Self-reporting of Conflicts of Interest by Ophthalmology Researchers Compared with the Open Payments Database Industry Reports

PURPOSE

To evaluate the completeness of conflict-of-interest self-reporting by ophthalmology researchers and to assess factors associated with self-reporting.

DESIGN

Cross-sectional observational study.

PARTICIPANTS

We evaluated articles published between January and June 2017 in Ophthalmology, JAMA Ophthalmology, the American Journal of Ophthalmology, and Investigative Ophthalmology and Visual Science. To assess more accurately the cases in which an author published multiple articles, we defined a unit of analysis, authorship, for which each author of each article is a unique data point. To enable comparison with the Open Payments Database (OPD), we only included United States physician authorships.

METHODS

For each authorship, we defined self-reported relationships as the companies listed in the article's conflict-of-interest disclosures. Based on journal policies, we defined OPD-reported relationships as the list of companies that reported payments to the author within 36 months before submission.

MAIN OUTCOME MEASURES

For each authorship, we assessed the proportion of OPD-reported relationships that were self-reported. The primary measurement was the proportion of authorships reporting none of their OPD-reported relationships.

RESULTS

Of the 660 total authorships (486 unique authors), 413 authorships (63%) reported none of their OPD-reported relationships, 112 (17%) reported some of them, 9 (1%) reported all of them, and 126 (19%) had 0 relationships. The proportion of authorships reporting none of their relationships did not differ significantly between journals that required reporting of all relationships compared with journals that required reporting only of relevant relationships (adjusted percentage, 61.4% vs. 64.3%; P = 0.46). Authorships with more dollars received during the reporting period showed higher rates of self-reporting (P < 0.001).

CONCLUSIONS

Even among journals that required complete reporting, self-reporting was low compared with an industry-maintained database of financial relationships. Deficiencies in reporting may undermine confidence in self-reporting and may compromise the transparency that is needed to interpret research results fairly.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Compound heterozygous splicing CDON variants result in isolated ocular coloboma

Ocular coloboma is caused by failure of optic fissure closure during development and recognized as part of the microphthalmia, anophthalmia, and coloboma (MAC) spectrum. While many genes are known to cause colobomatous microphthalmia, relatively few have been reported in coloboma with normal eye size. Genetic analysis including trio exome sequencing and Sanger sequencing was undertaken in a family with two siblings affected with bilateral coloboma of the iris, retina, and choroid. Pathogenic variants in MAC genes were excluded. Trio analysis identified compound heterozygous donor splice site variants in CDON, a cell-surface receptor known to function in the Sonic Hedgehog pathway, c.928 + 1G > A and c.2650 + 1G > T, in both affected individuals. Heterozygous missense and truncating CDON variants are associated with dominant holoprosencephaly (HPE) with incomplete penetrance and Cdon-/- mice display variable HPE and coloboma. A homozygous nonsense allele of uncertain significance was recently identified in a consanguineous patient with coloboma and a second molecular diagnosis. We report the first compound heterozygous variants in CDON as a cause of isolated coloboma. CDON is the first HPE gene identified to cause recessive coloboma. Given the phenotypic overlap, further examination of HPE genes in coloboma is indicated.

Assessment of Consistency Between Peer-Reviewed Publications and Clinical Trial Registries

Importance

Clinical trial registries are intended to increase clinical research transparency by nonselectively identifying and documenting clinical trial designs and outcomes. Inconsistencies in reported data undermine the utility of such registries and have previously been noted in general medical literature.

Objective

To assess whether inconsistencies in reported data exist between ophthalmic literature and clinical trial registries.

Design, Setting, and Participants

In this retrospective, cross-sectional study, interventional clinical trials published from January 1, 2014, to December 31, 2014, in the American Journal of Ophthalmology, JAMA Ophthalmology, and Ophthalmology were reviewed. Observational, retrospective, uncontrolled, and post hoc reports were excluded, yielding a sample size of 106 articles. Data collection was performed from January through September 2016. Data review and adjudication continued through January 2017.

Main Outcomes and Measures

If possible, articles were matched to registry entries listed in the ClinicalTrials.gov database or in 1 of 16 international registries indexed by the World Health Organization International Clinical Trials Registry Platform version 3.2 search engine. Each article-registry pair was assessed for inconsistencies in design, results, and funding (each of which was further divided into subcategories) by 2 reviewers and adjudicated by a third.

Results

Of 106 trials that met the study criteria, matching registry entries were found for 68 (64.2%), whereas no matching registry entries were found for 38 (35.8%). Inconsistencies were identified in study design, study results, and funding sources, including specific interventions in 8 (11.8%), primary outcome measure (POM) designs in 32 (47.1%), and POM results in 48 (70.6%). In addition, numerous data pieces were unreported, including analysis methods in 52 (76.5%) and POM results in 38 (55.9%).

Conclusions and Relevance

Clinical trial registries were underused in this sample of ophthalmology clinical trials. For studies with registry data, inconsistency rates between published and registered data were similar to those previously reported for general medical literature. In most cases, inconsistencies involved missing data, but explicit discrepancies in methods and/or data were also found. Transparency and credibility of published trials may be improved by closer attention to their registration and reporting.

An innovative visual acuity chart for urgent and primary care settings: validation of the Runge near vision card

Objective

We evaluated the Runge card, a near-vision eye chart designed for ease of use, by testing agreement in visual acuity results between it and the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity chart. As a clinical reference point, we compared the Runge card and an electronic Snellen chart with respect to agreement with ETDRS results.

Methods

Participants consisted of adult eye clinic patient volunteers who underwent a protocol refraction, followed by testing with a Runge card, ETDRS chart, and Snellen chart. Mean logMAR visual acuities were calculated for each method. Agreement levels among the tests were assessed for the group overall and for subjects with good (ETDRS logMAR < 0.6; better than 20/80 Snellen equivalent) and poor (logMAR ≥ 0.6) acuity.

Results

One hundred and thirty-eight participants completed testing. The mean ( ± standard deviation) logMAR visual acuities (Snellen equivalent) with Runge, ETDRS, and Snellen, respectively, were 0.66 ± 0.50 (20/91, n = 138), 0.59 ± 0.51 (20/78, n = 138), and 0.67 ± 0.62 (20/94, n = 137). Runge testing agreed similarly with ETDRS and Snellen testing, with CCC 0.92 between Runge and ETDRS, and 0.87 between Runge and Snellen (p = 0.14). Runge agreed better with ETDRS than Snellen agreed with ETDRS in participants with poor acuity (CCC = 0.79 vs. 0.63, respectively, p = 0.001) but not in those with good acuity (CCC = 0.70 vs. 0.87, respectively, p = 0.005).

Conclusion

Visual acuity measurements with the Runge near card agreed with measurements from the ETDRS to approximately the same degree as did the Snellen chart, suggesting potential utility of the Runge near card, particularly given its user-friendly characteristics and ease of use.

High-Resolution Imaging of Intraretinal Structures in Active and Resolved Central Serous Chorioretinopathy

Purpose

To improve our understanding of central serous chorioretinopathy (CSC), we performed an analysis of noninvasive, high-resolution retinal imaging in patients with active and resolved CSC.

Methods

Adaptive optics scanning light ophthalmoscopy (AOSLO) and spectral-domain optical coherence tomography (SD-OCT) were performed on five subjects with CSC. A custom AOSLO system was used to simultaneously collect confocal and split-detector images. Spectral domain–OCT volume scans were used to create en face views of various retinal layers, which then were compared to montaged AOSLO images after coregistration.

Results

Three distinct types of intraretinal hyperreflective clusters were seen with AOSLO. These clusters had a well-demarcated, round, and granular appearance. Clusters in active CSC over areas of serous retinal detachment were termed type-1. They were found primarily in the outer nuclear layer (ONL) and were associated with large defects in the photoreceptor mosaic and ellipsoid zone. Clusters in areas where the retina had reattached were termed type-2. They also were located primarily in the ONL but showed stability in location over a period of at least 8 months. Smaller clusters in the inner retina along retinal capillaries were termed type-3.

Conclusions

Retinal imaging in CSC using en face OCT and AOSLO allows precise localization of intraretinal structures and detection of features that cannot be seen with SD-OCT alone. These findings may provide greater insight into the pathophysiology of the active and resolved phases of the disease, and support the hypothesis that intraretinal hyperreflective foci on OCT in CSC are cellular in nature.

Assessing Photoreceptor Structure in Retinitis Pigmentosa and Usher Syndrome

Purpose

The purpose of this study was to examine cone photoreceptor structure in retinitis pigmentosa (RP) and Usher syndrome using confocal and nonconfocal split-detector adaptive optics scanning light ophthalmoscopy (AOSLO).

Methods

Nineteen subjects (11 RP, 8 Usher syndrome) underwent ophthalmic and genetic testing, spectral-domain optical coherence tomography (SD-OCT), and AOSLO imaging. Split-detector images obtained in 11 subjects (7 RP, 4 Usher syndrome) were used to assess remnant cone structure in areas of altered cone reflectivity on confocal AOSLO.

Results

Despite normal interdigitation zone and ellipsoid zone appearance on OCT, foveal and parafoveal cone densities derived from confocal AOSLO images were significantly lower in Usher syndrome compared with RP. This was due in large part to an increased prevalence of non-waveguiding cones in the Usher syndrome retina. Although significantly correlated to best-corrected visual acuity and foveal sensitivity, cone density can decrease by nearly 38% before visual acuity becomes abnormal. Aberrantly waveguiding cones were noted within the transition zone of all eyes and corresponded to intact inner segment structures. These remnant cones decreased in density and increased in diameter across the transition zone and disappeared with external limiting membrane collapse.

Conclusions

Foveal cone density can be decreased in RP and Usher syndrome before visible changes on OCT or a decline in visual function. Thus, AOSLO imaging may allow more sensitive monitoring of disease than current methods. However, confocal AOSLO is limited by dependence on cone waveguiding, whereas split-detector AOSLO offers unambiguous and quantifiable visualization of remnant cone inner segment structure. Confocal and split-detector thus offer complementary insights into retinal pathology.

Multimodal Imaging of Photoreceptor Structure in Choroideremia

PURPOSE

Choroideremia is a progressive X-linked recessive dystrophy, characterized by degeneration of the retinal pigment epithelium (RPE), choroid, choriocapillaris, and photoreceptors. We examined photoreceptor structure in a series of subjects with choroideremia with particular attention to areas bordering atrophic lesions.

METHODS

Twelve males with clinically-diagnosed choroideremia and confirmed hemizygous mutations in the CHM gene were examined. High-resolution images of the retina were obtained using spectral domain optical coherence tomography (SD-OCT) and both confocal and non-confocal split-detector adaptive optics scanning light ophthalmoscope (AOSLO) techniques.

RESULTS

Eleven CHM gene mutations (3 novel) were identified; three subjects had the same mutation and one subject had two mutations. SD-OCT findings included interdigitation zone (IZ) attenuation or loss in 10/12 subjects, often in areas with intact ellipsoid zones; RPE thinning in all subjects; interlaminar bridges in the imaged areas of 10/12 subjects; and outer retinal tubulations (ORTs) in 10/12 subjects. Only split-detector AOSLO could reliably resolve cones near lesion borders, and such cones were abnormally heterogeneous in morphology, diameter and density. On split-detector imaging, the cone mosaic terminated sharply at lesion borders in 5/5 cases examined. Split-detector imaging detected remnant cone inner segments within ORTs, which were generally contiguous with a central patch of preserved retina.

CONCLUSIONS

Early IZ dropout and RPE thinning on SD-OCT are consistent with previously published results. Evidence of remnant cone inner segments within ORTs and the continuity of the ORTs with preserved retina suggests that these may represent an intermediate state of retinal degeneration prior to complete atrophy. Taken together, these results supports a model of choroideremia in which the RPE degenerates before photoreceptors.

ASSESSING PHOTORECEPTOR STRUCTURE ASSOCIATED WITH ELLIPSOID ZONE DISRUPTIONS VISUALIZED WITH OPTICAL COHERENCE TOMOGRAPHY

PURPOSE

To compare images of photoreceptor layer disruptions obtained with optical coherence tomography (OCT) and adaptive optics scanning light ophthalmoscopy (AOSLO) in a variety of pathologic states.

METHODS

Five subjects with photoreceptor ellipsoid zone disruption as per OCT and clinical diagnoses of closed-globe blunt ocular trauma (n = 2), macular telangiectasia type 2 (n = 1), blue-cone monochromacy (n = 1), or cone-rod dystrophy (n = 1) were included. Images were acquired within and around photoreceptor lesions using spectral domain OCT, confocal AOSLO, and split-detector AOSLO.

RESULTS

There were substantial differences in the extent and appearance of the photoreceptor mosaic as revealed by confocal AOSLO, split-detector AOSLO, and spectral domain OCT en face view of the ellipsoid zone.

CONCLUSION

Clinically available spectral domain OCT, viewed en face or as B-scan, may lead to misinterpretation of photoreceptor anatomy in a variety of diseases and injuries. This was demonstrated using split-detector AOSLO to reveal substantial populations of photoreceptors in areas of no, low, or ambiguous ellipsoid zone reflectivity with en face OCT and confocal AOSLO. Although it is unclear if these photoreceptors are functional, their presence offers hope for therapeutic strategies aimed at preserving or restoring photoreceptor function.

Assessing photoreceptor structure after macular hole closure

PURPOSE

To describe photoreceptor structure and recovery after macular hole (MH) closure with pars plana vitrectomy (PPV) using adaptive optics scanning light ophthalmoscopy and spectral domain optical coherence tomography.

METHODS

A pilot imaging study of four eyes from four subjects undergoing PPV for MH was conducted. Imaging with spectral domain optical coherence tomography and adaptive optics scanning light ophthalmoscopy was performed at varying time points after PPV.

RESULTS

Despite successful MH closure, disruption of the foveal inner segment ellipsoid zone was seen in all patients when imaged at a mean of 117 days after PPV. Disruption of the photoreceptor mosaic was seen using adaptive optics scanning light ophthalmoscopy at locations corresponding to regions of ellipsoid zone disruption on spectral domain optical coherence tomography. Cone density immediately surrounding these disruptions was normal, except for one patient. In 2 patients who were imaged serially up to 516 days after PPV, recovery of cone cells within regions of mosaic disruption could be detected over time.

CONCLUSION

Photoreceptor disruption exists even after apparent MH closure. Remodeling of the foveal cone mosaic continues for many months after surgery, perhaps accounting for the delayed postoperative improvements of visual acuity in some patients. Spectral domain optical coherence tomography and adaptive optics scanning light ophthalmoscopy are useful tools for monitoring photoreceptor recovery after surgical closure of MH.

Microscopic inner retinal hyper-reflective phenotypes in retinal and neurologic disease

PURPOSE

We surveyed inner retinal microscopic features in retinal and neurologic disease using a reflectance confocal adaptive optics scanning light ophthalmoscope (AOSLO).

METHODS

Inner retinal images from 101 subjects affected by one of 38 retinal or neurologic conditions and 11 subjects with no known eye disease were examined for the presence of hyper-reflective features other than vasculature, retinal nerve fiber layer, and foveal pit reflex. The hyper-reflective features in the AOSLO images were grouped based on size, location, and subjective texture. Clinical imaging, including optical coherence tomography (OCT), scanning laser ophthalmoscopy, and fundus photography was analyzed for comparison.

RESULTS

Seven categories of hyper-reflective inner retinal structures were identified, namely punctate reflectivity, nummular (disc-shaped) reflectivity, granular membrane, waxy membrane, vessel-associated membrane, microcysts, and striate reflectivity. Punctate and nummular reflectivity also was found commonly in normal volunteers, but the features in the remaining five categories were found only in subjects with retinal or neurologic disease. Some of the features were found to change substantially between follow up imaging months apart.

CONCLUSIONS

Confocal reflectance AOSLO imaging revealed a diverse spectrum of normal and pathologic hyper-reflective inner and epiretinal features, some of which were previously unreported. Notably, these features were not disease-specific, suggesting that they might correspond to common mechanisms of degeneration or repair in pathologic states. Although prospective studies with larger and better characterized populations, along with imaging of more extensive retinal areas are needed, the hyper-reflective structures reported here could be used as disease biomarkers, provided their specificity is studied further.

Selective cone photoreceptor injury in acute macular neuroretinopathy

PURPOSE

To evaluate retinal structural and functional abnormalities in a patient with acute macular neuroretinopathy.

METHODS

An adaptive optics scanning light ophthalmoscope was used to image the photoreceptor mosaic and assess rod and cone structure. Spectral-domain optical coherence tomography was used to examine retinal lamination. Microperimetry was used to assess function across the macula.

RESULTS

Microperimetry showed reduced function of localized areas within retinal lesions corresponding to subjective scotomas. Spectral-domain optical coherence tomography imaging revealed attenuation of two outer retinal bands typically thought to reflect photoreceptor structure. Adaptive optics scanning light ophthalmoscope images of the photoreceptor mosaic revealed a heterogeneous presentation within these lesions. There were areas containing non-waveguiding cones and other areas of decreased cone density where the remaining rods had expanded to fill in the vacant space. Within these lesions, cone densities were shown to be significantly lower than eccentricity-matched areas of normal retina, as well as accepted histologic measurements. A 6-month follow-up revealed no change in rod or cone structure.

CONCLUSION

Imaging of acute macular neuroretinopathy using an adaptive optics scanning light ophthalmoscope shows a preferential disruption of cone photoreceptor structure within the region of decreased retinal sensitivity (as measured by microperimetry). Adaptive optics-based imaging tools provide a noninvasive way to assess photoreceptor structure at a level of detail that is not resolved by use of conventional spectral-domain optical coherence tomography or other clinical measures.

Giant macular hole in Alport syndrome

PURPOSE

To describe the evolution of a giant macular hole in a patient with Alport syndrome and review the literature.

METHODS

An observational case report is presented with serial clinical examination, visual acuity, fundus photographs, and ocular coherence tomography performed.

RESULTS

A man with Alport syndrome and a giant macular hole in one eye developed multiple, small lamellar macular holes which coalesced into a giant full thickness macular hole in the contralateral eye.

CONCLUSIONS

Giant macular holes may occur in Alport syndrome. The mechanism and clinical progression appear to differ from that of idiopathic macular holes and, is likely related to an abnormality in Type IV collagen in basement membrane of retinal Muller cells. Anomalous vitreoretinal adhesion may also play a role. Previous cases of giant macular holes in the literature may not have been properly associated with Alport syndrome.

The use of best visual acuity over several encounters as an outcome variable: an analysis of systematic bias

PURPOSE

To investigate whether the use of the best of multiple measures of visual acuity as an endpoint introduces bias into study results.

METHODS

Mathematical models and Monte Carlo simulations were used. A model was designed in which a hypothetical intervention did not influence the visual acuity. The best of one or more postintervention measures was used as the outcome variable and was compared to the baseline measure. Random test-retest variability was included in the model.

RESULTS

When the better of two postintervention measures was used as the outcome variable with a sample size of 25, the model falsely rejected the null hypothesis 55% of the time. When the best of three measures was used, the false-positive rate increased to 90%. The probability of falsely rejecting the null hypothesis increased with increasing sample size, also increasing the number of measures used to select the outcome variable.

CONCLUSIONS

Using the best of multiple measures as an outcome variable introduces a systematic bias resulting in false conclusions of improvement in that variable. The use of best of multiple measures of visual acuity as an outcome variable should be avoided.

Hemorrhagic Retinoschisis in Shaken Baby Syndrome Imaged with Spectral Domain Optical Coherence Tomography

Spectral domain optical coherence tomography (SD-OCT) images from an infant victim of shaken baby syndrome who presented with vitreous hemorrhage in the left eye and bilateral, large hemorrhages over both maculae. Both RetCam and SD-OCT images were obtained, demonstrating the position of the blood beneath the internal limiting membrane of the right macula. Image registration software was used to register the photographic images with the surface projection images obtained by the SD-OCT. In the left eye, the vitreous hemorrhage was removed with vitrectomy, and the retinoschisis cavity incised to allow drainage.

Dexamethasone posterior-segment drug delivery system in the treatment of macular edema resulting from uveitis or Irvine-Gass syndrome

PURPOSE

To evaluate the effects of a dexamethasone intravitreous drug delivery system (dexamethasone DDS) in patients with persistent macular edema (ME) resulting from uveitis or Irvine-Gass syndrome.

DESIGN

Randomized, prospective, single-masked, controlled trial.

METHODS

Three hundred and fifteen patients with persistent (>or= 90 days) ME were randomized in a multicenter study to surgical placement of 350 or 700 microg dexamethasone DDS or observation. This study evaluated the subset of patients with uveitis or Irvine-Gass syndrome (n = 41). The primary outcome measure was the proportion of patients achieving a 10-letter or more improvement in best-corrected visual acuity (BCVA) at day 90. Change in fluorescein angiographic leakage and safety also were evaluated.

RESULTS

At day 90, a 10-letter or more BCVA improvement was seen in 41.7% (5/12) of patients in the 350-microg group, in 53.8% (7/13) of patients in the 700-microg group, and in 14.3% (2/14) of patients in the observation group (P = .029 vs the 700-microg group). Improvement in visual acuity persisted to day 180. A 15-letter or more improvement was achieved in 53.8% (7/13) of 700-microg patients vs 7.1% (1/14) of observed patients (P = .008). There were significantly greater reductions in fluorescein leakage in treated patients than in observed patients. Dexamethasone DDS was well tolerated. Throughout the study, an increase in intraocular pressure of 10 mm Hg or more was seen in 5 of 13 patients in the 700-microg group, in 1 of 12 patients in the 350-microg group, and in no patients in the observation group. There were no reports of endophthalmitis.

CONCLUSIONS

In patients with persistent ME resulting from uveitis or Irvine-Gass syndrome, 700-microg dexamethasone DDS was well tolerated and produced statistically significant improvements in visual acuity and fluorescein leakage.

Randomized controlled study of an intravitreous dexamethasone drug delivery system in patients with persistent macular edema

OBJECTIVE

To evaluate a dexamethasone intravitreous drug delivery system (DDS) in patients with persistent (> or =90 days despite treatment) macular edema.

METHODS

This 6-month study randomized 315 patients with persistent macular edema with best-corrected visual acuity (BCVA) of 20/40 to 20/200 in the study eye to observation or a single treatment with dexamethasone DDS, 350 or 700 microg.

MAIN OUTCOME MEASURES

Proportion of patients achieving a BCVA improvement of 10 or more letters or 15 or more letters, safety measures, change in fluorescein angiographic leakage, and central retinal thickness.

RESULTS

At day 90 (primary end point), an improvement in BCVA of 10 letters or more was achieved by a greater proportion of patients treated with dexamethasone DDS, 700 microg (35%) or 350 microg (24%), than observed patients (13%; P<.001 vs 700-microg group; P = .04 vs 350-microg group); an improvement in BCVA of 15 letters or more was achieved in 18% of patients treated with dexamethasone DDS, 700 microg, vs 6% of observed patients (P = .006). Results were similar in patients with diabetic retinopathy, vein occlusion, or uveitis or Irvine-Gass syndrome. During 3 months of observation, 11% of treated patients and 2% of observed patients had intraocular pressure increases of 10 mm Hg or higher.

CONCLUSION

In persistent macular edema, a single dexamethasone DDS treatment produced statistically significant BCVA improvements 90 days after treatment and was well tolerated for 180 days. Application to Clinical Practice Dexamethasone DDS, 700 microg, may have potential as a treatment for persistent macular edema.

Clinician versus Reading Center Assessment of Cytomegalovirus Retinitis Lesion Size

PURPOSE

To compare clinician and fundus photograph reading center assessments of the cytomegalovirus (CMV) retinitis area and change in the CMV retinitis area over time, and to investigate how these assessments correlate with the visual field (VF) of eyes with CMV retinitis.

DESIGN

Analysis of pooled data from 2 multicenter randomized clinical trials and 1 prospective multicenter epidemiologic study.

PARTICIPANTS

Ninety-five eyes of 79 patients. At baseline, each eye had CMV retinitis restricted to zone 1 and/or zone 2 (approximately the photographable postequatorial retina), as assessed by the evaluating clinician.

METHODS

Comparison of CMV retinitis area, change in area over time as assessed by clinicians and a fundus photograph reading center, and correlation of these assessments with VF measurement.

MAIN OUTCOME MEASURES

Cytomegalovirus retinitis area, change in CMV retinitis area over time, and VF score.

RESULTS

Baseline assessments of the mean retinitis area were, by clinicians, 12.8% of the total retinal area and, by the reading center, 6.3% of the total retinal area (P<0.001). There was a positive correlation between clinician and reading center assessments of retinitis area at baseline (rho = 0.77 and P<0.0001 by Pearson correlation and rho = 0.54 and P<0.001 by concordance). Both clinician and reading center size measures correlated negatively with VF (Spearman correlation rhos = -0.38 and -0.52, respectively; P<0.001 each). Mean changes in area over a 3-month interval were, by clinicians, +1.2% and, by the reading center, +1.1% (P = 0.68). Regression analysis showed a positive concordance (rho = 0.42, P<0.001). Change in VF over a 3-month interval did not correlate with change in retinitis area as assessed by clinicians or the reading center.

CONCLUSIONS

Awareness of the similarities and differences between clinician and reading center assessments of CMV retinitis area should permit clinicians to apply research data to clinical practice more effectively. Clinician assessment of retinitis area correlates negatively with VF, a clinically meaningful visual outcome in patients with CMV retinitis.

Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: 2. Second eye involvement and retinal detachment

PURPOSE

To describe the course of cytomegalovirus (CMV) retinitis in patients with AIDS in the era of highly active antiretroviral therapy (HAART).

DESIGN

Multicenter, prospective, observational study.

PARTICIPANTS

Two hundred seventy-one patients with AIDS and CMV retinitis.

METHODS

Follow-up every 3 months with medical history, ophthalmologic examination, laboratory testing, and fundus photographs.

MAIN OUTCOME MEASURE

Second (contralateral) eye involvement among patients with unilateral disease and retinal detachment (RD).

RESULTS

The overall rate of second eye involvement among patients with unilateral CMV retinitis was 0.07 per person-year (PY); among those with CD4+ T-cell counts of <50/microl it was 0.34/PY, compared with 0.02/PY among those with CD4+ T-cell counts of > or =200/microl (P<0.0001). Risk factors for contralateral eye involvement included low CD4+ T-cell count and detectable CMV load. The overall rate of RD was 0.06/PY; among those with CD4+ T-cell counts of <50/microl it was 0.30/PY, compared with 0.02/PY among those with CD4+ T-cell counts of > or =200/microl (P<0.0001). Risk factors for RD included a low CD4+ T-cell count and larger area of CMV retinitis.

CONCLUSIONS

Compared with the rates reported in the pre-HAART era of second eye involvement (approximately 0.40/PY) and RD (approximately 0.50/PY), the rates of these events were reduced among patients in the HAART era. However, among patients with CD4+ T-cell counts of <50/microl, the rates were more similar to those from the pre-HAART era.

Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: 1. Retinitis progression

PURPOSE

To describe the course of cytomegalovirus (CMV) retinitis in patients with AIDS in the era of highly active antiretroviral therapy (HAART).

DESIGN

Multicenter, prospective, observational study.

PARTICIPANTS

Two hundred seventy-one patients with AIDS and CMV retinitis.

METHODS

Follow-up every 3 months with medical history, ophthalmologic examination, laboratory testing, and fundus photographs. Photographs were evaluated for relapse of the retinitis (progression) by graders at a centralized reading center.

MAIN OUTCOME MEASURE

Retinitis progression (movement of the border of a CMV lesion > or =750 microm over a > or =750-microm front or occurrence of a new lesion one-quarter disc area or more in size).

RESULTS

The overall rate of retinitis progression was 0.10/person-year (PY); among those with CD4+ T-cell counts of <50/microl, it was 0.58/PY, compared to 0.02/PY among those with CD4+ T-cell counts of > or =200/microl (P<0.0001). In the multivariate analysis, significant risk factors for retinitis progression included a low CD4+ T-cell count, positive CMV load, longer time from AIDS diagnosis, and low Karnofsky score.

CONCLUSIONS

Compared with the rate of retinitis progression (approximately 3.0/PY) reported in the pre-HAART era, the rate of retinitis progression was reduced among patients in the HAART era, even among those with low CD4+ T-cell counts, who might be expected to behave most like patients from the pre-HAART era. However, these events also occurred among patients with high CD4+ T-cell counts and presumed immune recovery. Continued ophthalmologic follow-up of patients with immune recovery is recommended to detect early retinitis progression.

In-the-bag intraocular lens dislocation

PURPOSE

To describe the presenting characteristics and management alternatives of posterior chamber intraocular lens (PC-IOL) dislocation secondary to dehiscence of the zonules supporting the capsular bag.

DESIGN

Observational case series.

METHODS

Multicenter retrospective analysis of the surgical treatment and predisposing factors associated with 25 eyes of 22 patients with dislocation of the PC-IOL encased within the capsular bag secondary to dehiscence of the zonules supporting the capsular bag.

RESULTS

The dislocated in-the-bag PC-IOL was replaced with an anterior chamber intraocular lens in 60% or repositioned/exchanged and scleral fixated in 40% of eyes. Associated conditions included pseudoexfoliation syndrome 44%, uveitis 16%, and trauma 16%. There was no identifiable cause in 24% of eyes.

CONCLUSIONS

In-the-bag PC-IOL dislocations are an unusual, sometimes bilateral, late complication of cataract surgery that can be managed by exchange with an anterior chamber intraocular lens or by PC-IOL repositioning or replacement with scleral fixation. The most common associated condition was pseudoexfoliation.

Rhegmatogenous retinal detachments in children: risk factors and surgical outcomes

PURPOSE

To describe the presenting features and surgical outcomes in a series of children with rhegmatogenous retinal detachments.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Thirty-nine eyes of 34 children 18 years of age or younger undergoing surgery for rhegmatogenous retinal detachment.

METHODS

Patients were identified by chart review at two affiliated tertiary care centers. Risk factors for retinal detachment were classified into four categories: (1). congenital or developmental structural ocular abnormalities, (2). trauma, (3). previous ophthalmologic surgery, and (4). preceding uveitis.

RESULTS

Median age was 10 years, and 79% of patients were boys. Nine patients (26%) had bilateral retinal detachment at presentation, or experienced a detachment in their second eye before their nineteenth birthday. Every eye had at least one risk factor for retinal detachment, and more than half had risk factors in two or more categories. Structural abnormalities were most common (56%). Fifty-one percent of eyes underwent previous surgery, 36% experienced trauma, and 15% had uveitis. Detachments tended to be complex. Median follow-up was 24 months. Retinal reattachment was achieved in 79% of eyes; however, visual recovery was modest. Median preoperative and postoperative visual acuities were counting fingers and 20/400, respectively. Predictors of a poor visual outcome were: unmeasurable or light perception-only preoperative vision (P = 0.0001), macula-off retinal detachment (P = 0.01), the need for vitrectomy surgery (P = 0.01), the presence of proliferative vitreoretinopathy grade C or worse (P = 0.02), and the use of silicone oil (P = 0.02).

CONCLUSIONS

Predisposing factors in pediatric retinal detachments, particularly congenital and developmental structural abnormalities, may be more common than previously reported. Modern vitreoretinal surgical techniques can help achieve retinal reattachment in most cases. Many factors contribute to the limited visual recovery in this patient population. Predictors of visual outcomes are similar to those observed in adults. Inability of the clinician to determine confidently the preoperative visual acuity is a newly identified predictor of poor visual outcomes.

Visual loss in patients with cytomegalovirus retinitis and acquired immunodeficiency syndrome before widespread availability of highly active antiretroviral therapy

OBJECTIVE

To evaluate rates and causes of visual loss among patients with acquired immunodeficiency syndrome (AIDS) and cytomegalovirus (CMV) retinitis before widespread availability of highly active antiretroviral therapy (HAART).

METHODS

Data from 681 patients with AIDS and newly diagnosed or relapsed CMV retinitis who enrolled in 3 clinical trials conducted by the Studies of Ocular Complications of AIDS (SOCA) Research Group (between 1990 and 1996) were combined to evaluate the rates and causes of visual loss. Visual acuity and visual field (Goldmann visual fields) losses were evaluated.

RESULTS

The rates of visual loss in eyes with CMV retinitis were substantial in all 3 clinical trials, ranging from 51.7 to 97.7 events per 100 eye-years for loss of visual acuity to worse than 20/40 and 18.9 to 49.1 events per 100 eye-years for loss of visual acuity to 20/200 or worse. The 2 major causes of visual loss were retinitis, involving either the macula or the optic nerve, and retinal detachment. After 1992, visual outcomes improved significantly. Antiretroviral therapy was associated with a 30% reduction in the risk of visual acuity loss (relative risk, 0.70; P =.02).

CONCLUSIONS

In the pre-HAART era, visual morbidity was substantial. However, there was a secular trend for improved outcomes. The principal causes of visual loss were CMV involvement of the posterior retina and retinal detachment.

Cytomegalovirus resistance to ganciclovir and clinical outcomes of patients with cytomegalovirus retinitis

PURPOSE

To evaluate whether cytomegalovirus resistant to ganciclovir, detected in either the blood or urine, correlates with adverse ocular outcomes.

DESIGN

Prospective cohort study.

METHODS

Patients with cytomegalovirus and AIDS were enrolled in a study of the occurrence and clinical correlates of resistant cytomegalovirus. Blood and urine cultures for cytomegalovirus were performed at the time of diagnosis of retinitis, 1 and 3 months after the initiation of therapy, and every 3 months thereafter. Patients were seen monthly, at which time fundus photographs were obtained and forwarded to the Fundus Photograph Reading Center for evaluation of retinitis progression (movement of a border of a cytomegalovirus lesion > or = 750 microm, or the occurrence of a new lesion > or = 0.25 disk area in size) and the amount of retinal area affected by cytomegalovirus retinitis. Visual acuity was measured using logarithmic visual acuity charts. Phenotypic resistance to ganciclovir was defined as an IC50 > 6.0 micromol/l, and genotypic resistance to ganciclovir was defined as the occurrence of a cytomegalovirus UL97 gene mutation known to confer ganciclovir resistance. Time-dependent analyses were performed and included viral resistance, highly active antiretroviral therapy, and treatment variables as predictors of clinical outcomes.

RESULTS

One hundred ninety-seven patients received ganciclovir therapy. Nineteen patients developed phenotypic resistance to ganciclovir, and 18 developed genotypic resistance. The detection of cytomegalovirus resistant to ganciclovir was associated with a 4.17- to 5.61-fold increase in the odds of retinitis progression (P values all < or = .0002), depending upon the definition of resistance and the culture sources analyzed. Resistance was associated with a greater increase in retinal area involved by cytomegalovirus by 3-month interval (1.10% vs 0.05% to 0.10%), which was significant for phenotypic resistance and for genotypic resistance in the blood or urine (P =.012 to.021). There was a suggestion that resistance was associated with a greater loss of visual acuity (P =.009 to.096). Highly active antiretroviral therapy was associated with an approximate 50% reduction in the odds of retinitis progression, and the ganciclovir implant was associated with an approximate 60% reduction.

CONCLUSIONS

The detection of cytomegalovirus resistant to ganciclovir in either the blood or urine of a patient with cytomegalovirus retinitis is associated with an increased risk of adverse ocular outcomes.

Accuracy and precision of intraocular injection volume

PURPOSE

To assess the accuracy and precision of methods in clinical use for intraocular drug injection.

DESIGN

Experimental laboratory investigation.

METHODS

A total of 800 injections were performed using 20 different 1-ml syringes at intended volumes of 0.10 ml and 0.05 ml. The volume of each injection was calculated from mass of water delivered onto an analytic balance.

RESULTS

The mean measured volume delivered was less than the intended volume for every syringe (P <.001 for each syringe at each volume). A total of 7% and 22% of injections differed by 20% or more from the intended volumes of 0.10 ml and 0.05 ml, respectively. Overdelivery of volume was uncommon.

CONCLUSION

Clinically relevant materials and methods used for intraocular injection of drugs systematically underdelivered the intended volume.

Comparison of cytomegalovirus (CMV) UL97 gene sequences in the blood and vitreous of patients with acquired immunodeficiency syndrome and CMV retinitis

Cytomegalovirus (CMV) resistance to ganciclovir occurs via mutations in the UL97 gene. CMV DNA, from vitreous and blood specimens and from culture isolates from 87 patients with acquired immunodeficiency syndrome and CMV retinitis who received a ganciclovir implant, was sequenced to identify the relationship between the UL97 DNA sequences in the eye and peripheral blood. There was 93.5% agreement between the UL97 gene sequences from paired vitreous specimens and blood specimens. Sequence analysis of vitreous specimens showed that 15% (13/87) of the patients had either a ganciclovir resistance-conferring mutation or a polymorphism in the CMV UL97 gene. Eleven of the 13 mutations or polymorphisms in the vitreous also were identified in blood. Although the number of mutations limits definitive interpretation, these data suggest that blood specimens may reflect the events occurring in the eyes of patients with CMV retinitis.

An analysis of lesion size and location in newly diagnosed cytomegalovirus retinitis

OBJECTIVE

To investigate the size and distribution of lesions in newly diagnosed cytomegalovirus retinitis (CMVR).

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Fundus photographs of 252 newly diagnosed CMVR lesions in 173 eyes of 130 patients (123 male, 7 female).

METHODS

Thirty-five millimeter (60 degrees ) color transparencies were digitized. A montage of the retina was assembled for each involved eye and was superimposed on a specially designed map of the postequatorial retina. Cytomegalovius retinitis lesions were delineated, and the size and location of each lesion was measured. The size of newly diagnosed CMVR lesions was computed in terms of percent postequatorial retinal surface area (PERSA), and the location of lesions was plotted on a polar coordinate system.

MAIN OUTCOME MEASURES

Size and location of patches of newly diagnosed CMVR.

RESULTS

The median lesion size was 3% PERSA. Peripheral CMVR lesions were larger than posterior ones (P < 0.001). The mean number of lesions was 1.6 per eye. The total area of CMVR involvement ranged from 1% to 76% PERSA, with a median of 5% PERSA. There was no difference between left and right eyes in the distribution of lesion centers (P = 0.27). The concentric distribution of lesion centers appeared to be homogeneous, except for fewer centers in the most peripheral 14 degrees (P < 0.001), and a greater than expected number of lesion centers in the macula (central 11.6 degrees, P < 0.001). Eyes of patients with unilateral retinitis had 1.3 lesions per involved eye compared with eyes of patients with bilateral retinitis, which had 1.6 lesions per eye (P = 0.003).

CONCLUSIONS

Most newly diagnosed CMVR lesions were small. Peripheral lesions were larger than more posterior lesions. Variations from a homogeneous distribution of lesions were noted only at the extreme peripheral and central locations and are probably explained by ascertainment bias. The macula was not spared from new CMVR lesions in this patient population.

Longitudinal observations on mutations conferring ganciclovir resistance in patients with acquired immunodeficiency syndrome and cytomegalovirus retinitis: The Cytomegalovirus and Viral Resistance Study Group Report Number 8

PURPOSE

Cytomegalovirus retinitis is the most common intraocular infection in patients with acquired immunodeficiency syndrome (AIDS). With prolonged suppressive anticytomegalovirus maintenance therapy, resistance occurs in over 25% of patients. We evaluated longitudinal changes in the cytomegalovirus genotype in patients with cytomegalovirus retinitis who developed ganciclovir resistance that was demonstrated in either the blood or urine.

METHODS

Patients with AIDS and previously untreated cytomegalovirus retinitis were followed prospectively for the occurrence of resistance while on treatment. Blood and urine specimens were obtained periodically for cytomegalovirus culture according to a predetermined schedule. Positive isolates were tested for phenotypic susceptibility and for mutations in the UL97 and UL54 genes.

RESULTS

A mutation conferring resistance to ganciclovir in either the UL97 or UL54 gene was detected in 18 patients. In general, patients with a genotypically resistant virus developed increasing phenotypic resistance over time. There was a suggestion that unless therapy was changed, UL97 mutations tended to persist. In seven of eight patients, the mutations identified in isolates from the blood and urine were identical. In selected patients, there was a suggestion that a mixed population of cytomegalovirus might be present. Progression of the retinitis in an involved eye (15 of 18), contralateral eye retinitis (10 of 11), and extraocular cytomegalovirus disease (5 of 18) occurred commonly among patients with resistant virus.

CONCLUSION

Resistance-conferring mutations in the cytomegalovirus genome emerge and may persist when the selective pressure for resistance is maintained. Some patients appear to harbor complex subpopulations of virus with different mutations and different levels of phenotypic resistance. Changes in therapy may result in a shift in virus population and changes in the cytomegalovirus genotype identified.

Laser photocoagulation for choroidal neovascularization associated with sympathetic ophthalmia

PURPOSE

To present a case of choroidal neovascularization associated with sympathetic ophthalmia successfully treated with photocoagulation.

DESIGN

Interventional case report.

METHODS

A 41-year-old man with a history of penetrating injury right eye, as well as sympathetic ophthalmia left eye, developed a classic choroidal neovascular membrane that threatened the center of the fovea.

RESULTS

The patient was treated with argon laser photocoagulation. He has maintained stable visual acuity without evidence of recurrence of the membrane with 4 years' follow-up.

CONCLUSION

Thermal laser should be considered as a treatment option in cases of choroidal neovascularization associated with sympathetic ophthalmia.

Sympathetic ophthalmia associated with pars plana vitrectomy without antecedent penetrating trauma

PURPOSE

To evaluate, describe, and categorize the clinical presentation, clinical course, histopathology, and response to therapy in patients without a history of penetrating ocular trauma who developed sympathetic ophthalmia following pars plana vitrectomy.

METHODS

The records of patients without a history of trauma who underwent pars plana vitrectomy and developed sympathetic ophthalmia were retrospectively reviewed. Cases were analyzed with respect to clinical presentation, fluorescein angiographic findings, anatomic and visual outcomes, histopathology, and response to therapy.

RESULTS

Eight eyes were identified. The median age at presentation was 55 years, with a range of 14 to 62 years. The time from vitrectomy to diagnosis of sympathetic ophthalmia ranged from 2 months to greater than 2 years, with a median of 7 months. Six of eight patients (75%) presented with anterior chamber reaction. All eight patients presented with a vitreous inflammatory response. The optic nerve was inflamed clinically or angiographically in four of eight cases (50%). Small yellow-white sub-retinal pigment epithelial deposits were present in four of eight cases (50%). Two eyes had lesions characterized as multifocal choroiditis. One eye had larger yellow placoid-like lesions. One eye presented with vitritis but no retinal lesions. Subretinal choroidal neovascularization was noted in the inciting eye of one patient. Vision improved in the sympathizing eye with immunosuppressive therapy in five of eight cases (62.5%).

CONCLUSIONS

Sympathetic ophthalmia can be seen following pars plana vitrectomy in patients without penetrating injuries or a history of trauma. Indeed, it may be seen after successful vitrectomy for retinal detachment. Diverse clinical presentations are possible, and persistent or atypical uveitis following vitrectomy should alert the surgeon to the development of sympathetic ophthalmia.

Mutations conferring ganciclovir resistance in a cohort of patients with acquired immunodeficiency syndrome and cytomegalovirus retinitis

Cytomegalovirus (CMV) retinitis is among the most common opportunistic infections in patients with acquired immunodeficiency syndrome. In a prospective study of 210 patients with CMV retinitis, 26 were identified as having either a phenotypic or a genotypic ganciclovir-resistant isolate from either blood or urine cultures. For blood culture isolates with an IC(50) >6.0 microm for ganciclovir, the sensitivity and specificity for detecting a UL97 mutation were 95% and 98%, respectively, whereas for an IC(50) >8.0 microM they were 79% and 99%, respectively. Although there were trade-offs between the 2 thresholds for blood culture isolates, for urine culture isolates an IC(50) >8.0 microM appeared to be better at identifying genotypic resistance. UL97 mutations identified in both the blood and urine cultures of individual patients were identical in 87.5% of cases. High-level ganciclovir resistance (IC(50), >30 microM) typically, but not invariably, was associated with a mutation in both the UL97 and UL54 genes.

A single-suture technique for placement of the ganciclovir implant

The ganciclovir implant is a surgically implanted sustained-release drug delivery system used for the treatment of cytomegalovirus retinitis. The device is suspended in the vitreous cavity through a pars plana incision. Previous reports of the surgical procedure have described securing the implant on 1 suture, tied with an external knot. The ends of this suture were left long to avoid sharp ends eroding through the conjunctiva. The wound was then closed with 1 or more additional sutures, with the ends tied and cut short. We describe a technique whereby the wound is closed and the implant secured with a single running suture. The advantages of this technique include efficiency and elimination of exposed knots. We have observed no complications attributable to this technique.

Novel mutations in XLRS1 causing retinoschisis, including first evidence of putative leader sequence change

Juvenile retinoschisis is an X-linked recessive disease caused by mutations in the XLRS1 gene. We screened 31 new unrelated patients and families for XLRS1 mutations in addition to previously reported mutations for 60 of our families (Retinoschisis Consortium, Hum Mol Genet 1998;7:1185-1192). Twenty-three different mutations including 12 novel ones were identified in 28 patients. Mutations identified in this study include 19 missense mutations, two nonsense mutations, one intragenic deletion, four microdeletions, one insertion, and one intronic sequence substitution that is likely to result in a splice site defect. Two novel mutations, c.38T-->C (L13P) and c.667T-->C (C223R), respectively, present the first genetic evidence for the functional significance of the putative leader peptide sequence and for the functional significance at the carboxyl terminal of the XLRS1 protein beyond the discoidin domain. Mutations in 25 of the families were localized to exons 4-6, emphasizing the critical functional significance of the discoidin domain of the XLRS1 protein.

Randomized, controlled study of the safety and efficacy of intravenous cidofovir for the treatment of relapsing cytomegalovirus retinitis in patients with AIDS

To assess the effect of intravenous cidofovir on delaying progression of previously treated, relapsing cytomegalovirus (CMV) retinitis, we conducted a randomized, controlled comparison of two maintenance dose levels of cidofovir. One hundred and fifty patients with AIDS and CMV retinitis that had progressed or was persistently active despite treatment with ganciclovir, foscarnet, or both were randomized to receive induction cidofovir, 5 mg/kg once weekly for 2 weeks, then maintenance therapy with either 5 mg/kg or 3 mg/kg once every other week. Concomitant probenecid and intravenous hydration were administered with each cidofovir dose. Retinitis progression was assessed in the first 100 patients by bilateral, full-field retinal photographs read at a central reading center by an ophthalmologist masked to treatment assignment. Incidence of side effects, changes in visual acuity, and mortality were also assessed. Median time to retinitis progression as assessed by retinal photography was not reached (95% confidence interval [CI], 115 days-upper limit not reached) in the 5-mg/kg group, and was 49 days (95% CI, 35-52 days) in the 3-mg/kg group (p = .0006). Dose-dependent asymptomatic proteinuria (39%) and serum creatinine elevation (24%) were the most common adverse events thought to be related to cidofovir. Reversible probenecid reactions including constitutional symptoms and nausea occurred in 65 of 150 (43%) patients. Cidofovir therapy is effective in delaying progression of CMV retinitis that had previously progressed using other anti-CMV therapies.

Results of peripheral laser photocoagulation in pars planitis

PURPOSE

To determine the effect of peripheral retinal laser photocoagulation (PLP) on visual acuity, intraocular inflammation, and other ocular findings, including retinal neovascularization in eyes with pars planitis.

METHODS

A retrospective chart review of eyes with pars planitis that had undergone PLP.

RESULTS

Twenty-two eyes in 17 patients with pars planitis had undergone treatment with PLP at 2 centers. The mean age at the time of treatment was 19.3 years. Following treatment, mean follow-up was 16.3 months (range, 6 to 37 months). Mean visual acuity was 20/60 preoperatively and 20/50 postoperatively. This level of improvement was not statistically significant (P > .10), but there was a statistically significant decrease in the use of corticosteroids between the preoperative examination and the last postoperative examination (86% versus 27%, P < .05). There was also a statistically significant decrease in vitritis at the last follow-up (P = .0008) and a decrease in neovascularization of the vitreous base (P = .03) and in clinically apparent cystoid macular edema (P = .02). Epiretinal membranes were noted in 23% of eyes preoperatively and in 45% of eyes postoperatively. Only one of these epiretinal membranes was considered to be visually significant. One eye developed a tonic dilated pupil, which slowly improved.

CONCLUSIONS

Although the long-term natural history of clinical findings in pars planitis is not well documented, PLP appears to decrease the need for corticosteroids while stabilizing visual acuity. It also appears to decrease vitreous inflammation. PLP has few complications and should be considered in patients with pars planitis who are unresponsive or have adverse reactions to corticosteroids.

Iritis and hypotony after treatment with intravenous cidofovir for cytomegalovirus retinitis

OBJECTIVE

To describe intraocular inflammation due to treatment with intravenous cidofovir dihydrate for cytomegalovirus retinitis.

DESIGN

Retrospective cohort.

SETTING

Three university outpatient ophthalmology clinics.

PATIENTS

All patients treated with intravenous cidofovir therapy before October 31, 1996.

INTERVENTION

Treatment with intravenous cidofovir was given according to standardized protocols. Intraocular inflammation was treated according to the best medical judgment.

MAIN OUTCOME MEASURES

The presence of new intraocular inflammation, the severity of inflammation, visual acuity, and intraocular pressure.

RESULTS

Eleven cases of iritis (26%) occurred among 43 patients. In 6 cases, the iritis was bilateral. Patients who experienced iritis were more likely to have been previously treated for cytomegalovirus retinitis (P = .03), to be diabetic (P = .05), or to be receiving protease inhibitors (P < .001). Four patients and 15 control subjects had also taken rifabutin (P = .70). The onset of iritis occurred at a mean (+/-SD) of 4.9 +/- 1.8 days after a cidofovir dose and after a mean (+/-SD) of 4.2 +/- 1.6 doses of cidofovir. Six eyes of 4 patients had hypotony. Five eyes of 5 patients had a persistent decrease in visual acuity of at least 2 Snellen lines.

CONCLUSIONS

Acute intraocular inflammation may occur with or without hypotony after intravenous cidofovir therapy, similar to the reactions seen after intravitreous administration. Although the manifestations may be severe, they are manageable with topical corticosteroid therapy in most cases. Cidofovir therapy can be continued in some patients if medical necessity warrants, but recurrent inflammation or permanent hypotony may occur.

Management of varicella zoster virus retinitis in AIDS

AIMS/BACKGROUND

Varicella zoster virus retinitis (VZVR) in patients with AIDS, also called progressive outer retinal necrosis (PORN), is a necrotising viral retinitis which has resulted in blindness in most patients. The purposes of this study were to investigate the clinical course and visual outcome, and to determine if the choice of a systemic antiviral therapy affected the final visual outcome in patients with VZVR and AIDS.

METHODS

A review of the clinical records of 20 patients with VZVR from six centres was performed. Analysis of the clinical characteristics at presentation was performed. Kruskall-Wallis non-parametric one way analysis of variance (KWAOV) of the final visual acuities of patients treated with acyclovir, ganciclovir, foscarnet, or a combination of foscarnet and ganciclovir was carried out.

RESULTS

Median follow up was 6 months (range 1.3-26 months). On presentation, 14 of 20 patients (70%) had bilateral disease, and 75% (15 of 20 patients) had previous or concurrent extraocular manifestations of VZV infection. Median initial and final visual acuities were 20/40 and hand movements, respectively. Of 39 eyes involved, 19 eyes (49%) were no light perception at last follow up; 27 eyes (69%) developed rhegmatogenous retinal detachments. Patients treated with combination ganciclovir and foscarnet therapy or ganciclovir alone had significantly better final visual acuity than those treated with either acyclovir or foscarnet (KWAOV: p = 0.0051).

CONCLUSIONS

This study represents the second largest series, the longest follow up, and the first analysis of visual outcomes based on medical therapy for AIDS patients with VZVR. Aggressive medical treatment with appropriate systemic antivirals may improve long term visual outcome in patients with VZVR. Acyclovir appears to be relatively ineffective in treating this disease.

Repair of retinal detachments due to herpes varicella-zoster virus retinitis in patients with acquired immune deficiency syndrome

PURPOSE

The authors characterize surgical techniques and report results for repair of retinal detachments due to varicella-zoster retinitis in patients with acquired immune deficiency syndrome (AIDS).

BACKGROUND

Varicella-zoster virus (VZV) retinitis is a distinctly aggressive infection in patients with AIDS. Retinal detachments occur in the majority of such patients, and contribute to their poor visual prognosis.

METHODS

A case series of five eyes in four patients with AIDS and retinal detachments due to VZV retinitis is presented, highlighting surgical technique and results. Pars plana vitrectomy, silicone oil tamponade, and endolaser photocoagulation were used in all cases.

RESULTS

Apparent contraction of the necrotic retina was observed, requiring large relaxing retinectomies to achieve retinal attachment in three of the five eyes. Follow up after surgery was 4, 6, 15, 29, and 30 months. Four eyes maintained ambulatory vision and the retinas remained attached.

CONCLUSION

Vitrectomy with silicone oil tamponade may be used to preserve ambulatory vision in carefully selected patients with AIDS and retinal detachments due to VZV retinitis. Relaxing retinectomy is a useful technique to achieve and maintain retinal attachment.