Comments on 'Presumed Post-COVID Infection Retinitis - Clinical and Tomographic Features of Retinitis as a Post-COVID Syndrome'

Characteristics and course of known seasonal diseases of pre-coronavirus disease (COVID-19) pandemic era may or may not change during the pandemic. Labelling COVID-19 as a novel etiology for those seasonal diseases or considering it as coinfection is debatable. Appropriate investigations are required to rule out previously known etiologies before correlating it with COVID-19. Epidemic retinitis (ER) or post fever retinitis is one such entity with seasonal variation. Multiple seropositivity for various organisms has been reported for ER during pre-pandemic era. This may significantly increase during the pandemic as the possibility of coinfection with COVID-19 is high. In the absence of gold-standard tests to exclude previously reported causes of ER, one should not undermine the possible coinfection before considering ER as post-COVID-19 syndrome. A study of incidence and pattern of seasonal variation of ER before and during the pandemic is needed before presumptively associating it with COVID-19.

Epidemic retinitis during pregnancy

Purpose

To study the clinical presentation and treatment outcome of epidemic retinitis (ER) during pregnancy.

Methods

This is a retrospective, observational chart review of pregnant patients diagnosed with ER from January 2014 to February 2023. Demographic details, month of pregnancy at the onset of ocular symptoms, history of present illness, clinical manifestations, and treatment outcomes were studied.

Results

In 9 years, ER was seen in 86 females, of whom 12 (13.9%) were pregnant. Twenty-one eyes of those 12 patients were studied. Most of the patients presented in the sixth month of pregnancy (range: 5-9 months, mean: 6.3 months). Physicians diagnosed viral exanthematous fever in six, typhoid in three, and suspected rickettsia in one patient. Medical termination of pregnancy (MTP) was performed in two patients before presentation. Weil-Felix test was positive in five, Brucella in one, WIDAL in three, and coronavirus disease 2019 (COVID-19) IgG and dengue IgG in one patient each. Oral antibiotics were given in five patients (two post-medical termination of pregnancy [MTP]) for the retinitis. All except four received oral steroids. Mean presenting corrected distant visual acuity (n = 21) was 20/125 (range: 20/20-20/20,000), which improved to (n = 18) 20/30 (range: 20/20-20/240). Macular edema (n = 11) resolved in 33.18 days (range: 20-50 days), and retinitis (n = 13) resolved in 58 days (range: 30-110 days). Ocular and systemic examination of newborn was possible in two and the babies were normal.

Conclusion

ER is seen commonly at the beginning of the third trimester. Lack of antibiotics may delay the resolution of retinitis. Ocular health needs to be assessed in larger series to conclude absence of retinal involvement in newborns.

Atypical Manifestations of Cat-Scratch Disease, United States, 2005-2014

Atypical manifestations that can be severe and difficult to diagnosis develop in 5%-20% of patients with cat-scratch disease. To clarify the epidemiology of atypical cat-scratch disease in the United States, we analyzed data from the 2005-2014 MarketScan national health insurance claims databases by using the International Classification of Diseases, 9th Revision, Clinical Modification, codes for cat-scratch disease and selected atypical manifestations: retinitis/neuroretinitis, conjunctivitis, neuritis, encephalitis, hepatosplenic disease, osteomyelitis, erythema nodosum, and endocarditis. Atypical cat-scratch disease accounted for 1.5% of all cases, resulting in an average annual incidence of 0.7 cases/100,000 population. Atypical cat-scratch disease was associated with increased risk for hospitalization (risk ratios 8.77, 95% CI 6.56-11.72) and occurred most often in female patients 10-14 years of age. Ocular (48.7%), hepatosplenic (24.6%), and neurologic (13.8%) manifestations were most common among patients. A more comprehensive understanding of atypical cat-scratch disease can improve patient diagnosis and potentially elucidate pathophysiology of the disease.

Retinitis due to opportunistic infections in Iranian HIV infected patients

We tried to evaluate prevalence and characteristics of Iranian HIV infected patients with retinitis due to opportunistic infections. In this cross sectional study, we evaluated 106 HIV infected patients via indirect ophthalmoscopy and slit lamp examination by 90 lens to find retinitis cases. General information and results of ophthalmologic examination were analyzed. Prevalence of retinitis due to opportunistic infections was 6.6%: cytomegalovirus (CMV) retinitis 1.88%, toxoplasmosis retinochoroiditis 1.88% and tuberculosis chorioretinitis 2.83%. CD4 count was higher than 50 cell/µlit in both cases with CMV retinitis. Along with increasing survival in the HIV infected patients, the prevalence of complications such as ocular manifestation due to opportunistic infections are increasing and must be more considered.

Candidaemia and risk of intraocular infection: A Danish hospital-based cohort study

Intraocular infection is a feared complication in patients with candidaemia. We therefore assessed the current risk and prognosis in Danish candidaemia patients. Candidaemia patients at a Danish university hospital were identified prospectively during a 10-y period, 1995-2004, and ophthalmologic records were retrieved retrospectively. Among 203 incident cases of candidaemia, 86 (42%) were examined at least once by an ophthalmologist. Nine patients had retinitis and 1 patient had endophthalmitis; eye involvement was bilateral in 8 and monocular in 2 patients. Lesions were generally mild and progression was observed in only 1 patient. Surgical treatment was not indicated and the median duration of systemic antifungal therapy was 19 d. The median survival time was 77 d for candidaemia patients with eye involvement, 480 d in candidaemia patients without such an involvement, and only 9 d in candidaemia patients without an ophthalmologic examination. In conclusion, the cumulative rate of intraocular infection was 11.6%, but we suspect an underestimation due to the circumstances of the eye examinations and the rapid death of many patients. We continue to recommend eye examinations for candidaemia patients, but timing seems not to be critical if overt signs of infection are absent, thereby facilitating the use of improved diagnostic methods.

Age and sex distribution of some retinal macular diseases: senile and presenile macular degeneration and central serous retinitis

The age and sex distribution of senile macular degeneration (SMD) was investigated at the Low Vision Clinic in Stockholm. SMD increased with age and was found to be more common among women than men. This difference was not due to the fact that women live longer than men or related to women consulting ophthalmologists more often than men because of visual handicap. The age and sex distribution of presenile macular degeneration ( PSMD ) and central serous retinitis (CSR) was investigated at the Department of Ophthalmology of Falun Hospital. Also PSMD increased with age and was found to be more common among women than men, even if the sex difference was not as clear as for SMD. CSR was found to be more frequent at younger ages and, contrary to SMD and PSMD , more common among men. The reasons for these sex differences in frequencies of SMD, PSMD and CSR are not known.

["White dot syndromes" in childhood]

BACKGROUND

The term "white dot syndromes" describes a group of heterogeneous inflammatory disorders of the choriocapillaris. They were first described a few decades ago and our knowledge about these variable diseases is very limited, especially in regard to their overall incidence and their differential diagnostic relevance in uveitis of childhood.

MATERIAL AND METHODS

A retrospective analysis has been performed of all cases of white dot syndromes in 407 patients with paediatric uveitis who were examined between 1996 and 2006. The relevant literature was reviewed.

RESULTS

The following incidence of white dot syndromes in childhood was found: acute posterior multifocal placoid pigmentepitheliopathy (APMPPE) (n = 4), multiple evanescent white dot syndrome (MEWDS) (n = 4), multifocal choroiditis and panuveitis (MCP) (n = 3) and 1 case of serpiginous choroiretinitis. The review of literature shows a different age predilection of the different white dot diseases. The relative frequency of white dot syndromes in paediatric uveitis patients is estimated to be between 1 - 5%.

CONCLUSION

"White dot syndromes" are an important differential diagnosis in uveitis of childhood. ICG angiography is an important tool for the diagnosis and follow-up examinations of these inflammatory diseases of the choriocapillaris. The different entities of white dot syndromes show differences concerning incidence, prevalence, course of disease, rate of complications and therapeutic implications.

Diffuse unilateral subacute neuroretinitis in Africa

PURPOSE

Diffuse unilateral subacute neuroretinitis (DUSN) is well known in endemic areas of the southeastern United States, South America, and the northern Midwestern United States. Two different categories of nematodes, according to their length, are related to endemic areas. We report the first case of DUSN caused by a small nematode in Africa.

METHODS

We describe the case of a 12-year-old Senegalese girl who presented a long-standing diffuse unilateral subacute neuroretinitis and in whom the worm could be localized.

RESULTS

The length of the unidentified worm measured using the software of the fundus camera was approximately 600 microm. This measurement corresponds to the smaller nematode usually found in patients from the southeastern United States and South America.

CONCLUSION

Diffuse unilateral subacute neuroretinitis can also be observed in patients living in Africa.

Diffuse unilateral subacute neuroretinitis in Venezuela

PURPOSE

To describe the clinical features and management of the largest reported series to date of patients with diffuse unilateral subacute neuroretinitis (DUSN).

DESIGN

Observational case series.

METHODS

The charts of all patients coded as having DUSN in a vitreoretinal clinic in Caracas, Venezuela between July 1979 and August 2000 were retrospectively reviewed.

MAIN OUTCOME MEASURES

Demographic information, presenting visual acuity, clinical course, and treatment were evaluated.

RESULTS

We identified 82 eyes of 78 patients with DUSN. The mean age at diagnosis was 16.7 years, significantly younger than the mean age of the Venezuelan population. Sixty-five (83.3%) patients were 20 years old or younger (P<0.001 when compared with the population of Venezuela). Thirty-three (42.3%) of the patients were female. The presenting visual acuity was 20/400 or worse in 69 eyes (84.1%). The subretinal nematode was identified in 33 eyes (40.2%). All nematodes were small, approximately 400 microm in length.

CONCLUSIONS

In Venezuela, DUSN is seen primarily in young patients without a significant gender predilection. The vast majority of patients in this population presented with severe vision loss that was irreversible.

An Epidemiological and Clinical Study of Ocular Manifestations of CongenitalRubella Syndrome in Omani Children

OBJECTIVE

To conduct a follow-up study in patients with congenital rubella syndrome (CRS) in Oman and analyze the prevalence of ophthalmic disorders and associated systemic problems.

METHODS

This historical prospective cohort study included review of 32 surviving patients with CRS reported by the surveillance system in Oman from 1987 through 2002. All patients underwent a complete ophthalmic examination that included visual acuity estimation, refraction and anterior and posterior segment evaluation, and intraocular pressure measurement. Pediatric and otorhinolaryngologic consultations were also performed.

RESULTS

The age-adjusted prevalence of CRS in Oman was 73.2 per million in the Omani population younger than 20 years, and the incidence was 0.6 per 1000 live births. Cataract, retinitis, microphthalmos, and glaucoma were observed in 11, 16, 6, and 4 patients, respectively. Keratoconus, corneal hydrops, and spontaneous resorption of lens were found in 1 patient each. Vision testing was possible in 16 children; 4 were bilaterally blind. Patients who had undergone eye surgery had significantly lower visual acuity, as compared with those who had not undergone surgery (relative risk 2.53; 95% confidence interval, 1.07-6.13). Among the 11 patients with CRS with cataract, we found hearing loss, cardiac anomalies, and neuropsychologic anomalies in 7, 4, and 6 children, respectively.

CONCLUSIONS

Congenital rubella syndrome has a wide variety of severe ophthalmic and systemic complications. High clinical vigilance for signs of CRS and regular observation of surviving patients with CRS is desirable. In patients with cataract, the functional results of surgery, despite state-of-the-art ophthalmic care, continue to be poor. Because of a high prevalence of visual, audiologic, and neurologic disabilities, surviving patients with CRS pose a burden on the medical and social communities. Emphasis in management ought to be prevention of CRS through effective immunization programs.

Neuroretinitis associated with cat-scratch disease in Japanese patients

PURPOSE

To clarify the prevalence and clinical profile of neuroretinitis associated with cat-scratch disease (CSD) in Japan.

METHODS

Japanese patients were searched using a computer web site, Japana Centra Revuo Medicina. Location of patients, medical history, systemic and intraocular findings, treatments and visual outcome were examined.

RESULTS

We reviewed 15 eyes of 14 patients, including our own case. Incidences of the disease were more common in summer than in winter and presented in the warmer parts of Japan. All patients had been previously healthy and had been exposed to cats or flea bites. Of the 14 patients, 13 (93%) had febrile illness and seven of these (54%) had lymphadenopathy. Uveitis and macular stars were observed in 11 of 15 eyes (73%). Most patients were treated with antibiotics and systemic steroids and visual prognoses were good.

CONCLUSIONS

The clinical features of CSD-associated neuroretinitis in Japan are similar to those in other countries. Its distribution may correlate with the prevalence of Bartonella henselae-seropositive cats in Japan.

Nematode infections of the eye: toxocariasis, onchocerciasis, diffuse unilateral subacute neuroretinitis, and cysticercosis

Nematode infections of the eye are common in different parts of the world, but some are usually encountered only in developing nations, such as onchocerciasis and cysticercosis. Ocular toxocariasis is a well-known cause of unilateral ocular disease affecting mainly children and young adults, and is usually caused by T canis. Prevention of ocular toxocariasis is based on such measures as appropriate health care for dogs and cats, including regular anthelmintic treatments, preventing contamination of the environment with feces, and promoting responsible pet ownership [1,49-51]. Onchocerciasis is caused by infection with the filarial parasite O volvulus, and occurs in endemic areas along rivers and streams. In hyperendemic areas almost every person is infected and about half of the population is eventually blinded by onchocerciasis. Because of this, elimination of host-vector contact is very important. DUSN is caused by a motile nematode and is found in the Southeastern and Midwestern United States and in many parts of the world. In Brazil, DUSN is becoming an important cause of posterior uveitis in children and young healthy adults. The destruction of the worm during the early stages of the disease can prevent progression of the visual loss. It is important to remain aware of this entity, not only in areas where it has been described, but also in regions not yet identified as being endemic [52]. Cysticercosis is caused by the encystment of the larvae of the tapeworm T solium, and usually results from ingesting eggs from food, water, or other material contaminated with human feces. Surgical removal of the cyst is usually indicated when possible.

[Ocular damage during HIV infection at the University Hospital Center of Casablanca. (Apropos of 400 cases)]

The objective of this study was to report ocular manifestations in Moroccan patients infected with HIV/AIDS. 400 patients were surveyed retrospectively from 1993 to 1998 as part of a co-operative study undertaken by the departments of infectious diseases and ophtalmology of the Casablanca Teaching Hospital. Of the 400 patients, 127 had an infection of the posterior segment and 7 showed signs of a palpebral infection. We also found 44 cases of opportunist retinal infections, dominated by the Cytomegalovirus (CMV) (18 cases). Our sample study indicates an intermediary position between western countries where the widespread use of the tritherapy has increased the life expectancy of patients and sub-Saharan Africa where epidemiological data are still characterised by high mortality and increasing endemic disease.

Multiple cases of acquired toxoplasmosis retinitis presenting in an outbreak

OBJECTIVE

The purpose of the study was to examine the variability in presentation and outcome of individuals presenting with acquired toxoplasmosis retinitis in the setting of an outbreak of the disease.

DESIGN

The study design was a case series.

PARTICIPANTS

Twenty-one eyes of 20 patients with equal gender distribution and a mean age of 54 years followed for 38 to 170 weeks (mean 113.7 weeks) were studied.

INTERVENTION

Systemic antimicrobials and corticosteroids when indicated were given.

MAIN OUTCOME MEASURES

Visual acuity, media inflammation and clarity, resolution of active retinitis, and appearance of recurrence were observed.

RESULTS

Fifteen of 21 lesions were active, and 7 of the total number of lesions fell within the macula-peripapillary region. Overall, vision improved with treatment except in cases of macular involvement (3 cases) and persistent vitritis (3 cases). Four recurrences have occurred to date.

CONCLUSIONS

This is the largest reported outbreak of acquired toxoplasmosis retinitis occurring within a single outbreak. Twenty-one eyes of 20 patients presented with retinal lesions, and on average, those treated for active retinitis had improvement in vision.

Spread of HSV-1 to the suprachiasmatic nuclei and retina in T cell depleted BALB/c mice

Following uniocular anterior chamber inoculation of the KOS strain of HSV-1 in euthymic BALB/c mice, virus spreads from the injected eye to the brain, and from the brain to the optic nerve and retina of the uninjected eye by day 7 post inoculation (p.i.), but the optic nerve and retina of the injected eye are not infected with virus. Infection of the optic nerve and retina of the injected eye is observed only in athymic mice or in mice depleted of both CD4+ and CD8+ T cells. To determine the role of T cells in virus spread, adult female BALB/c mice were thymectomized and T cell depleted. Mice were co-injected with the KOS strain of HSV-1 and RH116, a thymidine kinase-negative mutant of KOS containing the Escherichia coli lac Z gene. Animals were sacrificed on days 3-7 p.i., and the eyes and brains were examined for blue-stained, virus-infected cells. A difference in the timing of virus infection was observed in the area of the suprachiasmatic nuclei only in mice depleted of both CD4+ and CD8+ T cells, and in this group, the contralateral suprachiasmatic nucleus was infected two days earlier. Since one route by which virus could infect the retina of the injected eye is via connections of the contralateral suprachiasmatic nucleus to the ipsilateral optic nerve, these findings suggest that (a) retinitis observed in the injected eyes of mice depleted of both CD4+ and CD8+ T cells results from virus infection of the contralateral suprachiasmatic nucleus followed by spread of virus to the ipsilateral optic nerve and retina and (b) early HSV-1 infection of the contralateral suprachiasmatic nucleus is prevented by a T cell dependent mechanism.

Diffuse unilateral subacute neuroretinitis. Morphometric, serologic, and epidemiologic support for Baylisascaris as a causative agent

PURPOSE

Several nematodes have been postulated as etiologic agents in diffuse unilateral subacute neuroretinitis (DUSN), but the cause of this condition remains uncertain. The authors report the first case of DUSN from the western United States (northern California), along with morphometric, serologic, and epidemiologic evidence supporting Baylisascaris procyonis as its cause.

METHODS

One patient was examined and evaluated for disc edema and transient obscurations of vision. A diagnosis of DUSN was confirmed when a motile nematode was identified within the substance of the patient's retina. Morphometric analysis of the nematode was done from projected fundus photographs. Serologic evidence of Baylisascaris infection was suggested by Western blot analysis. A necropsy was done on 12 raccoons from the area. They were examined for evidence of Baylisascaris infection, previously believed to be nonendemic in the region.

RESULTS

The intraocular nematode measured 1727 x 67 microns, most consistent with Baylisascaris. The patient had considerable exposure to raccoons, and was seropositive for B. procyonis infection on Western blot analysis. Necropsy evaluation showed B. procyonis infection in 8 of 12 raccoons examined from the area.

CONCLUSIONS

The morphometric, serologic, and epidemiologic findings in this case provide evidence that the raccoon ascarid, B. procyonis, is a cause of the large nematode variant of DUSN.

[A strategy for preventing health injuries due to observing the solar eclipse in Mexico]

A total solar eclipse was watched by almost [corrected] 50 million people in the Mexican Republic on July 11, 1991. Cases of solar retinitis, which can even lead to permanent loss of visual function, have been reported in the international literature. The institutions of the National Health System employed a strategy for the prevention of risks and health damages caused by direct observation of the phenomenon, which implied the elaboration of a technical norm concerning the manufacturing of sun filters, the diffusion of preventive actions through the use of mass media, the detection and prompt care of cases and the establishment of an ophthalmologic care system and epidemiological surveillance system. The result was the detection of 21 moderate cases of solar retinitis, all of which recovered their full visual function after four months. The present article reports the implemented actions and the details of the cases.

[Ocular involvement in rheumatoid arthritis]

The authors evaluated ocular involvement in 23 patients affected by rheumatoid arthritis (RA) according to ARA criteria. Slit-lamp biomicroscopic examination showed signs of keratoconjunctivitis sicca in one patient (4%), while a positive bilateral Schirmer test was found in six subjects (26%). Fluorescein angiography, carried out in 11 of the 23 RA patients, showed retinal vasculitis in 18% of the patients examined, even if no clinical and ophthalmoscopic signs of retinal vessel inflammation were present. The authors suggest that fluorescein angiography should be performed in patients affected by particularly active RA, with recent onset of the disease (< 12 months), high titres of classical IgM rheumatoid factor and raised concentrations of circulating immune complexes. The study confirmed moreover the uncommon ocular toxicity related to the drugs frequently employed in RA treatment (antimalarials, gold salts, glucocorticoids). Indeed, only one case (4%) of posterior subcapsular cataract clearly related to steroid therapy was found.

Incidence and natural history of cytomegalovirus disease in patients with advanced human immunodeficiency virus disease treated with zidovudine. The Zidovudine Epidemiology Study Group

Data were analyzed from a multicenter observational cohort study of 1002 persons with AIDS or AIDS-related complex (ARC) and total CD4 cell count < 0.25 x 10(9)/L treated with zidovudine between April 1987 and April 1988. Cytomegalovirus (CMV) disease developed in 109 patients (10.9%), with a 2-year actuarial risk of 15%. Manifestations included retinitis (93 patients), esophagitis (10), colitis (8), gastritis (1), hepatitis (1), and encephalitis (1). The probability of CMV disease at 2 years for patients with initial counts < 0.1 x 10(9)/L was 21.4%, compared with 10.3% for patients with initial counts > or = 0.1 x 10(9)/L (P < .001). By proportional hazards analysis, baseline CD4 cell count < 0.1 x 10(9)/L, enrollment diagnosis of AIDS, and homosexuality were significantly associated with subsequently developing CMV disease. Median survival after diagnosis of CMV disease was 173 days, and CMV was an independent predictor of death. CMV contributes to AIDS-related morbidity and mortality. As new anti-CMV drugs become available, prophylaxis should be targeted at individuals with CD4 cell counts < 0.1 x 10(9)/L.

[Retinitis caused by cytomegalovirus in patients with AIDS. Clinico-therapeutic aspects and relationship with HIV retinal microangiopathy in a series of 38 patients]

We evaluate retrospectively 38 patients with AIDS and Cytomegalovirus (CMV) retinitis. In 72.5% (45 from 62 eyes) it carried an important sight risk; 50% of the end of the follow-up. Evidence of extraocular illness in 28.5% of the patients. Using control groups the AIDS microvasculopathy is neither more frequent in CMV-retinitis nor associated with a special risk group (p greater than 0.05), we review treatment, follow-up and complications. The median survival was 6 months without significan differences (p greater than 0.05) with or without the finding of microvasculopathy, bilaterality or extraocular illness.

Cytomegalovirus disease in AIDS: the Edinburgh experience

Retrospective analysis of medical records of 557 HIV positive patients (including 113 with AIDS) revealed 17 patients with an antemortem clinical diagnosis of cytomegalovirus (CMV) disease. This group comprised 7 injection drug users (2 male and 5 female) and 10 homosexual men. Males were significantly older than females, and homosexual men were significantly older than drug users at the time of diagnosis of CMV. All 17 patients had evidence of retinitis, and 6 also had evidence of extraocular disease. CMV retinitis was the AIDS defining diagnosis in two patients, and the attack rate of CMV in all AIDS patients progressively increased with time, with a 3-year CMV-free survival of 57%. Fifteen patients with CMV disease had evidence of previous CMV infection (CMV IgG positive), with 7 also having a positive CMV IgM and 10 a positive viral culture. The mean CD4+ lymphocyte count at diagnosis of CMV was 17 cells/mm3, compared with 68 cells/mm3 at diagnosis of AIDS. Therapy was unsatisfactory, often being complicated by marrow suppression. Relapse occurred in 11 patients after initial improvement but despite this only 3 patients died with severe visual impairment. The mean survival after a diagnosis of CMV was 10.5 months. This study confirms that disease caused by CMV is usually a late manifestation of AIDS, and the increasing prevalence among patients with AIDS implies that, the longer the survival, the greater the risk of disease. Frequent fundoscopy in HIV positive patients is of paramount importance particularly in patients who have a CD4+ lymphocyte count of less than 100 cells/mm3.

Diffuse unilateral subacute neuroretinitis in South America

We describe two cases of diffuse unilateral subacute neuroretinitis in South America. These Brazilian patients presented with subretinal worms similar in size to those described in the southeastern United States. This is the first report, to our knowledge, of diffuse unilateral subacute neuroretinitis occurring outside the United States and Caribbean Islands.

Screening indices for cytomegalovirus retinitis in patients with human immunodeficiency virus

Cytomegalovirus retinitis, the major cause of blindness in patients with the acquired immunodeficiency syndrome, can be arrested by early detection and treatment. We identified 9 screening indices for early CMV retinitis: T-4/T-8 ratio less than 0.11, T-4 count less than 30, T-8 count less than 500, leukocytes less than 4,200, platelets less than 240,000, hemoglobin less than 11.6, hematocrit less than 35, less than 6 for a diagnostic profile which incorporates these 7 indices, and less than 2 for the IA-sum which compounds T-cell inversion and anemia. A threshold value was determined for each index, identified by retrospective review of charts of 15 patients with CMV retinitis and 30 without. Sensitivity, specificity, positive predictive value, negative predictive value, and receiver operating characteristic curve area was calculated. The best screening index was the T-cell ratio, which had the highest sensitivity (0.93), negative predictive value (0.94-0.99) and receiver operating characteristic curve area (0.89), and a positive predictive value among the highest (0.50-0.82).

Risk of developing cytomegalovirus retinitis in persons infected with the human immunodeficiency virus

This study examines the risk of developing cytomegalovirus (CMV) retinitis as a function of the duration and degree of CD4+ lymphocyte depletion. A retrospective analysis of 135 persons infected with the human immunodeficiency virus (HIV) was performed. Kaplan-Meier estimates for the percentage of patients developing CMV retinitis during the 27-month study period were calculated. Twenty-six patients were diagnosed as having CMV retinitis. In 14 of these patients, T cell phenotyping was done within the 3 months preceding diagnosis. The mean CD4+ lymphocyte count for these patients was 15.6 cells/mm3 (range, 2-33/mm3). At 27 months, the percentage of patients developing CMV retinitis with baseline CD4+ lymphocyte counts of 0-50, 51-100, and 101-250 cells/mm3 was 41.9%, 26.3%, and 14.7%, respectively (log-rank test, p = 0.003). The odds ratio for developing CMV retinitis for those with baseline CD4+ lymphocyte counts of 0-50 cells/mm3 compared with those with CD4+ lymphocyte counts of 101-250 cells/mm3 was 4.62 (p = 0.002). Twenty-four patients had CD4+ lymphocyte counts of < or = 50 cells/mm3 for an average of 13.1 months prior to diagnosis. Twenty-two patients had an acquired immune deficiency syndrome (AIDS)-defining illness diagnosed for an average of 18.0 months prior to the onset of retinitis. CMV retinitis is most likely to develop in patients with AIDS when the CD4+ lymphocyte count is < or = 50 cells/mm3.

Cytomegalovirus infection in AIDS. Patterns of disease, response to therapy and trends in survival

Among 347 AIDS patients seen at St Mary's Hospital, London between 1983 and 1989, cytomegalovirus (CMV) disease was observed in 75 (22%). Of these, 58 (77%) had CMV retinitis, 26 (35%) CMV colitis, and 12 (16%) had CMV infection diagnosed at other sites. Relapse occurred in 71%. A favourable response to the use of ganciclovir as induction therapy for CMV retinitis was observed in 92%. Relapse of CMV retinitis occurred in 54% at a median time of 97 days. Neutropenia was the most frequent and serious side-effect of ganciclovir, 76% patients having neutrophil counts less than 1.0 x 10(9)/l and 48% less than 0.5 x 10(9)/l at some stage of therapy. Thrombocytopenia was also common, and platelet counts of less than 50 x 10(9)/l occurred in 43% patients on ganciclovir. The concurrent use of zidovudine made the development of severe neutropenia and thrombocytopenia more likely. Median survival following the diagnosis of CMV disease increased from 5-8 months between 1984 and 1987, to over 12 months in 1988. Patients with CMV colitis had a worse prognosis than patients with CMV retinitis, with median survival of 4.5 and 7 months respectively. In conclusion, CMV is an important opportunist infection in AIDS and both the disease and its treatment cause considerable morbidity. Hence, it is important to develop more effective and less toxic forms of therapy for CMV infection.

AIDS-CMV retinitis: Singapore's first cases

Since April 1988, four cases of AIDS-CMV retinitis were diagnosed in Singapore. Two patients were given intravenous ganciclovir. Clinical response was good but recurrent episodes of breakthrough infection occurred in one patient despite maintenance therapy. Another patient was started on intravenous foscarnet. The fourth patient succumbed to systemic AIDs-related infection before therapy could be started. AIDS-CMV retinitis is a new disease entity in Singapore. With increasing number of AIDS patients, more cases can be expected in the near future. Early treatment and long term maintenance therapy is essential for preserving sight.

Cytomegalovirus retinitis

Cytomegalovirus retinitis is a frequent and serious complication of various conditions, including diseases characterized by impaired immunity, such as the acquired immunodeficiency syndrome. Due to recent advances in the treatment of cytomegalovirus retinitis, accurate diagnosis and management have become increasingly important. In this review, the authors present the epidemiology, clinical features, diagnostic testing, treatment with complications, and prognosis of cytomegalovirus retinitis. A differential diagnosis is presented and the characteristic ocular lesions are illustrated.

Retinal and gastrointestinal disease due to cytomegalovirus in patients with the acquired immune deficiency syndrome: prevalence, natural history, and response to ganciclovir therapy

Of 760 AIDS patients seen at San Francisco General Hospital in 1986, 5.7 per cent had retinitis and 2.2 per cent had gastrointestinal disease caused by cytomegalovirus. We reviewed the records of 44 patients treated with ganciclovir for culture-confirmed cytomegalovirus retinal (31 patients) or gastrointestinal disease (17 patients) or both (four patients) in 1986. Retinitis stabilized or improved during initial treatment with ganciclovir in 22 of 27 (81.5 per cent) patients. Following a median 10-day induction course, 16 patients with retinitis continued to have serial ophthalmologic assessments: eight patients were maintained on treatment and eight had maintenance treatment deferred. Before treatment, the two groups were comparable in age, Karnofsky scores, hematologic assessment, visual acuity, and history with respect to Pneumocystis carinii pneumonia. Retinitis did not progress for a median 53.8 days in the immediate maintenance group compared to 18.8 days for the deferred maintenance group (p = 0.01). In 17 patients with CMV gastrointestinal disease, nine of 14 (64 per cent) had resolution of pain and eight of 11 (73 per cent) had resolution of diarrhea when treated initially with ganciclovir. In both retinitis and gastrointestinal disease patients, ganciclovir decreased recovery of CMV from urine and blood markedly. Ganciclovir also caused a decrease in mean absolute neutrophil counts to about half of baseline values; decreases in mean platelet count and hemoglobin were also noted but were less than 25 per cent. Neutropenia severe enough to require dose adjustment (less than 800 cells/microliters) occurred in 31 per cent of patients receiving maintenance ganciclovir.

Cytomegalovirus infection after autologous bone marrow transplantation with comparison to infection after allogeneic bone marrow transplantation

Cytomegalovirus (CMV) infection was detected in 65 of 143 (45%) autologous bone marrow transplant (BMT) patients. CMV pneumonitis occurred in only 2% of the patients and CMV retinitis occurred in none. Infection occurred in half of the 40 initially seronegative patients and 47% of the 94 initially seropositive patients. Among initially seropositive patients, platelet recovery was slower in infected patients than in those not infected (97 v 35 days median, P = .003), and neutrophil recovery was slightly delayed in infected patients (31 days v 24 days, P = .02). Although the incidence of CMV infection was comparable in autologous and allogeneic BMT patients, CMV pneumonitis was less frequent in autologous BMT patients (2% v 12%, P less than .001). The risk for CMV pneumonitis in autologous BMT patients was comparable with that in allogeneic BMT patients without graft-v-host disease (GVHD) (2% v 6%), but significantly lower than the risk in allogeneic BMT patients with GVHD (2% v 23%, P less than .001).

Solar retinopathy: a photobiological and geophysical analysis

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The acute retinal necrosis syndrome. Possible herpes simplex retinitis

The acute retinal necrosis (ARN) syndrome is a severe necrotic peripheral retinitis with vasculitis and vitritis. It attacks healthy people and carries a poor visual prognosis. Five patients with ARN were seen. Two showed interesting clinical features. One patient developed the ARN syndrome in both eyes but with a 14-year hiatus separating the two episodes, each being preceded by an infectious illness. A second patient had a possible recurrence of the ARN syndrome in the same eye, one year after the original episode. Each episode was preceded by an upper respiratory infection and ipsilateral vesicular skin lesions on the face. Biopsy of one lesion yielded herpes simplex virus (HSV) in culture. These associations, although not definitive, do lend support to the hypothesis that HSV may be the cause of the ARN syndrome.

Bardet-Biedl syndrome and retinitis punctata albescens in an isolated northern Canadian community

Autosomal recessive inheritance of various conditions is well documented among inbreeding groups. In northern Canada inbreeding occurs in communities as a result of language and cultural uniqueness as well as geographic isolation. In one such community--Rae, in the Northwest Territories--two autosomal recessive disorders, the Bardet-Biedl syndrome and retinitis punctata albescens, are segregating. This report outlines the major clinical features of the disorders, establishes for both conditions the high frequency of the heterozygous carrier genotype in the community and suggests a possible way to reduce the likelihood of increased numbers of affected individuals in forthcoming generations.