Iritis and hypotony after treatment with intravenous cidofovir for cytomegalovirus retinitis

The Impact of Systemic Medications on Retinal Function

This study will provide a thorough review of systemic (and select intravitreal) medications, along with illicit drugs that are capable of causing various patterns of retinal toxicity. The diagnosis is established by taking a thorough medication and drug history, and then by pattern recognition of the clinical retinal changes and multimodal imaging features. Examples of all of these types of toxicity will be thoroughly reviewed, including agents that cause retinal pigment epithelial disruption (hydroxychloroquine, thioridazine, pentosan polysulfate sodium, dideoxyinosine), retinal vascular occlusion (quinine, oral contraceptives), cystoid macular edema/retinal edema (nicotinic acid, sulfa-containing medications, taxels, glitazones), crystalline deposition (tamoxifen, canthaxanthin, methoxyflurane), uveitis, miscellaneous, and subjective visual symptoms (digoxin, sildenafil). The impact of newer chemotherapeutics and immunotherapeutics (tyrosine kinase inhibitor, mitogen-activated protein kinase kinase, checkpoint, anaplastic lymphoma kinase, extracellular signal-regulated kinase inhibitors, and others), will also be thoroughly reviewed. The mechanism of action will be explored in detail when known. When applicable, preventive measures will be discussed, and treatment will be reviewed. Illicit drugs (cannabinoids, cocaine, heroin, methamphetamine, alkyl nitrite), will also be reviewed in terms of the potential impact on retinal function.

Human Immunodeficiency Virus and Uveitis

Uveitis is one of the most common ocular complications in people living with the Human immunodeficiency virus (HIV) and can be classified into HIV-induced uveitis, co-infection related uveitis, immune recovery uveitis, and drug-induced uveitis. The introduction of antiretroviral therapy has considerably changed the incidence, diagnosis, and treatment of different types of HIV-related uveitis. Furthermore, the specific immune condition of patients infected with HIV makes diagnosing HIV-related uveitis difficult. Recent studies have focused on the growing prevalence of syphilis/tuberculosis co-infection in uveitis. Simultaneously, more studies have demonstrated that HIV can directly contribute to the incidence of uveitis. However, the detailed mechanism has not been studied. Immune recovery uveitis is diagnosed by exclusion, and recent studies have addressed the role of biomarkers in its diagnosis. This review highlights recent updates on HIV-related uveitis. Furthermore, it aims to draw the attention of infectious disease physicians and ophthalmologists to the ocular health of patients infected with HIV.

Pediatric uveitis: Role of the pediatrician

The challenges of childhood uveitis lie in the varied spectrum of its clinical presentation, the often asymptomatic nature of disease, and the evolving nature of the phenotype alongside normal physiological development. These issues can lead to delayed diagnosis which can cause significant morbidity and severe visual impairment. The most common ocular complications include cataracts, band keratopathy, glaucoma, and macular oedema, and the various associated systemic disorders can also result in extra-ophthalmic morbidity. Pediatricians have an important role to play. Their awareness of the various presentations and etiologies of uveitis in children afford the opportunity of prompt diagnosis before complications arise. Juvenile Idiopathic Arthritis (JIA) is one of the most common associated disorders seen in childhood uveitis, but there is a need to recognize other causes. In this review, different causes of uveitis are explored, including infections, autoimmune and autoinflammatory disease. As treatment is often informed by etiology, pediatricians can ensure early ophthalmological referral for children with inflammatory disease at risk of uveitis and can support management decisions for children with uveitis and possible underling multi-system inflammatory disease, thus reducing the risk of the development of irreversible sequelae.

Drug-induced uveitis: A review

Uveitis maybe induced by the use of various medications known as drug-induced uveitis (DIU), though rare it is an important cause of uveitis which one needs to be aware of. The drugs may be administered through any route including systemic, topical, and intravitreal. Ocular inflammation can be in the form of anterior, intermediate, posterior or pan uveitis, and rarely may present as episcleritis and scleritis. Identification of drug as the offending agent of uveitis is important as many a times stopping the drug may help recover the uveitis or the concomitant use of corticosteroids. An extensive literature review was done using the Pubmed. An overview of DIU is provided as it is important for us to be aware of this clinical entity.

[Drug-induced uveitis]

In recent years, an increasing amount of attention has been paid to medicinal products as possible risk factors in the development of eye diseases. The frequency of diagnosed drug-induced uveitis is growing yearly, which can be attributed to the appearance of new drugs - biological agents (immune checkpoint inhibitors, BRAF and MEK inhibitors, vascular endothelial growth factor inhibitors, tumor necrosis factor-α inhibitors), as well as systemic bisphosphonates and some antiviral drugs. The time interval between the beginning of the drug use and the appearance of uveitis symptoms varies from several days to months. Common symptoms include eye pain, photophobia, the appearance of floating opacities, and reduced vision associated with active inflammatory changes in the retina and optic nerve and outcomes of those inflammations. Timely diagnosis, cancellation of the drug that caused uveitis and appointment of adequate anti-inflammatory therapy in most cases effectively stops the symptoms of the disease, which determines the relevance of attention to the prevalence, pathogenesis, diagnosis and treatment of drug-induced uveitis.

Pharmacologically induced uveitis

Treatments of numerous systemic and local diseases of different etiologies may be accompanied by an unwanted side effect in the form of uveitis. We inform readers about medications that have the potential to cause uveitis and analyze the strength of association of these medications with uveitis. Subsequently, cessation of medication or appropriate treatment can be individualized for each patient for the purpose of preventing further damage to tissue structure and function. Being aware of these associations, physicians may readily identify medications that may cause uveitis and avoid expensive and unnecessary clinical and laboratory testing.

Medication-induced Uveitis: An Update

Drug-induced uveitis is an uncommon but important cause of ocular inflammation. Uveitis can be seen in association with various systemic, topical, and intraocular medications. In this article, we review common medications associated with uveitis. Most cases of drug-induced uveitis resolve with termination of the suspected medication with or without administration of topical or systemic steroids. It is important for clinicians to readily identify medications that may cause uveitis in order to provide rapid treatment, avoid consequences of longstanding inflammation, and prevent costly and excessive laboratory testing.

Drug-induced Uveitis in HIV Patients with Ocular Opportunistic Infections

Purpose: To describe drug-induced uveitis in immunocompromised patients diagnosed with Human Immunodeficiency Virus (HIV) infection Methods: Narrative Review Results: Systemic and intraocular medications administered for the treatment of acquired immune deficiency syndrome (AIDS)-associated diseases in patients infected with HIV are a well-known cause of uveitis. Conclusions: Cidofovir and rifabutin, among other novel anti-retroviral therapies, are strongly associated with drug-induced uveitis. It is imperative to understand the pathogenesis, clinical findings, and management of HIV patients with uveitis induced by these agents.

Safety considerations with current and emerging antiviral therapies for cytomegalovirus infection in transplantation

Introduction: Human cytomegalovirus (HCMV) is a major contributor of morbidity and mortality, and its management is essential for the successful outcome of solid organ and hematopoietic stem cell transplantation. Areas covered: This review discusses the safety profiles of currently available and emerging antiviral drugs and the other strategies for HCMV prevention and treatment after transplantation. Expert opinion: Strategies for management of HCMV rely largely on the use of antiviral agents that inhibit viral DNA polymerase (ganciclovir/valganciclovir, foscarnet, and cidofovir/brincidofovir) and viral terminase complex (letermovir), with different types and degrees of adverse effects. An investigational agent, maribavir, exerts its anti-CMV effect through UL97 inhibition, and its safety profile is under clinical evaluation. In choosing the antiviral medication to use, it is important to consider these safety profiles in addition to overall efficacy. In addition to antiviral drugs, reduction of immunosuppression is often generally needed in the management of HCMV infection, but with a potential risk of allograft rejection or graft-versus-host disease. The use of HCMV-specific or non-specific intravenous immunoglobulins remains debated, while adoptive HCMV-specific T cell therapy remains investigational, and associated with unique set of adverse effects.

Association of Intraocular Pressure With Human Immunodeficiency Virus

PURPOSE

Prior studies have shown an association between human immunodeficiency virus (HIV) and reduced intraocular pressures (IOP). The purpose of this study was to determine if patients with HIV on highly active antiretroviral therapy (HAART) had any difference in their IOP compared with patients without HIV or with HIV who are not on HAART.

DESIGN

Retrospective cross-sectional study.

METHODS

We included 400 patients from our academic eye center between 2000 and 2016. Group 1 (G1) consisted of patients with HIV on HAART (n = 176), Group 2 (G2) consisted of patients with HIV who were not on HAART (n = 48), and Group 3 (G3) consisted of controls without HIV (n = 176). An analysis of variance (ANOVA) was performed to compare mean IOP values. Multivariate linear and logistic regression models were performed to assess factors impacting IOP. Difference in IOP was the primary outcome being measured.

RESULTS

The mean IOPs in mm Hg were 13.7 ± 5.1 (G1), 13.1 ± 3.6 (G2), and 17.3 ± 3.8 (G3), P < .01. In regression modeling, having a CD4 count ≤700 cells/mm³ contributed to a 2.1 mm Hg decrease in IOP. Patients with HIV were 7 times more likely to have an IOP ≤10 mm Hg, and patients with a CD4 count ≤700 cells/mm³ were 13 times more likely to have an IOP ≤10 mm Hg.

CONCLUSIONS

Absolute CD4 counts may play a role in IOP fluctuations. This association was found in patients with HIV regardless of whether patients were on HAART.

Drug-induced uveitis

A number of medications have been associated with uveitis. This review highlights both well-established and recently reported systemic, topical, intraocular, and vaccine-associated causes of drug-induced uveitis, and assigns a quantitative score to each medication based upon criteria originally described by Naranjo and associates.

Intraocular pressure changes: an important determinant of the biocompatibility of intravitreous implants

BACKGROUND

In recent years, research efforts exploring the possibility of using biomaterial nanoparticles for intravitreous drug delivery has increased significantly. However, little is known about the effect of material properties on intravitreous tissue responses.

PRINCIPAL FINDINGS

To find the answer, nanoparticles made of hyaluronic acid (HA), poly (l-lactic acid) (PLLA), polystyrene (PS), and Poly N-isopropyl acrylamide (PNIPAM) were tested using intravitreous rabbit implantation model. Shortly after implantation, we found that most of the implants accumulated in the trabecular meshwork area followed by clearance from the vitreous. Interestingly, substantial reduction of intraocular pressure (IOP) was observed in eyes implanted with particles made of PS, PNIPAM and PLLA, but not HA nanoparticles and buffered salt solution control. On the other hand, based on histology, we found that the particle implantation had no influence on cornea, iris and even retina. Surprisingly, substantial CD11b+ inflammatory cells were found to accumulate in the trabecular meshwork area in some animals. In addition, there was a good relationship between recruited CD11b+ cells and IOP reduction.

CONCLUSIONS

Overall, the results reveal the potential influence of nanoparticle material properties on IOP reduction and inflammatory responses in trabecular meshwork. Such interactions may be critical for the development of future ocular nanodevices with improved safety and perhaps efficacy.

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

Ocular complications are known to occur as a result of human immunodeficiency virus (HIV) disease. They can be severe leading to ocular morbidity and visual handicap. Cytomegalovirus (CMV) retinitis is the commonest ocular opportunistic infection seen in acquired immune deficiency syndrome (AIDS). Though posterior segment lesions can be more vision-threatening, there are varied anterior segment manifestations which can also lead to ocular morbidity and more so can affect the quality of life of a HIV-positive person. Effective antiretroviral therapy and improved prophylaxis and treatment of opportunistic infections have led to an increase in the survival of an individual afflicted with AIDS. This in turn has led to an increase in the prevalence of anterior segment and adnexal disorders. Common lesions include relatively benign conditions such as blepharitis and dry eye, to infections such as herpes zoster ophthalmicus and molluscum contagiosum and malignancies such as squamous cell carcinoma and Kaposi′s sarcoma. With the advent of highly active antiretroviral therapy, a new phenomenon known as immune recovery uveitis which presents with increased inflammation, has been noted to be on the rise. Several drugs used in the management of AIDS such as nevirapine or indinavir can themselves lead to severe inflammation in the anterior segment and adnexa of the eye. This article is a comprehensive update of the important anterior segment and adnexal manifestations in HIV-positive patients with special reference to their prevalence in the Indian population.

AIDS and ophthalmology: the first quarter century

PURPOSE

To describe changes in the acquired immunodeficiency syndrome (AIDS) epidemic that are important to ophthalmologists, to provide an overview of issues relevant to current evaluation and treatment of human immunodeficiency virus (HIV)-related eye disease, and to identify problems related to the eye and vision that require continued study.

DESIGN

Literature review and commentary.

METHODS

Selected articles from the medical literature and the author's clinical and research experiences over 25 years were reviewed critically.

RESULTS

The AIDS epidemic has had a profound impact on ophthalmology since the ophthalmic manifestations of AIDS were first described in 1982. The introduction of highly active antiretroviral therapy (HAART) has markedly reduced the incidence of cytomegalovirus (CMV) retinitis, but has not eliminated new cases altogether. Treatment strategies for CMV retinitis have evolved over the past decade. Current issues of importance include choice of initial anti-CMV drugs; time at which anti-CMV drug treatment is discontinued in patients who achieve immune recovery; strategies for monitoring patients at risk for disease reactivation; and management of complications (retinal detachment, immune recovery uveitis). Attention also is being directed to the problem of visual disturbances (reduced contrast sensitivity, altered color vision, visual field abnormalities) that can occur in HIV-infected individuals without infectious retinopathies.

CONCLUSIONS

Ocular disorders associated with HIV disease remain important problems in the United States, despite HAART, and increasingly are important worldwide. The approach to management of CMV retinitis has evolved from short-term treatment of a preterminal infection to the long-term management of what has become a chronic disease. Many challenges remain to be addressed.

Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease

The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.

Outcomes Associated with Ganciclovir Implants in Patients with AIDS-Related Cytomegalovirus Retinitis

PURPOSE

To investigate complications associated with ganciclovir implants used to treat AIDS-related cytomegalovirus (CMV) retinitis, and to identify factors that predict poor outcomes.

DESIGN

Retrospective chart review.

PARTICIPANTS

Consecutive patients with AIDS-related CMV retinitis from 3 clinical facilities who underwent implantation procedures during the period January 1, 1995 through December 31, 2001.

METHODS

Baseline for each patient was the date of the first implantation procedure performed during the study period by one of the facilities' surgeons (index implant). Medical and ophthalmological data were collected at baseline and at specific time points after baseline. The dates on which additional implantation procedures were performed and the dates on which complications or vision loss were identified were also recorded. Relationships between potential risk factors and outcomes were studied by Kaplan-Meier analyses and Cox proportional hazards regression models.

MAIN OUTCOME MEASURES

Primary outcome measures included postoperative complications specifically related to or possibly related to ganciclovir implants. A secondary outcome measure was vision loss after implantation procedures.

RESULTS

The charts of 174 patients (one study eye per patient; 279 implants) were reviewed. Median follow-up was 14.4 months (range, 0-7 years). Complications specifically related to implants occurred throughout follow-up at a rate of 0.064 events per patient-year. Complications possibly related to implants occurred at an overall rate of 0.377 per patient-year, but seemed to be more common during the first 2 years after baseline. During the first 2 years of follow-up, retinal detachments occurred at a rate of 0.156 events per patient-year. The cumulative risk of vision loss (> or =3 lines of Snellen visual acuity) at 7 years was 70%. Poor outcomes were associated with disease factors (size and activity of lesions), lack of highly active antiretroviral therapy (HAART), and lack of HAART-associated immune reconstitution, but not with surgical factors or implant-specific complications.

CONCLUSIONS

Complications specifically associated with ganciclovir implants can occur many years after implantation procedures, but the incidence of such complications is low. Continued vision loss is not attributable directly to complications of implants in most cases. This information will help in planning of treatment strategies for CMV retinitis in long-term survivors of human immunodeficiency virus disease.

Risk of Immune Recovery Uveitis in Patients with AIDS and Cytomegalovirus Retinitis

OBJECTIVE

To evaluate the prevalence of and risk factors for immune recovery uveitis (IRU) in eyes of patients with AIDS and cytomegalovirus (CMV) retinitis.

DESIGN

Enrollment data from a 19-clinical center cohort study.

PARTICIPANTS

Three hundred seventy-four patients with AIDS and CMV retinitis affecting 539 eyes.

METHODS

Patients with AIDS were enrolled at 19 United States AIDS ophthalmology clinics. Data were collected by interview, review of medical records, ophthalmic examination, and phlebotomy.

MAIN OUTCOME MEASURE

Immune recovery uveitis.

RESULTS

Thirty-six patients (9.6%) were diagnosed with IRU involving 50 eyes. The CD4+ T-cell count of 31 of these had risen by > or =50 cells per microliter above nadir to a level > or = 100 cells per microliter (immune recovery), making up 17.6% of the patients known to have immune recovery after diagnosis of CMV retinitis (95% confidence interval, 12.3%-24.1%). No patients with IRU were observed to have active retinitis or detectable CMV DNA in peripheral blood (P<0.001 and P<0.001 with respect to patients without IRU). Other factors associated with IRU were > or =25% retinal area (odds ratio [OR], 2.72; P = 0.014) or posterior pole involvement with CMV retinitis (odds ratio, 0.43; P = 0.039), treatment with intravitreous injection of cidofovir (OR, 10.6 with respect to eyes never exposed to intravitreous or IV cidofovir; P<0.001), and male gender (OR, 0.26; P = 0.012). More eyes with IRU had visual acuity (VA) of 20/50 or worse (38.0% vs. 26.3%, P = 0.077) relative to eyes without IRU, but the proportions with VA of 20/200 or worse were similar (14.0% vs. 13.8%, P = 0.96). Eyes with IRU more commonly had cystoid macular edema (CME) (45.5% vs. 3.7%, P<0.001) and epiretinal membrane (48.9% vs. 13.3%, P<0.001) than eyes without IRU.

CONCLUSIONS

Among eyes of patients with immune recovery, the prevalence of IRU is substantial. Eyes with IRU have a high risk of additional morbidity over and above that seen with CMV retinitis, with several-fold higher risk of CME and epiretinal membrane. Large CMV lesions and use of intravitreous cidofovir are risk factors for IRU.

Treatment of cytomegalovirus retinitis with oral valganciclovir in an acquired immunodeficiency syndrome patient unresponsive to combination antiretroviral therapy

BACKGROUND

Cytomegalovirus (CMV) retinitis was a much-feared visual complication of late-stage acquired immunodeficiency syndrome (AIDS) in the past. Its incidence has waned significantly owing to the benefits of potent antiretroviral combination therapy, which for many individuals has provided some degree of immune reconstitution and avoidance of opportunistic infections, particularly this blinding disease.

CASE REPORT

A 45-year-old white man with long-standing, multidrug-resistant human immunodeficiency virus (HIV) infection and severe immunodeficiency despite multiple antiretroviral drug regimens, presented to the eye clinic reporting decreased vision and spider web patterns in his left eye for the past week. Best-corrected visual acuity was 20/20 in the right (O.D.) and 20/25 in the left eye (O.S.). Dilated funduscopic examination of the left eye found vasculitis of the midperipheral inferonasal arcade in the midperiphery, with surrounding intraretinal hemorrhage and granular retinal necrosis. Diagnosis of cytomegalovirus retinitis was made, and the patient began induction therapy with oral valganciclovir 900 mg twice a day for 3 weeks. Maintenance therapy after retinitis stabilization was 900 mg every day until any observed recurrence of infection. Three months after complete resolution of the active retinitis, the patient returned to the clinic reporting new floaters of recent onset. A reactivation of the CMV retinitis warranted a reinduction with valganciclovir 900 mg orally twice a day for 3 weeks.

CONCLUSION

This case is illustrative of the efficacy and relative ease of administration of valganciclovir, the newest medication approved for treatment and maintenance of CMV retinitis. Despite his severe immunodeficiency, our patient tolerated the induction and maintenance therapy of oral valganciclovir well, and the CMV retinitis was stabilized and resolved with full recovery of visual acuity.

Long-term Study of Intraocular Pressure Changes in Patients with Human Immunodeficiency Virus Treated with Highly Active Antiretroviral Therapy

PURPOSE

To characterize a longitudinal relationship between highly active antiretroviral therapy immune recovery as defined by an increase in CD4 cell counts and any associated changes in intraocular pressure (IOP) in both patients with and patients without a history of cytomegalovirus (CMV) retinitis and to determine if human immunodeficiency (HIV)-induced reduction in IOP is reversible.

DESIGN

Retrospective analysis of patient data collected from 1997 through 2004.

PARTICIPANTS

Cohort of patients from one eye center, including patients from the Longitudinal Study of Ocular Complications of Acquired Immunodeficiency Syndrome.

METHODS

Linear regression analyses were conducted within the CMV and non-CMV groups to determine the change in IOP per 100-unit change in CD4 count. Average changes in IOP per change in CD4 count were compared between the CMV and the non-CMV groups using a Wilcoxon rank-sum test. Linear regression analyses were conducted within the CMV and non-CMV groups to determine the linear relationship between the 12-month change in IOP per 12-month 100-unit change in CD4 count.

MAIN OUTCOME MEASURE

Intraocular pressure in relation to changes in CD4 cell counts.

RESULTS

Compared with the non-CMV group, the median IOP change per change in CD4 count was not statistically different from the CMV group (0.9 vs. 1.7 mmHg/100 CD4 cells, respectively; P = 0.20). Analysis of the linear relationship between the 12-month change in IOP and the 12-month change in CD4 count within both the CMV and non-CMV groups showed a strong linear relationship: 67% of the variability in a 12-month IOP change for the CMV group (P<0.0001) and 36% of the variability in a 12-month IOP change for the non-CMV group (P<0.001).

CONCLUSIONS

Reduction in T-lymphocyte count in HIV infection is accompanied by a decrease in IOP in both CMV-infected and non-CMV-infected eyes, and immune recovery is associated with an increase in IOP.

HIV-associated retinopathy in the HAART era

BACKGROUND

The effectiveness of highly active antiretroviral therapy (HAART) in restoring immune function in patients with acquired immunodeficiency syndrome (AIDS) has led to changes in the incidence, natural history, management, and sequelae of human immunodeficiency virus (HIV)-associated retinopathies, especially cytomegalovirus (CMV) retinitis.

METHODS

The medical literature pertaining to HIV-associated retinopathies was reviewed with special attention to the differences in incidence, management strategies, and complications of these conditions in the eras both before and after the widespread use of HAART.

RESULTS

In the pre-HAART era, CMV retinitis was the most common HIV-associated retinopathy, occurring in 20%-40% of patients. Median time to progression was 47 to 104 days, mean survival after diagnosis was 6 to 10 months, and indefinite intravenous maintenance therapy was mandatory. Retinal detachment occurred in 24%-50% of patients annually. Herpetic retinopathy and toxoplasmosis retinochoroiditis occurred in 1%-3% of patients and Pneumocystis carinii choroiditis, syphilitic retinitis, tuberculous choroiditis, cryptococcal choroiditis, and intraocular lymphoma occurred infrequently. In the HAART era the incidence of CMV retinitis has declined 80% and survival after diagnosis has increased to over 1 year. Immune recovery in patients on HAART has allowed safe discontinuation of maintenance therapy in patients with regressed CMV retinitis and other HIV-associated retinopathies. Immune recovery uveitis (IRU) is a HAART dependent inflammatory response that may occur in up to 63% of patients with regressed CMV retinitis and elevated CD4 counts and is associated with vision loss from epiretinal membrane, cataract, and cystoid macular edema.

CONCLUSIONS

The incidence, visual morbidity, and mortality of CMV retinitis and other HIV-associated retinopathies have decreased in the era of HAART and lifelong maintenance therapy may safely be discontinued in patients with restored immune function. Patients with regressed CMV retinitis, however, may still lose vision from epiretinal membrane, cystoid macular edema, and cataract secondary to IRU.

RISKS OF INTRAVITREOUS INJECTION: A COMPREHENSIVE REVIEW

PURPOSE

To evaluate the prevalence of the most common serious adverse events associated with intravitreous (IVT) injection.

METHODS

A systematic search of the literature via PubMed from 1966 to March 1, 2004, was conducted to identify studies evaluating the safety of IVT injection. Data submitted in New Drug Applications to the U.S. Food and Drug Administration for drugs administered into the vitreous were included where available. Serious adverse events reported in each study were recorded, and risk per eye and risk per injection were calculated for the following serious adverse events: endophthalmitis, retinal detachment, iritis/uveitis, intraocular hemorrhage, ocular hypertension, cataract, and hypotony. Rare complications also were noted.

RESULTS

Data from 14,866 IVT injections in 4,382 eyes were analyzed. There were 38 cases of endophthalmitis (including those reported as pseudoendophthalmitis) for a prevalence of 0.3% per injection and 0.9% per eye. Excluding cases reported specifically as pseudoendophthalmitis, the prevalence of endophthalmitis was 0.2% per injection and 0.5% per eye. Retinal detachment, iritis/uveitis, ocular hypertension, cataract, intraocular hemorrhage, and hypotony were generally associated with IVT injection of specific compounds and were infrequently attributed by the investigators to the injection procedure itself. Retinal vascular occlusions were described rarely in patients after IVT injection, and it was unclear in most cases whether these represented true injection-related complications or chance associations.

CONCLUSION

The risk of serious adverse events reported after IVT injection is low. Nevertheless, careful attention to injection technique and appropriate postinjection monitoring are essential because uncommon injection-related complications may be associated with permanent vision loss.

[The latest in herpes simplex keratitis therapy]

Herpetic keratitis is characterized by spontaneous recurrences and a risk of vision loss, the latter being more serious when relapses are frequent and severe. Two clinical forms are commonly distinguished: epithelial keratitis, usually quickly resolved with topical antivirals, and stromal keratitis, which has a slower progression, even when both steroids and antivirals are used. Great strides have been made during the last 20 Years in the therapy of herpes keratitis, which is now considered and treated as a chronic disease. Randomized controlled studies definitively showed the decrease in spontaneous herpetic ocular events in patients treated with long-term oral acyclovir. The effectiveness of preventive treatment has also been shown during high-risk periods, especially ocular surgery, in patients with a history of herpes keratitis. However, the optimal duration and dosage of antiviral prevention have yet to be defined. We can also hope that in the future novel antiviral strategies such as vaccination will reduce the place of herpes keratitis as an indication for corneal graft.

Intraocular pressure in patients with human immunodeficiency virus and treated with highly active antiretroviral therapy

PURPOSE

To compare the intraocular pressure (IOP) of patients infected with human immunodeficiency virus (HIV) and treated with highly active antiretroviral therapy (HAART) to a control group and to determine whether HAART reverses the previously reported reduction in IOP associated with HIV infection.

DESIGN

Retrospective case control study.

METHODS

Review of patients with HIV infection on HAART compared with a matched control group.

RESULTS

Among 64 patients and 56 control subjects, no significant difference in IOP was found (P =.520), nor was correlation noted between IOP and either CD4+ T-lymphocyte counts, or viral load.

CONCLUSION

When HIV infection is treated with HAART, IOP is not significantly different from that of control subjects.

HIV/AIDS and the eye

The type of ocular involvement in the patient with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) depends on the level of immune function and systemic diseases present. Although the prognosis for patients with HIV/AIDS has changed dramatically with the introduction of antiretroviral therapy, infections involving the retina, such as toxoplasmosis, herpes simplex and herpes zoster (HZV), still occur although opportunistic infections such as cytomegalovirus (CMV) retinitis are much less common except in patients who present late in the course of the disease (Jabs and Bartlett, 1997; Jabs et al, 2002).

Correlation between cidofovir-associated uveitis and failing immunorestoration during HAART

In order to elucidate the factors related to the development of cidofovir-associated uveitis in AIDS patients receiving highly active antiretroviral therapy, the characteristics of 17 AIDS patients with Cytomegalovirus retinitis ( n=10) or progressive multifocal leukoencephalopathy ( n=7) treated with intravenous cidofovir were evaluated. Six cases of cidofovir-associated uveitis occurred among the patients with retinitis. No cases were detected among the patients with progressive multifocal leukoencephalopathy. Stepwise linear regression analysis revealed a significantly higher HIV-viremia level ( P=0.01) and a significantly lower CD4+ cell count ( P=0.009) among cases at the time of uveitis onset in comparison with patients who did not develop uveitis. Thus, cidofovir-associated uveitis seems to occur more frequently in AIDS patients with retinitis in whom highly active antiretroviral therapy fails to restore immunity.

A pilot study of cidofovir for progressive multifocal leukoencephalopathy in AIDS

OBJECTIVE

To assess the safety, tolerability and effect of cidofovir for HIV-1 associated progressive multifocal leukoencephalopathy.

DESIGN

Prospective, open-label study in nine AIDS Clinical Trials Units.

PATIENTS AND METHODS

Twenty-four HIV-1-infected individuals, with neuroimaging and clinical findings consistent with PML, and symptoms for 90 days or less, whose diagnosis was confirmed by the detection of JC virus DNA in the cerebrospinal fluid or brain biopsy, received cidofovir 5 mg/kg intravenously at baseline and 1 week, followed by infusions every 2 weeks with the dose adjusted for renal function. Follow-up continued to 24 weeks. The safety of cidofovir and changes in neurological examination scores between baseline and week 8 were assessed.

RESULTS

Seventeen subjects were receiving potent antiretroviral agents. Survival at 12 weeks was 54%. The CD4 cell count at entry was significantly associated with survival (P = 0.02). Five subjects discontinued treatment because of toxicity: a 50% or greater decrease in intraocular pressure in either eye in four, and proteinuria in one. Overall, magnetic resonance imaging abnormalities and neurological examination scores worsened. Only two subjects experienced a 25% or greater improvement in neurological examination scores at week 8, which were significantly better in subjects with HIV-1-RNA levels of 500 copies/ml or less at entry compared with those with HIV-1-RNA levels over 500 copies/ml (P = 0.05).

CONCLUSION

Cidofovir did not improve neurological examination scores at week 8. However, such scores were significantly better in subjects who entered with suppressed plasma HIV-1-RNA levels, which could be the result of control of HIV-1 infection itself or cidofovir.

Successful treatment of an aciclovir-resistant herpes simplex type 2 infection with cidofovir in an AIDS patient

Management of the increasing frequency of aciclovir-resistant herpes simplex virus (HSV) infections among immunocompromised human immunodeficiency virus-infected people demands additional treatment options. We report the case of a 38-year-old patient with acquired immune deficiency syndrome who suffered from a perianal butterfly ulcer, which was HSV-2 positive by polymerase chain reaction (PCR) analysis. The ulcer appeared during treatment of a cytomegalovirus (CMV) pneumonitis with ganciclovir. Despite additional valaciclovir therapy the lesion gradually progressed in size. Investigations including histology, PCR analysis and in situ hybridization of a biopsy from the growing ulcer margin confirmed the presence of HSV-2 infection. Importantly, HSV isolates from this specimen were resistant to aciclovir. Based on a report about the successful treatment of aciclovir-resistant HSV infection with cidofovir, our patient received this drug intravenously at a dose of 5 mg kg-1 body weight once weekly for a total of 3 weeks. Concomitant oral probenecid and prehydration were administered to minimize nephrotoxicity. Within 30 days of treatment the ulcer had almost (> 95%) completely healed. We conclude that cidofovir is a potent antiviral drug with a potential usefulness in the treatment of aciclovir-resistant HSV-2 infection. It deserves further investigation in clinical trials.

Safety of intravitreous fomivirsen for treatment of cytomegalovirus retinitis in patients with AIDS

PURPOSE

To report data regarding the safety of intravitreous fomivirsen for treatment of cytomegalovirus (CMV) retinitis in patients with acquired immunodeficiency syndrome (AIDS).

DESIGN

Critical review of safety data from three randomized controlled clinical trials with supplemental information from an expanded drug access program.

METHODS

Adverse ocular events reported by clinician investigators were listed using terms modified from the COSTART dictionary. Data for two doses (165-microg/injection [35 eyes, 30 patients] and 330-microg/injection [153 eyes, 120 patients]) and two 330-microg/injection dose schedules of different intensity were pooled to calculate incidence rates for each event. Rates were calculated as "events/patient-year" (based on total cumulative reported events and duration of treatment) for events that could recur during treatment. Rates were calculated as "patients with events/person-year" for the following events: retinal detachment, cataract, visual field disturbance, and retinal pigment epitheliopathy. To assess the ability to manage events, we reviewed treatments given for two events (anterior chamber inflammation, increased intraocular pressure) in one trial. We also report an analysis comparing the proportion of eyes that developed one or more key events to the cumulative number of injections.

RESULTS

Incidence rates were dose and schedule dependent (165 microg/injection, 4.06 events/patient-year; 330 microg/injection, 6.58 events/patient-year [less intense regimen] and 8.35 events/patient-year [more intense regimen]). The most frequently reported events were anterior chamber inflammation and increased intraocular pressure. We found no evidence that the proportion of patients with events increased as the number of injections increased.

CONCLUSIONS

Intravitreous fomivirsen is well tolerated with an acceptable safety profile. Adverse ocular events associated with doses and schedules used clinically can be managed successfully with medical therapy.

Treatment of severe ocular hypotony in AIDS patients with cytomegalovirus retinitis and cidofovir-associated uveitis

OBJECTIVE

To describe the medical treatment of severe ocular hypotony in HIV-seropositive patients with cytomegalovirus retinitis and cidofovir-associated uveitis.

PATIENTS AND METHODS

Two HIV-seropositive patients with cytomegalovirus retinitis and cidofovir-associated uveitis complicated by severe ocular hypotony were unresponsive to conventional therapy after treatment with cidofovir was stopped. They were subsequently treated successfully with ibopamine 2% eyedrops and dexamethasone 0.1% eyedrops.

RESULTS

In both cases, an increase in intraocular pressure to normal values was observed on average 18.5 days after starting treatment. Intraocular pressure remained stable while on therapy for a mean follow-up of 9.5 months. During the follow-up period, any attempt to stop treatment was followed by an intraocular pressure decrease; conversely, restoration of therapy increased intraocular pressure to normal values. No reactivation of cidofovir-associated uveitis or cytomegalovirus retinitis was observed during the follow-up period.

CONCLUSIONS

Ibopamine 2% eyedrops in combination with dexamethasone 0.1% eyedrops is a satisfactory therapy for severe ocular hypotony in patients with cytomegalovirus retinitis and cidofovir-associated uveitis.