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How to take care of our patients

How to take care of our patients. How to take care of our patients ’. eye. How to take care of our patients ’eye. Adequate prevention of preventable disease Appropriated treatment of treatable disease. How to prevent. What is preventable disease How to detect preventable disease

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How to take care of our patients

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  1. How to take care of our patients

  2. How to take care of our patients’ eye

  3. How to take care of our patients’eye • Adequate prevention of preventable disease • Appropriated treatment of treatable disease

  4. How to prevent • What is preventable disease • How to detect preventable disease • Who is responsible for detection • Who is target group to be prevented

  5. CMVR is preventable disease • Who is the high risk group for CMV retinitis • Prevention is done by early detection • Early detection is for early treatment • The best way to prevent CMVR occurrence is HAART in timely period?

  6. Cytomegalovirus Retinitis High Risk • CD Count < 50 • The following clinical risk factors* were significant predictors of CMV retinitis: flashing lights or floaters (OR, 11.42; 95% CI, 3.43 to 38.01), cotton-wool spots (OR, 2.90; 95% CI, 1.01 to 8.29), previous opportunistic infections (OR, 1.81; 95% CI, 1.24 to 2.64), previous nonocular CMV infection (OR, 82.99; 95% CI, 6.86 to 1004.58), previous Mycobacterium infection (OR, 3.41; 95% CI, 0.99 to 11.85), homosexuality (OR, 2.83; 95% CI, 1.13 to 7.12). • HLA B44 , B51 , DR7 Clinical risk factors for cytomegalovirus retinitis in patients with AIDS * Ophthalmology. 2004 Jul;111(7):1326-33.

  7. Cytomegalovirus Retinitis Diagnosis based on • Clinical Fundus Appearance • vitreous and aqueous humor analysis for CMV DNA ** • endoretinal biopsy ** ** for atypical presentation or unresponsive to treatment (not be done in normal setting)

  8. Cytomegalovirus Retinitis Symptoms • asymptomatic • light flash • floater • visual field loss • blurred or distorted vision • red eye,eye pain,photophobia are rare Peripheral retinitis Visual field loss at correspondent retinitis Hemorrhage involve macula CMV papillitis CMVR c CRAO CMVR c RRD

  9. Cytomegalovirus Retinitis Signs • no conjunctival hyperemia • minimal anterior chamber inflammatoryreaction • minimal vitreous inflammatory reaction • typically yellow to white area of retinal necrosis that follow a vascular distribution

  10. Cytomegalovirus Retinitis Clinical Presentation Spectrum of fundus appearance • Fulminant / Edematous form • Indolent form • Frosted Branch Angiitis form • Atypical form Post Treatment • Inactive lesion • Reactivated lesion

  11. Cytomegalovirus Retinitis Clinical Presentation Fulminant form • dense confluent area of retinal opacification • location along vesseles • no clear central atrophic area • sufficient retinal hemorrhage • inflammatory perivascular sheathing

  12. Cytomegalovirus Retinitis Clinical Presentation Indolent form • faint grainy opacification or blush fire • location not overlying vessel • may have central clear atrophic area • no or minimal retinal hemorrhage • no inflammatory vascular sheathing

  13. Cytomegalovirus Retinitis Clinical Presentation Frosted branch angiitis form • usually neglected case • indicate insufficient control of disease : practically seen in patient who lost follow up after treatment

  14. CMV papillitis after treatment

  15. Inactive CMVR (retinal scar) • Occur after treatment (HAART+/-intravitreal gancyclovir)

  16. D/D for CMVR • HIV retinopathy • Progressive Outer Retinal Necrosis • Toxoplasma Retinitis • Multiple choroiditis • Intraocular Lymphoma • Ocular Syphilis

  17. HIV retinopathy • most common ophthalmic lesion • characterized by cotton wool spot retinal hemorrhage microaneurysm telangiectatic vessel • indicate immune deterioration

  18. Progressive Outer Retinal Necrosis • caused by VZV , Herpes simplex virus , CMV • minimal anterior and vitreal inflammatory reaction • start at peripheral retina first as deep multifocal opacification • then progress rapidly to posterior pole and cause secondary retinal detachment finally

  19. Toxoplasma Retinitis • usually acquired disease • granulomatous anterior uveitis • focal or multifocal retinitis +/- vitritis • With or without previous toxoplasma retinochoroidal scar • approximately 50% of retinitis patient have encephalitis ** (not vice versa) after treatment

  20. Multiple Choroiditis • This slide show cryptococcal choroiditis • They finally gone without visual compromise

  21. Take a break please

  22. Who is responsible for detection • Detection is diagnosis • Diagnosis is both process and output • What is/are input ? • Inputs are doctor,knowledge,skill,instrument • Doctor should be ophthalmologist,internist or general physician? • The truth(answer) is out there…..

  23. Ophthalmologist Indirect ophthalmoscopy Non ophthalmologist Direct ophthalmoscopy doctor

  24. direct v.s. Indirect ophthalmoscopy

  25. Systematic evaluation of fundus bydirect ophthalmoscopy

  26. Inactive CMVR without antiCMV treatment* *IVOS , Oct2000, Vol41, No.11 *IVOS , Oct2000, Vol41, No.11

  27. When CMVR was treated Zone1 is retinal area that risk to vision loss • CMVR in critical zone = zone1 (posterior pole) is perfect indication • VA is finger count or better (useful vision) • Receive Antiretroviral treatment (since July 2000) Holland GN , Buhles WC Jr , Mastre B , et al. A controlled retrospective study of gancyclovir treatment for cytomegalovirus retinopathy: use of a standardized system for the assessment of disease outcome. Arch Ophthalmol 1989;107:1759-66.

  28. Appropriated Treatment • For thai patients? • For rich or poor patients? • For urban or rural patients? • For Cytomegalovirus retinitis is/are………………

  29. CMVR Treatment in Bamrasnaradura Institute • Intravitreal ganciclovir is first line treatment option in AIDS patients (except comorbid extraocular cytomegalovirus infection such as CMV colitis, esophagitis) • Dosage 2000 microgram in 0.02 cc every 2 weeks (No induction) • Insulin syringe 29 gauge U100 type • OPD setting • Release pressure by AC tapping as necessary

  30. FDA approved Drug for treatment Cytomegalovirus Retinitis Systemic Treatment • IV ganciclovir Induction and Maintenance • IV Foscarnet Induction and Maintenance • IV ganciclovir Induction and Oral ganciclovir Maintenance • IV Cidafovir Induction and Maintenance • Oral valganciclovir for Induction and Maintenance (CMVR not in zone1) Local treatment • Intravitreal fomivirsen • ganciclovir implant NoteIntravitreal ganciclovir were not approved by FDA

  31. Cytomegalovirus Retinitis Local Treatment (available) • Intravitreal drugs ganciclovir Induction 200-4000 mcg 2-3times/week Maintenance: same dose weekly Foscarnet Induction 1.2-2.4 mg twice/week Maintenance same dose weekly Cidofovir 20 mcg every 5-6 weeks Fomivirsen induction 330 mcg biweekly x2 maintenance same dose monthly • ganciclovir Intraocular Implant every 6-8 months

  32. How to prepare intravitreal drug

  33. Cytomegalovirus Retinitis Intravitreal Injection

  34. CYTOMEGALOVIRUS RETINITISlocal treatment advantages • prevent systemic side effect • need less drug so less cost* • improve quality of life • higher drug concentration disadvantages • Inability to protect contralateral eye • increase risk of extraocular cmv infection • less survival

  35. Intraocular ganciclovir Level microgram/ml • intravenous induction 0.78 • intravenous maintenance 0.63 • oral ganciclovir 0.83 • implant 4 • intravitreal injection ( at 24hr ) 143* • intravitreal injection ( at 72hr ) 23* *Morlet N,Young S,Naidoo D,Graham G,Coroneo MT. High dose intravitreal ganciclovir injection provides a prolonged therapeutic intraocular concentration. Br J Ophthalmol. 1996;80:214-216

  36. increase intraocular pressure increase risk of retinal detachment vitreous hemorrhage scarring of injected site retinal toxicity? Endophthalmitis Post-surgical scleritis* CYTOMEGALOVIRUS RETINITISLocal Treatment(complications) After treatment *Ophthalmic Surg Lasers Imaging. 2004 May-Jun;35(3):254-5.

  37. Rhegmatogenous retinal detachmentmay result from tear of retinitis NORMAL compared to RRD retinal tear not shown here left fundus of another patient

  38. Cytomegalovirus Retinitisin HAART era • Decrease IncidenceFrom 21.9 Per 100 Person-Year (PY) To 3.7 Per 100 Person-Year • Change in the Clinical Course of the Disease From Progressive if lefted untreated To Ability to discontinue AntiCMV agent without progression • Altered Clinical Presentation

  39. Clinical Course Change (more) • CMVR is still be risk factor for mortality in AIDS patients* : RR=1.6 when CMVR presence : RR=1.9 when CMV viral load >400 copy/ml • Decrease rate of second eye involvement ** from 0.40 to 0.07(0.34:0.02)/PY • Decrease rate ofretinal detachment** from 0.50 to 0.06(0.30:0.02)/PY • Decrease rateof retinitis progression*** from 3.0 to 0.10(0.58:0.02)/PY *Risk factors for mortality in patients with AIDS in the era of highly activeantiretroviral therapy. Ophthalmology.2005 May;112(5):771-9 **Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: 2. Second eye involvement and retinal detachment. Ophthalmology. 2004 Dec;111(12):2232-9.).. *** Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: 1. Retinitis progression. Ophthalmology. 2004 Dec;111(12):2224-31 *Ophthalmology.2005 May;112(5):771-9 **Ophthalmology. 2004 Dec;111(12):2232-9. ***Ophthalmology. 2004 Dec;111(12):2224-31.

  40. Altered Clinical Presentation • Immune Recovery Vitritis • Cystoid Macula Edema* *** • Epiretinal Membrane • Vitreomacula traction syndrome • Disc Edema and Neovascularization • Uveitic glaucoma • Panuveitis • Varicella zoster virus immune recovery stromal keratitis** *Retina. 2004 Jun;24(3):376-82. **Br J Ophthalmol 2001 ( November ) ; 85:1384 ***Am J Ophthalmol. 2004 Apr;137(4):636-8.

  41. Immune Recovery Uveitis (IRU) Criteria diagnosis is 3I • Intraocular inflammation characterized by vitritis ,disc edema , cystoid macula edema • Inactive cytomegalovirus retinitis • Immune recovery by CD4 rise >50 longer than 3 months

  42. question

  43. ปัญหาและอุปสรรค • คนใข้ loss follow up เพราะ ไม่มีเงินค่าเดินทาง จากการเก็บรวบรวมข้อมูลวิจัยสถาบันบำราศนราดูรพบ29คนใน98คน (29.5%) • คนใข้ฉีดยาเข้าตาเกินความจำเป็นเพราะไม่มีเงินตรวจCD4 count • คนใข้ไม่มีคนรักษาโรคจอตาอักเสบจากcytomegalovirus • หมอใช้เวลากับคนใข้น้อยเกินไปเพราะคนใข้มาก • หมอสงสัยว่าทำไมต้องเป็นฉันเท่านั้นที่รักษาโรคพวกนี้

  44. Thank you for your attention

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