is based initially on the clinical appearance of the lesions. However, retinal and choroidal lesions in AIDS patients are frequently the manifestation of disseminated disease. In one autopsy series, 15 of 18 patients with infectious choroiditis died of systemic infection by the same organism causing the choroiditis. Despite the fact that more than 90% of posterior segment infections in AIDS patients are caused by CMV, careful examination with appropriate consideration of differential diagnosis is necessary in all cases in which a classic pattern of CMV retinitis is not seen. Extensive history taking, discussion with the primary care physician, and the appropriate systemic work-up can greatly facilitate the diagnosis of the most likely cause of the apparent opportunistic infection. It is important to remember that noninfectious causes of HIV-related retinal disease can have a similar clinical pattern as infectious causes. In particular, physicians must be careful not to confuse early CMV retinitis with HIV-related noninfectious retinal vasculopathy, the most common retinal finding in patients with HIV disease. In a patient with multifocal superficial lesions in the posterior pole, particularly if the CD4+ count is more than 100 cells/microL, reevaluation rather than immediately initiating therapy may prevent the inadvertent commitment to chronic therapy implicit in a diagnosis of CMV retinitis.     

High-dose (5000-microg) intravitreal ganciclovir combined with highly active antiretroviral therapy for cytomegalovirus retinitis in HIV-infected patients in Venezuela

PURPOSE: To describe the use of high doses of intravitreal ganciclovir combined with highly active antiretroviral therapy (HAART) for the treatment of cytomegalovirus (CMV) retinitis in human immunodeficiency virus (HIV)-infected patients. METHODS: Thirteen HIV-infected patients (18 eyes) with active CMV retinitis (83.3% in zone 1 and 38.4% resistant) participated in this prospective interventional case series. Patients were treated with high dose intravitreal ganciclovir (5.0 mg/0.1 mL once a week) in combination with HAART therapy. Intravitreal injections were discontinued once CMV retinitis healed if there was a significant increase in CD4+ count (any increase of > or 50 cells/microL to levels over 100 cells/microL sustained for at least 3 months). Mean follow-up was 15.6 months. Main outcome measures included assessment of visual acuity and retinal inflammation (CMV retinitis activity). A matched historical control group of 20 eyes (15 patients) with CMV retinitis treated with systemic ganciclovir (intravenous [induction] and oral [maintenance]) was included. RESULTS: Complete regression of the retinitis was obtained with high doses of intravitreal ganciclovir in 88.8% of eyes (two patients died during follow-up) at a mean of 4.5 weeks (2 to 8 weeks). Visual acuity improved two or more lines in 61.1% of eyes. No ganciclovir retinal toxicity was identified. Three eyes presented CMV retinitis reactivation at a mean of 25.6 days after their last injection. Complications (33.3%) included retinal detachment (RD; 3 eyes), immune recovery uveitis (IRU; 2 eyes), and endophthalmitis (1 eye). In our control group complete regression of the retinitis was obtained in 100% of eyes at a mean of 4 weeks (3 to 7 weeks). However, 12 eyes (60%) presented with CMV retinitis relapse at a mean of 29 days (21 to 32 days) after initiating oral ganciclovir (maintenance). Complications included RD (7 eyes, 35%) and IRU (3 eyes, 15%). Severe neutropenia occurred in 2 patients (13%). CONCLUSIONS: High doses of intravitreal ganciclovir (5.0 mg) once a week in combination with HAART therapy is effective to control CMV retinitis, and may be discontinued after CMV retinitis has healed if immune reconstitution with a significant increase in CD4+ count has occurred.     

Coat's type retinitis pigmentosa

A twenty-two-year-old woman with a history of long-Standing retinitis pigmentosa and recently discovered bilateral exudative retinal detachments of the Coats' type is described. This widely unrecognized association has been reported to occur in up to 2% of patients with retinitis pigmentosa. Unlike the usual Coats' syndrome, it is more often bilateral, shows no sex preference and occurs in older individuals. Heightened awareness of this potentially treatable complication of retinitis pigmentosa may facilitate earlier recognition of the problem, which may lead to more timely treatment and a better prognosis.     

Failure of argon laser to halt cytomegalovirus retinitis

This report describes the experience with Argon laser used in an attempt to slow the advance of CMV retinitis in two eyes of two patients with AIDS, who were not able to be treated with antiviral chemotherapy. The treatment was performed to create a retinal scar to attempt to slow cell-to-cell spread of the virus through retinal tissue. In both patients, treatment was not successful in preventing spread of the CMV infection. Foci of retinitis, beyond the treated areas, became apparent within 2 weeks of treatment. Autopsy histopathology confirmed the diagnosis of CMV retinitis in both patients and necrosis due to CMV retinitis was seen in laser treated retina, and on both sides of laser treated retina.