CMVR-Related

Retinal Detachment

Nawat Watanachai

RCOPT 2014

Bangkok

AIDS : in the past• pre-HAART era : 1981-1995

• AIDS : fatal disease

• CMVR : CD4 <100/ml

• CMVR :*

• 25-42% of AIDS

• strong predictor of mortality

• aim of eye treatment :

• short-term ctrl of retinitis

• RRD 40% of CMVR eyes

•—> blind —>dead

• * Bowen EF, Wilson P, Cope A, et al. Cytomegalovirus retinitis in AIDS patients: Influence of cytomegaloviral load on response to

ganciclovir, time to recurrence and survival. AIDS 1996, 10(13):1515-20.

AIDS : in the present

• HAART era : 1996-now

• AIDS : NOT a fatal disease

• newer medication

• screen if CD4<100/ml

• oral valgancyclovir or others

• pts live a longer life

• stop/ slow the progression of CMVR

• incidence decrease 80%*

• * Skiest DJ. Cytomegalovirus retinitis in the era of highly active antiret- roviral therapy

(HAART). Am J Med Sci. 1999;317:318–335.

AIDS : in the present

• HAART era : 1996-now

• HAART-treated puts

• lower incidence of RD 40%—>3.2% of CMVR eyes**

• disease progression***

• 2nd eye involvement***

• aim of treatment : long-term vision preservation

** Jabs DA, van Natta ML, Thorne JE, et al. Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: 2. Second eye

involvement and retinal detachment. Ophthalmology. 2004;111: 2232–2239.

*** Jabs DA, van Natta ML, Thorne JE, et al. Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: 1. Retinitis

progression. Ophthalmology. 2004;111:2224–2231.

then,

why CMVR is

still be a serious

problem?

why CMVR is still be a serious problem?

• CMVR related visual loss is usually severe

• WHO : blindness = VA<3/60

• CMVR : HM or worse in 89% of CMVR-related blind eyes

• 21-36% already had blind eye when eye doc gave dx of CMVR*

• non-ambulatory vision in the young

1. Heiden D, Ford N, Wilson D, Rodriguez WR, Margolis TM, et al: Cytomegalovirus retinitis: the neglected disease of the AIDS pandemic. PLoS Med 2007, 4(12):e334.

2. Shi Y, Lu H, He T, Yang Y, Liu L, et al: Prevalence and Clinical Management of Cytomegalovirus Retinitis in AIDS patients in Shanghai, China. BMC Infectious Diseases .

3. Ausayakhun S, Watananikorn S, Ngamtiphakorn S, Prasitsilp J: Intravitreal foscarnet for cytomegalovirus retinitis in patients with AIDS. J Med Assoc Thai 2005, 88:103-107.

4. Ausayakhun S, Yuvaves P, Ngamtiphakorn S, Prasitsilp J: Treatment of cytomegalovirus retinitis in AIDS patients with intravitreal ganciclovir. J Med Assoc Thai 2005, 88(Suppl 9):S15-S20.

why CMVR is still be a serious problem?

• second most common cause of blindness in the

northern thailand*

• HIV pts = 2% of the general population*

• * Pathanapitoon K, Ausayakhun S, Kunavisarut P, Wattananikorn S, Leeungurastien T, Yodprom R,

Narongjunchai D, Rothova A: Blindness and low vision in a tertiary ophthalmologic center in

Thailand: the importance of cytomegalovirus retinitis. Retina 2007, 27(5):635-640.

why CMVR is still be a serious problem?

• CMVR-RRD

• higher rate of failure after treating by standard

techniques of SBP, Pneumatic retinopexy, PPV, FGX

• why?

WHY CMVR-RRD is so stubborn?

• factors

• large areas of full thickness retinitis —

> full thickness retinal necrosis

• multiple RBs in multiple quadrants

• frequent posterior location of the RBs

• hard to identify RBs in areas of

necrotic detached retina

• Brar M, Kozak l, et al: Vitreoretinal interface abnormalities in healed cytomegalovirus retinitis. Retina 2010;30(8):1262-6.

• Cavan P, Chris OR, et al: Optical coherence tomography in the diagnosis and management of uveitis. Can J Ophthalmol2014:49(1):18-

29.

WHY CMVR-RRD is so stubborn?

• factors

• laser not works well in the atrophic areas

• vitritis —> persistent VR traction over the healed areas

• ERM

• vitreoretinal gliosis

• vit traction, esp. on the rims

• ongoing nature of retinitis

• Brar M, Kozak l, et al: Vitreoretinal interface abnormalities in healed cytomegalovirus retinitis. Retina 2010;30(8):1262-6.

• Cavan P, Chris OR, et al: Optical coherence tomography in the diagnosis and management of uveitis. Can J

Ophthalmol2014:49(1):18-29.

treatment : nonRD-related CMVR• IV ganciclovir/ foscarnet/ cidofovir

• oral valganciclovir

• intravit ganciclovir inj*

• the most cost effective

• usual : 0.2-4 mg/0.1ml*,**

• safe : 6 mg

• NOOOO! : 40 mg

• intravit foscarnet(yes?)/ cidofovir(no)

• intravit ganciclovir implant

• *Stewart M, et al. : Optimal management of cytomegalovirus retinitis in patients with AIDS: Clin Ophthal: open access

• **Yutthitham K, Ruamviboonsuk P. The high-dose, alternate-week intravitreal ganciclovir intentions for cytomegalovirus

retinitis in AIDS patients on HAART. J Med Assoc Thai. 2005, 88:63-8.

Treatment : RD-related CMVR

• choices of RRD treatment

• laser retinopexy

• SBP

• pneumatic retinopexy

• PPV+gas?

• PPV+SOI

Treatment : RD-related CMVR

• choices of RRD treatment

• laser retinopexy

• SBP

• pneumatic retinopexy

• PPV+gas?

• PPV+SOI

laser :

walling off

• conditions :

• macula on RRD, not close to post. pole

• wide/ many areas of atrophic retina

• 3 rows of confluent laser burns

• place in healthy retina surrounding RD, whole

area of necrotic healed retinitis

laser : walling off

• may failed due to

• vitreous contraction (incomplete PVD)

• too large and bullies

• advancing CMVR

• success

• 78.2% in eyes without RRD*

• 57-68% in eyes with RRD**

• * Althaus C, Loeffer KU, Schimkat M, et al. Prophylactic argon laser coagulation for rhegmatogenous retinal detachment in AIDS patients with

cytomegalovirus retinitis. Graefes Arch Clin Exp Ophthalmol. 1998;236:359-64.

• **Vrabec TR. Laser photocoagulation repair of macula-sparing cytomegalovirus-related retinal detachment. Ophthalmic. 1997;104:2062-7.

• **Davis JL, Hummer J, Feuer WJ. Laser photocoagulation for retinal detachments and tears in cytomegalovirus retinitis. Ophthalmology, 1997;104:2053-

60.

Treatment : RD-related CMVR

• choices of RRD treatment

• laser retinopexy

• SBP

• pneumatic retinopexy

• PPV+gas?

• PPV+SOI

Scleral Buckle Procedure

• usually failed in advanced cases

• hard to identify RBs in the atrophic areas

• SBP should cover all areas of atrophic retina

• higher risk of accident

• use only in selected cases

• localized anterior RRD

Treatment : RD-related CMVR

• choices of RRD treatment

• laser retinopexy

• SBP

• pneumatic

retinopexy

• PPV+gas?

• PPV+SOI

• pneumatic retinopexy

Treatment : RD-related CMVR

• choices of RRD treatment

• laser retinopexy

• SBP

• pneumatic retinopexy

• PPV+gas?

• PPV+SOI

PPV+gas

• mixed results

• depended on case selection

• conditions

• simple RRD

• RB in 1-2 quadrants

• superior breaks

• no/ few PVR

• inacive CMVR

• Canzano JC, Morse LS, Wendel RT. Surgical repair of cytomegalovirus-related retinal detachment without silicone

oil in patients with AIDS. Retina. 1999;19:274-8.

Treatment : RD-related CMVR

• choices of RRD treatment

• laser retinopexy

• SBP

• pneumatic retinopexy

• PPV+gas?

• PPV+SOI

PPV+SOI

• 1987 Freeman and assocites :

• successful treatment of PPV+SOI

• Freeman WR, HenderlyDE, Wan WL, etal:Prevalence,pathophysiology,andtreat-

mentofrhegmatogenousretinaldetachmentintreatedcytomegalovirusretinitis.AmJ Ophthalmol 1987; 103:527-536.

2 Irvine AR. The treatment of retinal detachment due to CMV retinitis in AIDS. Trans Am Ophthalmol Soc 1991;89:

34967.

3 Dugel PU, Liggett PE, Lee MB, Ziogas A, Forster DJ, Smith RE, et al. Repair of retinal detachment caused by

cytomegalovirus retinitis in patients with the acquired immunodeficiency syndrome. Am J Ophthalmol 1991;112: 235–42.

4 Sidikaro Y, Silver L, Holland GN, Krieger AE. Rhegmato- genous retinal detachments in patients with AIDS and

necrotizing retinal infections. Ophthalmology 1991;98:129– 35.

5 Freeman WR, Quiceno JI, Crapotta JA, Listhaus A, Mungria D, Aguilar MF. Surgical repair of rhegmato- genous retinal

detachment in immunosuppressed patients with cytomegalovirus retinitis. Ophthalmology 1991;99: 466–74.

6 Kupperman BD, Flores-Aguilar M, Quiceno JI, Capparelli EV, Levi L, Mungria D, et al. A masked prospective evalu-

ation of outcome parameters for cytomegalovirus-related retinal detachment surgery in patients with acquired immune

deficiency syndrome. Ophthalmology 1994;101: 46–55.

7 LimJI,EngerC,HallerJA,CampochiaroPA,MeredithTA, de Bustros S, et al. Improved visual results after surgical repair of

cytomegalovirus-related retinal detachments. Ophthalmology 1994;101:264–9.

8 Garcia RF, Flores-Aguilar M, Quiceno JI , Capparelli EV, Mungria D, Kupperman BD, et al. Results of rhegmato-

genous retinal detachment repair in cytomegalovirus retinitis with and without scleral buckling. Ophthalmology

1995;102:236–45.

9 Nasemann JE, Mutsch A, Wiltfang R, Klauss V. Early pars plana vitrectomy without buckling procedure in cytomega-

lovirus retinitis-induced retinal detachment. Retina 1995; 15:111–6.

10 Regillo CD, Vander JF, Duker JS, Fischer DH, Belmont JB, Kleiner R. Repair of retinitis-related retinal detachments

with silicone oil in patients with acquired immunodefi- ciency syndrome. Am J Ophthalmol 1992;113:21–7.

11 Dowler JGF, Towler HMA, Mitchell SM, Cooling RJ, Lightman SL. Retinal detachment and herpesvirus retinitis in

patients with AIDS. Br J Ophthalmol 1995;79:575–80.

PPV+SOI

• 1. Singh R, Bhalekar S, et al: Outcome of surgery in post-

cytomegalovirus retinal detachment: Indian J Ophthalmol.

2013:61(11)636-9.

• 2. Gore SK, Gore DM, Chetty K, Visser L:

Cytomegaloviral retinitis-related retinal detachment:

outcomes following vitrectomy in the developing world: Int

Ophthalmic. 2014:34(2):205-10.

PPV+SOI

• highest success rates

• became standard treatment for advanced CMVR-related RRD

• Freeman WR, HenderlyDE, Wan WL, etal:Prevalence,pathophysiology,andtreat-

mentofrhegmatogenousretinaldetachmentintreatedcytomegalovirusretinitis.AmJ Ophthalmol 1987; 103:527-536.

PPV+SOI : problems

• 5-7D hyperopic shift

• usually decreased by 1-4D when SBP was done

• 18-53%risk of redetachment

• increased in eyes after silicone oil removal

• Dave V, Mathai A, Pappuru R. Results of silicone oil removal in post-cytomegalovirus retinitis-related retinal

detachment. J Ophthal Inflame Infect. 2012;2:153-155.

• Davis J. Removing silicone oil from eyes with cytomegalovirus retinitis. Am J Ophthalmol. 2005;140:900–902.

• Morrison VL, Labree LD, Azen SP, et al: Result of silicone oil removal in patients with cytomegalovirus retinitis

related retinal detachments. Am J Ophthalmic. 2005;130:786-793.

PPV+SOI : problems

• high incidence of cataract after PPV+SOI

• PCO in pseudophakic

• poor retina visualisation

• glaucoma

• Tanna AP, Kempen, JH, et al. Incidence and management of cataract after retinal detachment

repair with silicone oil in immunocompromised patients with cytomegalovirus retinitis. Am J

Ophthalmic. 2008: 1009-15.

Treatment :

nonRD-related CMVR• early detection : screening

• CD4<100/ml

• all including asymptomatic ones*

• telemedicine can work well*

• Treatment

• nonRD-related :antiviral Rx

• * Gellrich MM, Lagreze WD, Rump JA, Hansen LL: [Indications for eye examination of HIV patients - screening parameters for cytomegalovirus

retinitis]. Klin Monbl Augenheilkd 1996, 209(2-3):72-8.

• ** Ausayakhun S, Skalet AH, Jirawison C, Ausayakhun S, Keenan JD, Khouri C, Nguyen K, Kalyani PS, Heiden D, Holland GN, Margolis TP:

Accuracy and Reliability of Telemedicine for Diagnosis of Cytomegalovirus Retinitis. Am J Ophthalmol 2011.

Treatment :

RD-related CMVR

TREATMENT MACULA RRD

LASER on not involve posterior pole

SBP on/off simple/ unable position

PPV+GAS on/off

simple/ few breaks/ atrophic areas

located in 1-2 adjacent sup.

quadrants

PPV+SOI

+/-SBPon/off difficult/ unable position