RESUMEN
OBJECTIVE: To evaluate the efficacy of the ganciclovir implant in the setting of silicone oil vitreous substitute. MATERIALS AND METHODS: The authors retrospectively reviewed the charts of 19 patients with cytomegalovirus retinitis who had both a ganciclovir implant and silicone oil vitreous substitute. None of the patients was receiving highly active antiretroviral therapy during the study period. Kaplan-Meier analysis was used to evaluate time to progression in eyes with the ganciclovir implant and silicone oil. RESULTS: In all eyes, the ganciclovir device implantation preceded or coincided with silicone injection. Kaplan-Meier analysis revealed that time to 25% failure from the date of the presence of both the implant and oil was 129 days. Time to 25% failure from the date of ganciclovir device implantation was 179 days. CONCLUSIONS: These results compare favorably with conventional treatment. The ganciclovir implant can be a useful treatment modality in eyes with silicone oil.
Asunto(s)
Antivirales/administración & dosificación , Retinitis por Citomegalovirus/tratamiento farmacológico , Ganciclovir/administración & dosificación , Desprendimiento de Retina/tratamiento farmacológico , Aceites de Silicona/uso terapéutico , Retinitis por Citomegalovirus/complicaciones , Evaluación de Medicamentos , Implantes de Medicamentos , Humanos , Proyectos Piloto , Desprendimiento de Retina/etiología , Estudios Retrospectivos , Seguridad , Resultado del Tratamiento , Cuerpo VítreoRESUMEN
OBJECTIVE: To study the aqueous humor dynamics in subjects with human immunodeficiency virus (HIV) with and without cytomegalovirus (CMV) retinitis. DESIGN: Prospective cross-sectional study. PARTICIPANTS: Fourteen HIV-positive subjects (27 eyes, 19 with CMV retinitis and 8 without CMV retinitis), and a control group of 9 HIV-negative subjects (17 eyes). TESTING: Fluorophotometry. MAIN OUTCOME MEASURES: Aqueous flow rates as measured by fluorophotometry and intraocular pressure (IOP). RESULTS: Analysis of variance of the mean corrected aqueous flow rate revealed that both HIV-positive groups had significantly lower aqueous flow rates than did the control group (P < 0.03). No difference in mean aqueous flow rates was found between the HIV-positive eyes with or without CMV retinitis. Comparison of mean IOP revealed that HIV-positive eyes with CMV retinitis had significantly lower IOP than did the HIV-positive eyes without CMV retinitis (P = 0.03) and HIV-negative subjects (P = 0.002). There was no correlation between aqueous flow rate and IOP in HIV-positive subjects (P > 0.5). CONCLUSION: The lack of correlation between the aqueous flow rate and IOP suggests that there may be some disassociation between these parameters in HIV-positive patients. Further studies are needed to better understand the mechanism of aqueous formation and in the management of disorders affecting IOP in this population.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/metabolismo , Humor Acuoso/metabolismo , Retinitis por Citomegalovirus/metabolismo , Fluorofotometría , Infecciones Oportunistas Relacionadas con el SIDA/complicaciones , Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Adulto , Cámara Anterior/metabolismo , Estudios Transversales , Retinitis por Citomegalovirus/complicaciones , Retinitis por Citomegalovirus/tratamiento farmacológico , Femenino , Humanos , Presión Intraocular , Masculino , Estudios ProspectivosRESUMEN
For many years the clinician's arsenal for managing cytomegalovirus (CMV) retinitis included only systematic therapies that required daily infusions via a central venous catheter. The introduction of cidofovir has permitted biweekly maintenance therapy by peripheral IV. Local therapies, such as the ganciclovir intraocular device and intravitreal injections of cidofovir, fomavirsen, or ganciclovir, have reduced toxicity while increasing absorption of drug in the eye. At the same time, due to highly active antiretroviral therapy (HAART), the incidence of CMV retinitis is dropping. Current investigation into the natural history of CMV retinitis in the era of HAART may ultimately result in new management strategies.
Asunto(s)
Infecciones por Citomegalovirus/tratamiento farmacológico , Citosina/análogos & derivados , Organofosfonatos , Retinitis/tratamiento farmacológico , Terapia Antirretroviral Altamente Activa , Cidofovir , Citosina/uso terapéutico , Quimioterapia Combinada , Foscarnet/uso terapéutico , Ganciclovir/uso terapéutico , Humanos , Compuestos Organofosforados/uso terapéuticoRESUMEN
This study was undertaken to evaluate the intravitreal and plasma concentrations of cidofovir (HPMPC) after intravitreal and intravenous administration in AIDS patients with cytomegalovirus retinitis. Cohort series; undiluted vitreous and blood were collected from 9 patients at the time of pars plana vitrectomy. Vitreous samples from 9 eyes of 9 patients and plasma samples from 4 patients were assayed with high-performance liquid chromatography to determine cidofovir levels. The only eye that had a detectable vitreous concentration (673.7 ng/ml) was injected with 20 microg 24 hours prior to the surgery. The remaining samples including plasma were below the detection point of the assay (100 ng/ml) and were injected between 5 and 40 days prior to sampling. The intravitreal concentration of cidofovir in humans is consistent with pharmacokinetics data in laboratory animals, and suggests that the long duration of antiviral effect (1-3 months) in clinical trials is due to a prolonged intracellular half-life in retinal tissue.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/complicaciones , Antivirales/sangre , Antivirales/farmacocinética , Infecciones por Citomegalovirus/complicaciones , Infecciones por Citomegalovirus/tratamiento farmacológico , Citosina/análogos & derivados , Organofosfonatos , Compuestos Organofosforados/sangre , Compuestos Organofosforados/farmacocinética , Retinitis/virología , Cuerpo Vítreo/metabolismo , Adulto , Antivirales/uso terapéutico , Cidofovir , Estudios de Cohortes , Citosina/sangre , Citosina/farmacocinética , Citosina/uso terapéutico , Humanos , Inyecciones , Inyecciones Intravenosas , Masculino , Persona de Mediana Edad , Compuestos Organofosforados/uso terapéutico , Concentración Osmolar , Estudios ProspectivosRESUMEN
OBJECTIVES: To determine the incidence of clinical resistance to intraocular cidofovir injection for treatment of acquired immunodeficiency syndrome (AIDS)-related cytomegalovirus (CMV) retinitis, and to identify virologic features associated with cidofovir treatment failure. PATIENTS AND METHODS: Clinical resistance to intravitreal cidofovir was examined in 64 patients with CMV retinitis who received at least 1 injection of 20 pg of cidofovir. Histopathologic examination, culture, and polymerase chain reaction were used to detect CMV in ocular specimens. Antiviral resistance was assessed by plaque reduction assay and DNA sequencing. RESULTS: Clinical resistance to intravitreal cidofovir injections was identified in 3 patients (5%) and was associated with prior oral ganciclovir or intravenous cidofovir use. Ganciclovir- and cidofovir-resistant CMV isolates were cultured from 2 patients and harbored resistance-associated mutations in the UL97 and polymerase genes. Resistance mutations were also detected by direct analysis of vitreous. In 1 patient, different resistance mutations were identified in ocular vs extraocular CMV strains. CONCLUSIONS: Clinical failure of intravitreal cidofovir occurs infrequently, but may be associated with cidofovir-resistant CMV selected by prior ganciclovir or cidofovir treatment. Ocular CMV disease can result from a localized infection with a resistant CMV strain, and antiviral resistance may develop at a local site of infection independently from resistance that develops systemically.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Antivirales/uso terapéutico , Retinitis por Citomegalovirus/tratamiento farmacológico , Citomegalovirus/efectos de los fármacos , Citosina/análogos & derivados , Organofosfonatos , Compuestos Organofosforados/uso terapéutico , Infecciones Oportunistas Relacionadas con el SIDA/patología , Infecciones Oportunistas Relacionadas con el SIDA/virología , Adulto , Cidofovir , Citomegalovirus/genética , Citomegalovirus/aislamiento & purificación , Retinitis por Citomegalovirus/patología , Retinitis por Citomegalovirus/virología , Citosina/uso terapéutico , ADN Viral/análisis , Farmacorresistencia Microbiana , Ganciclovir/uso terapéutico , Humanos , Inyecciones , Masculino , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa , Insuficiencia del Tratamiento , Cuerpo VítreoRESUMEN
PURPOSE: To investigate the effect of posterior subtenon injections of corticosteroids on intraocular pressure in a variety of ocular diseases. METHODS: We retrospectively analyzed 202 consecutive posterior subtenon corticosteroid injections (148 of methylprednisolone acetate, 80 mg, and 54 of triamcinolone acetonide, 40 mg) in 63 eyes of 55 patients (26 male, 29 female; mean age +/- SD, 60.17 +/- 26.55 years). All patients had received topical or systemic corticosteroids before the injection, and no rise in intraocular pressure had been noted. Preinjection and postinjection intraocular pressure measurements were compared by two-tailed paired t test. Statistical analysis was performed separately by patient (first injection of first injected eye), by eye (first injection of each eye), and by all injections. To detect increase in intraocular pressure during follow-up, statistical analysis was performed separately 14 to 90 days, 91 to 150 days, and 151 to 270 days after injection. RESULTS: No statistically significant difference was found between preinjection and postinjection intraocular pressure measurements. A power calculation in the most stringent subanalysis (by patient) proved that there is only a 3.87% chance to statistically miss a clinically significant rise in intraocular pressure from 15 to 21 mm Hg. CONCLUSIONS: Posterior subtenon injection of corticosteroids does not cause an increase in intraocular pressure. All patients in our study had been treated previously with topical or systemic corticosteroids and did not react with an excessive increase in intraocular pressure. This safety of repository corticosteroids may therefore not apply to patients whose status in responding to corticosteroids is not known.
Asunto(s)
Glucocorticoides/administración & dosificación , Presión Intraocular/efectos de los fármacos , Metilprednisolona/administración & dosificación , Triamcinolona/administración & dosificación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Tejido Conectivo , Femenino , Humanos , Inyecciones , Masculino , Persona de Mediana Edad , Soluciones Oftálmicas , Estudios RetrospectivosRESUMEN
OBJECTIVE: The purpose of the study is to evaluate the adverse events and autopsy findings in a series of consecutive 20-microg intravitreous cidofovir injections at a single institution. DESIGN: The study design was a nonrandomized, consecutive case series. PARTICIPANTS: Seventy-six patients with acquired immune deficiency syndrome with cytomegalovirus retinitis were studied prospectively. Sixty-three patients had 1 month's follow-up or longer, and this comprised the study group. In addition, histopathologic findings from 18 eyes of 9 patients were studied at autopsy. INTERVENTION: A total of 296 injections of 20 microg cidofovir were given in 115 eyes. Sixty-three patients who had 246 injections in 93 eyes had 1 month's follow-up or longer for the evaluation of adverse events. MAIN OUTCOME MEASURES: Postinjection chronic hypotony associated with permanent visual loss, transient hypotony, iritis, and its long-term sequela (posterior synechia and cataract, retinal detachment, extraocular cytomegalovirus involvement) were the outcomes of interest in this study. Additionally, light and electron microscopic studies of human eyes were performed. RESULTS: The most severe adverse event was postinjection chronic hypotony. This phenomenon was associated with permanent visual loss. This was observed in 1% of the injections and 3% of the eyes of the patients (95% confidence interval, 0%-6%). Transient hypotony associated with mild-to-moderate visual loss developed in 14%, but vision recovered to baseline levels in these eyes subsequently. Analysis showed that transient hypotony in the injected eye could predict postinjection chronic hypotony in the fellow eye (two-tailed Fisher's exact test, P = 0.02). The incidence of iritis was 32%; posterior synechia and cataract were the long-term sequela of the iritis and developed in 19% and 11% of the eyes, respectively. The incidence of retinal detachment was lower (6%). Histopathologic evaluation of the eyes showed mild-to-moderate atrophy of the nonpigmented epithelium of the ciliary body and no other evidence of intraocular toxicity. CONCLUSIONS: The most serious adverse event was postinjection chronic hypotony, which occurred in 3% of eyes. Episodes of transient hypotony appear to indicate that the fellow eye was predisposed to chronic hypotony. Therefore, it may be prudent to give intravitreous injections at least 2 weeks apart in the fellow eye to evaluate the clinical response of the injected eye.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Antivirales/efectos adversos , Retinitis por Citomegalovirus/tratamiento farmacológico , Citosina/análogos & derivados , Iritis/inducido químicamente , Hipotensión Ocular/inducido químicamente , Organofosfonatos , Compuestos Organofosforados/efectos adversos , Adulto , Segmento Anterior del Ojo/efectos de los fármacos , Segmento Anterior del Ojo/patología , Antivirales/administración & dosificación , Autopsia , Cidofovir , Citosina/administración & dosificación , Citosina/efectos adversos , Femenino , Estudios de Seguimiento , Fondo de Ojo , Humanos , Inyecciones , Iritis/patología , Masculino , Persona de Mediana Edad , Hipotensión Ocular/patología , Compuestos Organofosforados/administración & dosificación , Epitelio Pigmentado Ocular/efectos de los fármacos , Epitelio Pigmentado Ocular/ultraestructura , Estudios Prospectivos , Cuerpo VítreoRESUMEN
PURPOSE: To evaluate the decrease in intraocular pressure associated with cidofovir (1-[(S)-3-hydroxy-2-(phosphonomethoxy)propyl]cytosine dihydrate; HPMPC) intravitreal injections. METHODS: We followed up 97 eyes of 63 patients with acquired immunodeficiency syndrome (AIDS) who had cytomegalovirus retinitis and had been treated with up to nine 20-microgram intravitreal cidofovir injections. Measurements were taken at baseline, between 2 and 3 weeks, and at 5 to 6 weeks after injections. Anterior chamber fluorophotometry was studied in seven eyes (four patients) before and after injections. Ciliary body anatomy was evaluated in two patients. RESULTS: After the first intravitreal injection, mean intraocular pressure was 2.2 mm Hg lower than that at baseline at 2 to 3 weeks (P < .001) and 1.3 mm Hg lower than at baseline at 5 to 6 weeks (P = .0025). After the second injection, mean pressure was 2.6 mm Hg lower at 2 to 3 weeks (P = .0013) and 1.5 mm Hg lower at 5 to 6 weeks (P = .043). After subsequent injections, however, the decrease was less than 1 mm Hg, suggesting that a plateau had been reached. Pressure in eyes with anterior uveitis after the first injection was lower than that in eyes without anterior uveitis (P < .0001). The mean rate of aqueous flow decreased from 2.8 to 1.9 microliters per minute 2 to 4 weeks after injection (P < .015). Ultrasound biomicroscopy disclosed that severe hypotony after cidofovir injections is associated with ciliary body atrophy. CONCLUSIONS: Intraocular pressure decreases after the initial 20-microgram cidofovir intravitreal injection. However, eyes stabilize (pressure plateaus) after three injections. Effects on the ciliary body are the main cause of the decrease after cidofovir injections.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/fisiopatología , Antivirales/uso terapéutico , Humor Acuoso/efectos de los fármacos , Infecciones por Citomegalovirus/tratamiento farmacológico , Citosina/análogos & derivados , Presión Intraocular/efectos de los fármacos , Organofosfonatos , Compuestos Organofosforados/uso terapéutico , Retinitis/virología , Adulto , Cámara Anterior/patología , Humor Acuoso/fisiología , Cidofovir , Cuerpo Ciliar/diagnóstico por imagen , Cuerpo Ciliar/efectos de los fármacos , Infecciones por Citomegalovirus/fisiopatología , Citosina/efectos adversos , Citosina/uso terapéutico , Esquema de Medicación , Femenino , Fluorofotometría , Humanos , Inyecciones , Masculino , Persona de Mediana Edad , Compuestos Organofosforados/efectos adversos , Estudios Prospectivos , Ultrasonografía , Cuerpo VítreoRESUMEN
PURPOSE: The authors have shown that long-term treatment of cytomegalovirus (CMV) retinitis with 20-microgram intravitreal injections of cidofovir (HPMPC) is highly effective but may be associated with iritis and profound hypotony. They evaluated the efficacy and safety of 10-microgram intravitreal injections of cidofovir and made comparisons with their findings of 20-microgram injections. METHODS: The current study was conducted as a nonrandomized consecutive case series at the AIDS Ocular Research Unit of the University of California at San Diego. Twenty-seven eyes of 18 patients were injected with 10 micrograms intravitreal cidofovir and had complete follow-up. These were compared with another consecutive series of 24 eyes of 17 patients injected with 20 micrograms of cidofovir. MAIN OUTCOME MEASURES: The main outcome in this study was the incidence of failure to respond to treatment with 10-microgram injections. The authors also compared the time to progression of CMV retinitis after the initial intravitreal injections of 10 micrograms and 20 micrograms of cidofovir. Secondary outcomes included incidence of iritis and changes in intraocular pressure (IOP) after cidofovir injections. RESULTS: The median time to retinitis progression was 45 days after a single intravitreal injection of 10 micrograms cidofovir compared with 55 days with the authors' series of 20-microgram injections. This difference was statistically significant (P = 0.033, log-rank test) and appeared to be due principally to a 26% incidence of primary failure in the 10-microgram group (progression > or = 750 microns within 28 days, P = 0.0017 Wilcoxon test). Progression after a second injection of 10 micrograms cidofovir was more rapid (32 days, P = 0.037). The incidence of iritis after 10-microgram injections was 2.2% compared with 23% with 20-microgram injections (P = 0.003, Fisher's exact test, two-tailed). There was less decrease in IOP between the baseline injection and subsequent visits in the 10-microgram group. CONCLUSIONS: Treatment of CMV retinitis with 10-microgram intravitreal cidofovir injection was not as effective as with 20 micrograms and may allow development of drug resistance, but there were fewer side effects with the 10-microgram dose. The drug appears to have a narrow therapeutic index, and other attempts at reducing the side effects while preserving the long-acting effect, such as liposome delivery, may be warranted.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Antivirales/administración & dosificación , Retinitis por Citomegalovirus/tratamiento farmacológico , Citosina/análogos & derivados , Organofosfonatos , Compuestos Organofosforados/administración & dosificación , Infecciones Oportunistas Relacionadas con el SIDA/complicaciones , Infecciones Oportunistas Relacionadas con el SIDA/patología , Adolescente , Adulto , Antivirales/uso terapéutico , Cidofovir , Retinitis por Citomegalovirus/complicaciones , Retinitis por Citomegalovirus/patología , Citosina/administración & dosificación , Citosina/uso terapéutico , Progresión de la Enfermedad , Relación Dosis-Respuesta a Droga , Femenino , Estudios de Seguimiento , Fondo de Ojo , Humanos , Inyecciones , Masculino , Persona de Mediana Edad , Compuestos Organofosforados/uso terapéutico , Estudios Retrospectivos , Resultado del Tratamiento , Cuerpo VítreoRESUMEN
BACKGROUND AND OBJECTIVE: The authors characterize and analyze the incidence of a previously reported mild anterior nongranulomatous uveitis associated with intravitreal injections of (S)-1-(3-hydroxy-2-phosphonylmethoxypropyl)cytosine (HPMPC), also termed cidofovir (Vistide, Gilead Sciences, Foster City, CA). This is an acyclic nucleoside phosphonate analogue with a potent anticytomegalovirus effect. The authors also analyzed the effects of probenecid therapy, as well as prophylaxis with probenecid plus topical corticosteroids and cycloplegics on the course and outcome of the uveitis. METHODS: Prospective case series from a tertiary referral center, which included 46 consecutive patients with acquired immune deficiency syndrome (AIDS) and cytomegalovirus (CMV) retinitis. There was a total of 130 injections in 69 eyes treated with 20 micrograms of intravitreal HPMPC. Forty-one patients (119 injections) received oral probenecid, 5 patients (11 injections) did not, and 21 patients (53 injections) received topical corticosteroids and cycloplegics as an adjuvant to probenecid in the prophylaxis of iritis. RESULTS: Mild to moderate nongranulomatous iritis was seen in 26% of patients after their first injection (n = 12). Patients receiving probenecid prophylaxis after first injection had a significantly lower frequency of iritis versus patients who did not receive probenecid at the time of first injection (P = 0.0089). In contrast, treatment with topical corticosteroid and cycloplegics after injection did not statistically significantly affect the frequency of iritis in patients (P = 0.44). The development of iritis after a second injection of HPMPC was more likely if it had occurred after the initial injection (P = 0.015; Fisher's exact test). All cases of iritis were treated with topical corticosteroids and cycloplegics, and there was no permanent impairment of vision secondary to iritis after HPMPC injection in any eyes. CONCLUSIONS: Anterior uveitis was seen in 26% of patients after first-time HPMPC injection. Concomitant use of probenecid appears to decrease the frequency of the iritis from 71% to 18% in patients with AIDS and CMV retinitis after the first intravitreal injection of HPMPC. Topical corticosteroid administration after injection (before iritis) was ineffective in preventing iritis treatment with topical corticosteroids and cycloplegics resulted in resolution of all iritis cases.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Antivirales/efectos adversos , Retinitis por Citomegalovirus/tratamiento farmacológico , Citosina/análogos & derivados , Iritis/inducido químicamente , Iritis/prevención & control , Organofosfonatos , Compuestos Organofosforados/efectos adversos , Infecciones Oportunistas Relacionadas con el SIDA/patología , Antivirales/uso terapéutico , Cidofovir , Retinitis por Citomegalovirus/patología , Citosina/efectos adversos , Citosina/uso terapéutico , Glucocorticoides/uso terapéutico , Granuloma , Humanos , Incidencia , Inyecciones , Iritis/patología , Midriáticos/uso terapéutico , Compuestos Organofosforados/uso terapéutico , Probenecid/uso terapéutico , Estudios Prospectivos , Uricosúricos/uso terapéutico , Cuerpo VítreoRESUMEN
OBJECTIVE: To describe the clinical course of varicella-zoster optic neuropathy preceding acute retinal necrosis in patients with acquired immunodeficiency syndrome. DESIGN: Case series. SETTING: Two tertiary care centers in San Diego, Calif, and London, England. PATIENTS: Three human immunodeficiency virus-positive men with previous cutaneous zoster infection, optic neuropathy, and necrotizing retinitis. RESULTS: All patients had an episode of zoster dermatitis treated with acyclovir. Visual loss consistent with an optic neuropathy ensued, followed by typical herpetic retinitis. The cause of visual loss was not suspected to be varicella-zoster until after the retinitis occurred. Despite aggressive medical treatment, 4 of 6 eyes progressed to retinal detachment. CONCLUSIONS: Varicella-zoster may cause an optic neuropathy in patients with acquired immunodeficiency syndrome, especially in those with previous shingles. A high index of suspicion is necessary to establish the diagnosis and begin early antizoster treatment.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/etiología , Herpes Zóster Oftálmico/etiología , Enfermedades del Nervio Óptico/virología , Síndrome de Necrosis Retiniana Aguda/virología , Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Infecciones Oportunistas Relacionadas con el SIDA/patología , Aciclovir/uso terapéutico , Adulto , Antígenos Virales/análisis , Antivirales/uso terapéutico , Dermatitis/tratamiento farmacológico , Dermatitis/virología , Angiografía con Fluoresceína , Fondo de Ojo , Herpes Zóster/tratamiento farmacológico , Herpes Zóster/etiología , Herpes Zóster Oftálmico/tratamiento farmacológico , Herpes Zóster Oftálmico/patología , Herpesvirus Humano 3/inmunología , Herpesvirus Humano 3/aislamiento & purificación , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Enfermedades del Nervio Óptico/tratamiento farmacológico , Enfermedades del Nervio Óptico/patología , Retina/patología , Retina/virología , Síndrome de Necrosis Retiniana Aguda/tratamiento farmacológico , Síndrome de Necrosis Retiniana Aguda/patología , Enfermedades Cutáneas Virales/tratamiento farmacológico , Enfermedades Cutáneas Virales/etiología , Agudeza Visual , Cuerpo Vítreo/patología , Cuerpo Vítreo/virologíaRESUMEN
The acute retinal necrosis syndrome is a rapidly progressive and potentially devastating disease. A case of acute retinal necrosis developed in an immunocompetent man, Presumably due to the stress, trauma, or immunomodulation related to a craniotomy for a parasellar craniopharyngioma. Vitrectomy and endoretinal biopsy were performed. Polymerase chain reaction studies of the vitreous revealed herpes simplex virus type 2 as the cause, which has not been previously well documented. Results of cerebrospinal fluid antibody studies were also consistent with the diagnosis. Results of cytology and histopathologic examination demonstrated extensive retinal destruction and mononuclear cell infiltration. Sloughing of the inner retina was evidenced by the presence of retinal vascular remnants in the vitreous cytology specimen. As is characteristic of this disease, the visual outcome of this patient was poor.
Asunto(s)
Infecciones Virales del Ojo/patología , Herpes Simple/patología , Herpesvirus Humano 2/genética , Síndrome de Necrosis Retiniana Aguda/patología , Síndrome de Necrosis Retiniana Aguda/virología , Adulto , Craneofaringioma/cirugía , Craneotomía , ADN Viral/análisis , Enucleación del Ojo , Fondo de Ojo , Herpes Simple/complicaciones , Herpesvirus Humano 2/aislamiento & purificación , Humanos , Inmunocompetencia , Masculino , Neoplasias Hipofisarias/cirugía , Reacción en Cadena de la Polimerasa , Retina/patología , Vitrectomía , Cuerpo Vítreo/patología , Cuerpo Vítreo/virologíaRESUMEN
PURPOSE: To evaluate the efficacy and safety of multiple intravitreal cidofovir (HPMPC) injections given every 5 to 6 weeks for the maintenance treatment of cytomegalovirus (CMV) retinitis. METHODS: A prospective consecutive case series of 53 eyes in 35 patients with acquired immune deficiency syndrome and CMV retinitis was treated with maintenance intravitreal injections of cidofovir (20 micrograms) at one referral center between April 1994 and September 1995. Twenty-four eyes received intravitreal cidofovir as their initial treatment for CMV retinitis (group A), and 29 eyes previously had received systemic therapy (group B). None of the patients in either group received systemic anti-CMV therapy at any time during the study period. Progression of retinitis was the primary end point. RESULTS: All eyes with active retinitis healed in response to treatment. None of the 24 eyes in group A demonstrated any progression during the study period. Four (14%) of the 29 eyes in group B had one episode each of retinitis progression (mean follow-up, 15 weeks; range, 0-58 weeks). In 1 (1.9%) of the 53 eyes, a retinal detachment developed. A mild iritis was observed after 14% of injections, which were prophylaxed with oral probenecid. Irreversible visually significant hypotony developed in two eyes (3.8%). CONCLUSION: Treatment and subsequent maintenance therapy of CMV retinitis with 20 micrograms intravitreally injected cidofovir, given at 5- to 6-week intervals, is highly effective, with only rare episodes of re-activation and progression.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Antivirales/uso terapéutico , Retinitis por Citomegalovirus/tratamiento farmacológico , Citosina/análogos & derivados , Organofosfonatos , Compuestos Organofosforados/uso terapéutico , Infecciones Oportunistas Relacionadas con el SIDA/etiología , Infecciones Oportunistas Relacionadas con el SIDA/mortalidad , Adulto , Antivirales/administración & dosificación , Antivirales/efectos adversos , Cidofovir , Retinitis por Citomegalovirus/etiología , Retinitis por Citomegalovirus/mortalidad , Citosina/administración & dosificación , Citosina/efectos adversos , Citosina/uso terapéutico , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Inyecciones , Masculino , Compuestos Organofosforados/administración & dosificación , Compuestos Organofosforados/efectos adversos , Estudios Prospectivos , Desprendimiento de Retina/etiología , Seguridad , Tasa de Supervivencia , Cuerpo VítreoRESUMEN
PURPOSE: To determine the intraocular pressure in patients with human immunodeficiency virus (HIV) with and without cytomegalovirus retinitis, and to correlate intraocular pressure with CD4+ T-lymphocyte count and the presence, extent, and activity of cytomegalovirus retinitis. METHODS: Intraocular pressure was measured with calibrated Goldmann applanation tonometers in two groups of patients. Group A included 84 patients with HIV (120 eyes) with cytomegalovirus retinitis, and Group B included 110 patients with HIV (183 eyes) without cytomegalovirus retinitis. Thirty-three patients without HIV (66 eyes) were included as a control group. Step-wise regression analysis of intraocular pressure included correlation with cytomegalovirus retinitis (presence, extent, and activity), CD4+ T-lymphocyte count, age, and gender. RESULTS: The mean intraocular pressure was 9.8 mm Hg in Group A, 12.6 mm Hg in Group B, and 16.1 mm Hg in the control group. All three groups were statistically different from each other when intraocular pressure was compared (P < .0001). Step-wise regression showed that low CD4+ T-lymphocyte count (r2 = .20; P < .0001) and extent of cytomegalovirus retinitis (r2 = .08; P = .007) both correlated to low intraocular pressure. CONCLUSION: Intraocular pressure is lower than normal in patients with HIV. Decreased CD4+ T-lymphocyte count is the major association with low intraocular pressure (20% of the effect); extent of cytomegalovirus retinitis accounts for 8% of the effect. Knowledge of the normal range of intraocular pressure in patients with HIV will be important to the understanding and treatment of glaucoma and other disorders or treatments affecting intraocular pressure.
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Linfocitos T CD4-Positivos/inmunología , Retinitis por Citomegalovirus/complicaciones , Infecciones por VIH/complicaciones , VIH-1 , Presión Intraocular , Adulto , Recuento de Linfocito CD4 , Retinitis por Citomegalovirus/inmunología , Retinitis por Citomegalovirus/fisiopatología , Femenino , Infecciones por VIH/inmunología , Infecciones por VIH/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Hipotensión Ocular/etiología , Hipotensión Ocular/fisiopatología , Estudios Prospectivos , Análisis de Regresión , Tonometría OcularRESUMEN
BACKGROUND: Cytomegalovirus retinitis remains a major cause of illness in patients with the acquired immunodeficiency syndrome (AIDS), and existing therapies for this condition are relatively ineffective and toxic. OBJECTIVE: To evaluate the efficacy of intravitreous cidofovir injections alone for initial and maintenance therapy for cytomegalovirus retinitis. DESIGN: Prospective, nonrandomized, consecutive case series. SETTING: University ophthalmology referral clinic. PATIENTS: 22 patients with AIDS and cytomegalovirus retinitis. In 15 of 32 affected eyes, intravitreous cidofovir was administered as the initial treatment for cytomegalovirus retinitis (group A); 17 eyes had previously been treated with intravenous therapy (group B). INTERVENTION: All eyes were intravitreously injected with 20 micrograms of cidofovir at 5- to 6-week intervals. No patient in either group received systemic anticytomegalovirus therapy at any time during the study period. MEASUREMENTS: Healing of retinitis was defined as resolution of retinal opacification and cessation of border progression. Progression, the primary end point, was defined as 750 microns of border progression or development of a new lesion. RESULTS: The mean duration of follow-up was 15.3 weeks (range, 5 to 44 weeks). Of the eyes with active retinitis, 100% (95% CI, 87% to 100%) healed in response to the initial injection. In two eyes (6%; CI, 0% to 15%), two episodes of retinitis progression occurred (one in each eye). Both of these eyes were in a patient with clinically resistant retinitis. In 3% of eyes (CI, 0% to 9%), the retina became detached. Mild iritis developed after 14% of the injections that had been preceded by prophylaxis with oral probenecid. Irreversible, visually significant hypotonia developed in one eye. CONCLUSION: Treatment and subsequent maintenance of cytomegalovirus retinitis with 20 micrograms of intravitreously injected cidofovir, given at 5- to 6-week intervals, is safe and highly effective.
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Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Antivirales/uso terapéutico , Infecciones por Citomegalovirus/tratamiento farmacológico , Citosina/análogos & derivados , Organofosfonatos , Compuestos Organofosforados/uso terapéutico , Retinitis/tratamiento farmacológico , Retinitis/virología , Adulto , Antivirales/administración & dosificación , Cidofovir , Citosina/administración & dosificación , Citosina/uso terapéutico , Progresión de la Enfermedad , Femenino , Humanos , Inyecciones Intralesiones , Masculino , Persona de Mediana Edad , Compuestos Organofosforados/administración & dosificación , Estudios Prospectivos , Resultado del Tratamiento , Cuerpo VítreoRESUMEN
AIMS/BACKGROUND: Recent work using computerised perimetry has documented predictable visual field defects in patients with choroidal melanoma. Despite the higher frequency of occurrence of choroidal metastases, relatively little is known about their exact effects on visual performance, specifically with respect to visual field. This study is a pilot retrospective analysis of the results of automated perimetry testing in patients with choroidal metastatic disease. METHODS: The Humphrey field analyser was used to perform visual field tests on 15 eyes in 11 patients diagnosed with choroidal metastases. All 11 primary tumours were carcinomas originating in the breast (seven), lung (one), kidney (one), stomach (one), and prostate (one). All patients had either central 30 and/or peripheral 30-60 threshold strategies. RESULTS: Each of the 15 eyes tested had a demonstrable visual field defect. Eight eyes (53%) had absolute scotomas and seven (43%) had relative scotomas; the defects did not consistently correspond in size or location to the tumour as depicted by ophthalmoscopy or ultrasonography. This is in contradistinction to automated perimetry results in patients with choroidal melanoma. Three of the four eyes (75%) which were retested after treatment of the metastases showed improvement of the visual field. Seven of nine eyes (77%) that initially had reduced visual acuity had improvement after treatment. This clinical improvement corresponded well to tumour shrinkage and resolution of subretinal fluid. CONCLUSION: These findings may be useful in the decision to initiate treatment for symptomatic choroidal metastatic disease and in explaining to patients and their referring physicians what improvement could be expected from such treatment. A prospective evaluation of patients with choroidal metastases seems appropriate based on this pilot experience and may elucidate if the differences noted between visual field performance of these patients and those with choroidal melanoma may be useful in some diagnostically difficult cases.
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Neoplasias de la Coroides/complicaciones , Neoplasias de la Coroides/secundario , Melanoma/complicaciones , Melanoma/secundario , Escotoma/etiología , Pruebas del Campo Visual/métodos , Adulto , Anciano , Femenino , Fondo de Ojo , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Retrospectivos , Escotoma/diagnósticoAsunto(s)
Linfoma Relacionado con SIDA/patología , Neoplasias Orbitales/patología , Adulto , Diagnóstico Diferencial , Humanos , Linfoma Relacionado con SIDA/diagnóstico por imagen , Masculino , Órbita/diagnóstico por imagen , Órbita/patología , Neoplasias Orbitales/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
Several studies have suggested differences in aqueous humor composition in Fuchs' dystrophy, including elevations in fibrinogen-related factors, compared with controls. In the current study, aqueous humor was obtained at surgery from 10 uninflamed eyes with advanced Fuchs' dystrophy and cataracts and 11 control eyes with cataracts alone. Total fibrinogen-related antigen was measured in a masked manner using an enzyme-linked immunosorbant assay (ELISA). There was no statistically significant difference between the means of the two groups (0.281 +/- 0.292 (SD) and 0.176 +/- 0.090 mg/ml, respectively). Similarly, there was no difference in ELISA-determined aqueous humor small molecular weight fibrinogen-derived metabolites between the two groups, 623 +/- 141 and 550 +/- 55 fibrinogen equivalents, respectively. Also, no statistically significant difference was detected between Fuchs' dystrophy and control eyes in aqueous humor ascorbate, glucose, carbon dioxide, bicarbonate, and pH. Therefore, this study found no evidence of alterations in aqueous humor composition in Fuchs' dystrophy and supports the hypothesis that the disease is a primary disorder of the corneal endothelium.