Retinal vasculitis associated with chickenpox

PURPOSE: To report retinal vasculitis in a young, immunocompetent Asian female adult with chickenpox. METHODS: Interventional case report. A 32-year-old woman had chickenpox 2 weeks before blurred vision in the left eye. The visual acuity was 20/20 for the right eye and 30/50 for the left eye. The left eye presented keratic precipitates, moderate (2+) cells in the anterior chamber and numerous cells (3+) in the vitreous. The disk was normal. Perivenous exudation was noted mainly in the inferior retina. The sheathed retinal vessels showed late staining but no remarkable leakage on fluorescein angiography. The right eye was normal. RESULTS: After treatment with acyclovir for 10 days, the visual acuity in the left eye improved to 20/20, and the vasculitis resolved. CONCLUSION: Retinal vasculitis may present as a complication of primary varicella infection in an immunocompetent adult.     

Cytomegalovirus in aqueous humor from an eye with corneal endotheliitis

PURPOSE: To report cytomegalovirus (CMV) DNA in aqueous humor from a patient with unilateral corneal endotheliitis. DESIGN: Case report. METHODS: A 51-year-old man presented with unilateral corneal endotheliitis with linear keratic precipitates and coin-shaped lesions. Tear and aqueous humor samples were subjected to polymerase chain reaction to look for DNA from herpes simplex virus (HSV), varicella zoster virus (VZV), and CMV. RESULTS: Aqueous humor from the diseased eye contained DNA from CMV but not HSV or VZV. Its specificity was confirmed by Southern blot tests. Intravenous ganciclovir treatment resulted in the localization of his corneal edema and the reduction in keratic precipitates. There was severe destruction of corneal endothelial cells. CMV DNA was not detected in tears or control samples. CONCLUSIONS: In this healthy man with corneal endotheliitis, we detected CMV DNA in aqueous humor from the affected eye, but not HSV or VZV. This suggests that CMV may cause corneal endotheliitis in patients without immunodeficiency.     

Demonstration of "owl's eye" morphology by confocal microscopy in a patient with presumed cytomegalovirus corneal endotheliitis

PURPOSE: To report confocal microscopic observations of characteristic corneal endothelial lesions in a patient with presumed cytomegalovirus (CMV) corneal endotheliitis. DESIGN: Case report. METHODS: A 77-year-old, immunocompetent man was admitted with corneal edema, keratic precipitates, and coin-shaped lesions in the right eye. Confocal microscopy was performed to examine the corneal endothelium. Polymerase chain reaction (PCR) was used to identify viral DNA in an aqueous humor sample. RESULTS: CMV DNA was detected by PCR. Confocal microscopy showed large corneal endothelial cells with an area of high reflection in the nucleus surrounded by a halo of low reflection. This "owl's eye" morphology is characteristic of CMV infection. Topical and intravenous ganciclovir treatment resulted in rapid resolution of the corneal precipitates and edema, followed by disappearance of the owl's eye morphology. CONCLUSIONS: Confocal microscopy can detect the owl's eye morphology in the corneal endothelium of patients with presumed CMV corneal endotheliitis.     

Clinical Features of CMV-Associated Anterior Uveitis

Cytomegalovirus (CMV) anterior uveitis is the most common ocular manifestation of CMV disease in immunocompetent individuals. It is thought to be due to a local reactivation of latent CMV and is usually unilateral. The acute form presents as Posner-Schlossman Syndrome, a recurrent hypertensive anterior uveitis with few granulomatous keratic precipitates. There are geographic differences in the chronic form of CMV anterior uveitis. Asian patients commonly present as Fuchs Uveitis Syndrome with diffuse stellate keratic precipitates, while the European patients present with a chronic hypertensive anterior uveitis with fewer keratic precipitates that are brown in color and located inferiorly. Characteristic features of CMV anterior uveitis include mild anterior chamber inflammation, elevated intraocular pressure, stromal iris atrophy. Synechiae, macular edema and retinitis are typically absent. CMV disease may also be associated with the development of corneal endotheliitis with a reduced endothelial cell count. Long-term complications include glaucomatous optic neuropathy and cataract formation.     

人类免疫缺陷病毒感染及获得性免疫缺陷综合征患者眼部病变的诊断与治疗

目的 探讨人类免疫缺陷病毒(HIV)感染及获得性免疫缺陷综合征(AIDS)患者的眼部病变特点、临床症状及治疗原则.方法 回顾性系列病例研究.回顾性分析110例(220只眼)HIV感染和AIDS患者的临床资料,包括患者视力、眼前节、眼底检查和荧光素眼底血管造影及外周血CD_4~+T淋巴细胞检测结果,其中2例(4只眼)AIDS合并巨细胞病毒(CMV)性视网膜炎患者施行了更昔洛韦玻璃体腔注药治疗.患者年龄、HIV感染时间与HIV视网膜病变及CMV性视网膜炎的相关性采用Pearson相关分析法,性别与HIV视网膜病变及CMV性视网膜炎的相关性采用Pearson ChiSquare分析法,正常眼底组、HIV视网膜病变组、CMV性视网膜炎组间CD_4~+T淋巴细胞计数比较采用多个独立样本的秩和检验.结果 患者初诊视力为无光感者5只眼,光感至0.04者10只眼,0.05～0.2者14只眼,0.3～0.7者62只眼,0.8及以上者129只眼.110例(220只眼)HIV感染和AIDS患者中,有25只眼角膜后有灰白色细小或色素性沉着物.22只眼房水闪光(+)或(++).4只眼虹膜后粘连.28只眼晶状体混浊.34只眼确诊为HIV视网膜病变,眼底表现为棉絮斑、视网膜出血及微血管瘤.32只眼确诊为AIDS合并CMV性视网膜炎,26只眼的眼底表现为沿血管分布的浓厚黄白色病损区,其上片状出血,边缘有不规则黄白色颗粒.3只眼为眼底病变晚期,表现为视网膜萎缩、视网膜血管硬化和狭窄、视神经萎缩.3只眼合并视网膜脱离.正常眼底的HIV感染者及AIDS患者CD_4~+T淋巴细胞计数中位数为100.0个/mm~3,HIV视网膜病变患者CD_4~+T淋巴细胞计数中位数为41.0个/mm~3,CMV性视网膜炎患者CD_4~+T淋巴细胞计数中位数为18.0个/mm~3.CD_4~+T淋巴细胞计数比较,正常眼底组与HIV视网膜病变组相比,差异有统计学意义(x~2=4.848,P=0.028);正常眼底组与CMV性视网膜炎组相比,差异有统计学意义(x~2=15.696,P=0.000);HIV视网膜病变组与CMV性视网膜炎组相比,差异有统计学意义(x~2=4.860,P=0.027).2例(4只眼)CMV性视网膜炎患者行更昔洛韦(400 μg)玻璃体腔注药后,视力提高,眼底病变明显消退.结论 视网膜微血管病变是HIV感染及AIDS常见的眼部并发症,CMV性视网膜炎是AIDS晚期最严重的眼部并发症.高效抗逆转录病毒治疗可重建患者的免疫功能,更昔洛韦玻璃体腔注药可有效治疗CMV性视网膜炎并挽救患者视力.     

Regression of cytomegalovirus retinitis after decreased doses of immunosuppressive agents in a renal transplant recipient

A renal transplant recipient treated with immunosuppressive agents complained of blurred vision in 1 eye. Hemorrhages and fluffy, white retinal lesions were seen in both fundi. Cytomegalovirus (CMV) DNA was detected in the vitreous. Dosages of cyclosporine and methylprednisolone were decreased, and the azathioprine regimen was discontinued. No anti-CMV agents were given. The retinitis diminished markedly. Possibly, CMV retinitis in immunosuppressive conditions other than acquired immunodeficiency syndrome may regress if dosages of immunosuppressive drugs are decreased.     

Preservation of vision through Weiss ring after dense vitreous hemorrhage.

PURPOSE: To report an unusual case of retained vision through a Weiss ring in the setting of dense vitreous hemorrhage. METHOD: Case report of a 55-year-old woman with a 23-year history of type 1 diabetes mellitus who presented with new onset of blurred vision in the left eye as a result of a dense vitreous hemorrhage. RESULTS: The patient had received full scatter laser photocoagulation for proliferative diabetic retinopathy in the right eye several years earlier and reported previous resolving episodes of vitreous hemorrhage in the left eye. Best-corrected visual acuity in the left eye was hand motions at 3 feet. However, with careful head positioning visual acuity improved to 20/40 through a small clear central island. Examination of the left fundus showed a dense vitreous hemorrhage with a clear, mobile opening in the posterior hyaloid corresponding to the Weiss ring. The retina could be partially visualized only through the area of the Weiss ring. CONCLUSIONS: This unusual case demonstrates the anatomical relationship between the posterior hyaloid and Weiss ring.     

Prevalence of visual symptoms among patients with newly diagnosed cytomegalovirus retinitis

PURPOSE: To determine the prevalence and type of visual symptoms among human immunodeficiency virus (HIV)-positive patients with newly diagnosed cytomegalovirus (CMV) retinitis. METHODS: The authors conducted a retrospective review of the charts of all HIV type 1-infected patients at Parkland Memorial Hospital (Dallas, TX) who had newly diagnosed CMV retinitis between July 1, 1993, and September 30, 1997. Information recorded included demographics, results of laboratory evaluations including CD4 cell count, visual symptoms at the time of diagnosis, and the zone and extent of retinal involvement at presentation. Visual symptoms in the patients with CMV retinitis were compared with those in a control group of HIV-positive patients who were screened for CMV retinitis but were not diagnosed with retinitis. RESULTS: Of 183 eyes (138 patients), 83% (88% of patients) had visual symptoms at the time of diagnosis. The most common presenting symptoms were blurred vision (67% of patients), floaters (49%), flashes of light (16%), eye pain (7%), and scotomata (3%). Compared with the control group of patients without CMV retinitis, patients with CMV retinitis were more likely to have any eye symptoms (88% versus 53%, respectively) as well as blurred vision, floaters, and either blurred vision or floaters (P < 0.0001). Eyes with zone 1 retinal involvement had an 88% incidence of visual symptoms at the time of diagnosis compared with 77% of eyes with peripheral retinal involvement (zones 2 and 3) (P > 0.05). Patients with zone 1 disease were more likely to note blurred or decreased vision than were patients with zone 2 or 3 disease (75% versus 47%, respectively; P < 0.0001). Eyes with <25% retinal involvement had a 76% rate of visual symptoms, which was significantly lower than the 90% rate noted among eyes with >25% retinal involvement (P < 0.05). CONCLUSIONS: Most HIV-infected patients with newly diagnosed CMV retinitis had visual symptoms at presentation regardless of the zone of retinal involvement. The incidence of visual symptoms correlated with the degree of retinal involvement.     

Bilateral toxoplasma retinochoroiditis simulating cytomegalovirus retinitis in an allogeneic bone marrow transplant patient

A 36-year old female with acute myelogenous leukemia presented with a sudden decrease in vision one month following bone marrow transplantation (BMT). She had been taking multiple immunosuppressants to treat her recently-developed graft-versus-host-disease (GVHD). Visual acuity was 20/60 in her right eye and 20/25 in her left. Ophthalmic examination revealed mild inflammatory reaction in both the anterior chamber and the vitreous of both eyes, as well as densely opaque yellow-white infiltrates with well-demarcated borders in the posterior retina of both eyes. She was originally diagnosed as CMV retinitis, but treatment with ganciclovir failed to improve her ocular condition. Subsequent work-up, including serology and brain MRI, led to a diagnosis of combined ocular and cerebral toxoplasmosis. After 6 weeks of antiparasitic therapy, her retinal lesions became inactive and her cerebral lesions improved. Immunosuppressed patients with necrotizing retinochoroiditis should be suspected of having toxoplasmosis. Accurate differentiation between this condition and CMV, and early intervention with the appropriate treatment may be critical to preserve the best vision.     

Cytomegalovirus retinitis after low-dose intravitreous triamcinolone acetonide in an immunocompetent patient: a warning for the widespread use of intravitreous corticosteroids

We report the case of an immunocompetent 78-year-old woman who developed cytomegalovirus (CMV) retinitis after a single intravitreous injection of triamcinolone acetonide (IVTA). Review of medical records. The patient with macular edema secondary to branch retinal vein occlusion developed peripheral retinitis with hemorrhagic and inflammatory vascular sheathing 3 months after IVTA. A presumptive diagnosis of viral retinitis was confirmed by polymerase chain reaction (PCR) of the aqueous humor tap. The PCR test was positive for CMV DNA. The patient slowly responded to intravenous ganciclovir and oral valganciclovir. After therapeutic vitrectomy for intercurrent vitreous hemorrhage, and while still under treatment, the retinitis resolved completely with final visual acuity of 20/25. CMV retinitis can occur after local immunosuppression with IVTA in an immunocompetent patient with no other systemic risk factors.     

High-dose intravitreal gancyclovir for cytomegaloviral (CMV) retinitis

Abstract
A patient with acquired immune deficiency syndrome (AIDS) with bilateral cytomegaloviral (CMV) retinitis who had become neutropaenic from intravenous gancyclovir, was treated with a total of 16 intravitreal 2 mg/0.l ml doses of gancyclovir in each eye under topical anaesthesia. The injections were well tolerated with no evidence of retinal toxicity. A moderate vitreous haze which did not affect vision was the only complication. The patient retained useful vision until the time of his death, three months later.     

High-dose intravitreal gancyclovir for cytomegaloviral (CMV) retinitis

A patient with acquired immune deficiency syndrome (AIDS) with bilateral cytomegaloviral (CMV) retinitis who had become neutropaenic from intravenous gancyclovir, was treated with a total of 16 intravitreal 2 mg/0.1 ml doses of gancyclovir in each eye under topical anaesthesia. The injections were well tolerated with no evidence of retinal toxicity. A moderate vitreous haze which did not affect vision was the only complication. The patient retained useful vision until the time of his death, three months later.     

Stromal Keratitis with Endophthalmitis Caused by Vittaforma Corneae in an Immunocompetent Patient: A Case Report

Purpose: To describe a case of microsporidial stromal keratitis with endophthalmitis in an immunocompetent patient.Methods: Case reportResults: A 58-year-old HIV-negative man presented with stromal keratitis in his right eye. The patient demonstrated subsequent vitritis, multifocal retinitis and arteritis, and macular edema with recurrent vitreous hemorrhage after therapeutic keratoplasty. Numerous microsporidial spores were detected in corneal tissues by modified trichrome stain. Both corneal tissues and vitreous sample of the affected eye showed positive results by polymerase chain reaction targeting the microsporidial small subunit rRNA gene whose sequences belonged to Vittaforma corneae. Post-keratoplasty and vitrectomy, his best-corrected visual acuity was hand motion due to pale optic disc.Conclusion: Endophthalmitis can be a consequence of microsporidial stromal keratitis in an immunocompetent host. Early recognition and prompt treatment should be considered in patients diagnosed with microsporidial keratitis presenting with mild vitritis, retinitis, and recurrent vitreous hemorrhage.     

Herpes simplex virus in the trabeculum of an eye with corneal endotheliitis

PURPOSE: To report an eye with corneal endotheliitis and increased intraocular pressure in which the trabeculum demonstrated immunoreactivity for herpes simplex virus. METHOD: Case report. A 62-year-old man presented with increased intraocular pressure, keratic precipitates, and corneal stromal edema in his left eye. The tissue excised during trabeculectomy was immunohistochemically examined for herpetic viruses. RESULT: Immunoreactivity for herpes simplex virus was identified in the trabeculum. CONCLUSION: Herpes simplex virus may cause trabeculitis and increased intraocular pressure in patients with corneal endotheliitis.     

Cytomegalovirus retinitis following intravitreal injection of triamcinolone: report of two cases

CONTEXT: Cytomegalovirus (CMV) retinitis usually affects severely immunosuppressed individuals. However, some exceptional and isolated cases of CMV retinitis have been described in immunocompetent patients. METHODS: We report two cases of non-immunodeficient patients seen in our institution over a period of 6 months, who presented with CMV retinitis a few weeks after an intravitreal injection of triamcinolone acetonide. RESULTS: Although the cellular and molecular mechanisms underlying the development of CMV in an immunocompetent patient's eye have not yet been precisely established, the well known immunosuppressive properties of corticosteroids suggest that triamcinolone probably plays a role in the endogenous reactivation of latent CMV. CONCLUSIONS: Our two patients received high doses of triamcinolone. Both had also pseudophakia, vitrectomy and a past medical history of type 2 diabetes mellitus. Such features, individually or combined, may be risk factors for local reactivation of CMV and should be considered prior to the administration of triamcinolone acetonide in ophthalmology.     

Rare Association of Perivascular Granulomatous Lesions in a Patient with Acute Retinal Necrosis

Purpose

The aim of this study was to examine sequential changes in perivascular granulomatous lesions with acute retinal necrosis (ARN).

Methods

A healthy 46-year-old Japanese woman, who developed floaters and pain in her left eye, underwent optical coherence tomography (OCT), fluorescein angiography, and routine ophthalmological examinations. Treatment-associated changes in perivascular granulomatous lesions were monitored using spectral-domain (SD)-OCT.

Results

The patient had no previous ophthalmic history, and her general condition was good. A slit-lamp examination revealed keratic precipitates and aqueous cells (2+) in the left eye. A fundus examination showed yellow-white patches of necrotizing retinal lesions in the temporal upper area, retinal arteritis, retinal hemorrhage, and vitreous opacities. The patient was diagnosed with ARN according to diagnostic criteria. SD-OCT images confirmed high-intensity and uniform granulomatous deposits in the perivascular area and fovea. Systemic corticosteroids and antiviral therapy were initiated, resulting in the gradual resolution of granulomatous lesions. The patient continues to be followed untreated without evidence of recurrence, retinal detachment, or active inflammation.

Conclusions

This is the first report of perivascular granulomatous lesions in a patient with ARN. Our results showed that the formation of granulomas may be induced in the retina of ARN patients without fulminant inflammation.Key Words: Acute retinal necrosis, Optical coherence tomography, Granuloma     

Vitrectomy for large vitreous opacity in retinitis pigmentosa

PURPOSE: To describe a patient with bilateral retinitis pigmentosa and visually disabling vitreous opacities, who benefited from vitrectomy in both eyes. METHODS: A 37-year-old man with retinitis pigmentosa and severely constricted visual fields developed a large, dense, vitreous floater and visual obscuration in the right eye. Subsequently, diffuse vitreous opacification and visual obscuration developed in the left eye. RESULTS: Bilateral pars plana vitrectomy relieved the patient's visual obscurations. Electron micrographs of the excised vitreous opacity from the left eye showed collagen fibrils and cellular debris. CONCLUSION: Visually significant vitreous opacities may develop as a complication of retinitis pigmentosa. The visual impact of such opacities may be magnified by its superimposition on limited visual fields. Vitrectomy may be of benefit in such cases.     

Cytomegalovirus and the eye

Following primary infection, cytomegalovirus (CMV) establishes latent infection in myeloid progenitor cells and intermittent viral reactivation from activated macrophages or dendritic cells, which is brought under control by strong virus-specific CD4+ T-cell and CD8+ T-cell responses. CMV retinitis characterized by spreading retinal necrosis due to viral cytopathic effect occurs in patients who have impaired T-cell function as a result of transplantation, AIDS, or immuno-suppressive treatment. The diagnosis of CMV retinitis can be confirmed by PCR amplification of viral DNA in aqueous. When administered intravenously, the antiviral drugs Ganciclovir and Foscarnet have modest penetration into the vitreous compared with direct intra-vitreal injection. In randomized trials of HIV-associated CMV retinitis, a Ganciclovir implant was consistently superior to intravenous Ganciclovir in preventing progression of retinitis. CMV is also implicated in two forms of anterior segment disease in immuno-competent adults, namely CMV anterior uveitis and CMV corneal endotheliitis.     

Phacolytic glaucoma and lens-induced uveitis

The pathogenesis of lens-induced uveitis and phacolytic glaucoma is still not fully understood. The authors report a case of a 62-year-old white female, with bilateral lens dislocation into the vitreous, who presented clinical and pathological features of phacolytic glaucoma in the left eye. The ultrastructural study of aqueous and vitreous aspirates showed lenticular fragments and macrophages with lipofuscin granules and phagocytic vacuoles containing lens proteins. Immunocytochemistry revealed foamy macrophages immunoreactive for CD68 and HLA-DR. One year later the right eye disclosed a mild anterior granulomatous uveitis with corneal mutton-fat keratic precipitates that remained unchanged in the course of sixteen months follow-up without further treatment. These findings corroborate the possibility that, besides their mechanical and inflammatory roles in the impairment of the outflow system of the (exciting) left eye, phacolytic macrophages might also have been involved in the afferent phase of the mild chronic uveitis of the (fellow) right eye.     

PCR with the aqueous humor, blood leukocytes and vitreous of patients affected by cytomegalovirus retinitis and immune recovery uveitis

PURPOSE: To detect the cytomegalovirus (CMV) genome by PCR in the aqueous humor, blood leukocytes and vitreous of patients affected by retinitis and immune recovery uveitis (IRU). METHODS: A PCR for CMV genome detection was carried out with the aqueous humor, vitreous and blood leukocytes of 54 patients with retinitis, including 25 HIV-infected patients presenting CMV retinitis in different stages (active lesion 6 cases, healed lesion 14 cases and IRU 5 cases), and 29 non-HIV-infected patients (retinitis unrelated to CMV) as negative controls. RESULTS: The CMV genome was detected in the vitreous, aqueous humor and blood leukocytes of 3 out of 6 HIV-infected patients, presenting active lesions in the retina. No CMV genome was detected in the vitreous, aqueous humor and blood leukocytes of the 5 HIV-infected patients presenting IRU. CONCLUSIONS: CMV genome detection by PCR in aqueous humor could be used as a specific and highly predictive technique for confirmation of this infection in the retina. The absence of CMV, based on the results of PCR done in clinical samples of the 5 IRU cases, does not confirm the hypothesis of a viral replication in the vitreous body and aqueous humor of these patients.