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Case Presentation SAC

Case Presentation SAC. Juan G. Santiago, MD Department of Ophthalmology University of Puerto Rico. Chief Complaint. “Veo un area de sombras por el ojo izquierdo hace 3 semanas aproximadamente”. Present History.

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Case Presentation SAC

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  1. Case PresentationSAC Juan G. Santiago, MD Department of Ophthalmology University of Puerto Rico

  2. Chief Complaint • “Veo un area de sombras por el ojo izquierdo hace 3 semanas aproximadamente”

  3. Present History • SAC is a 44 y/o female with history of HIV+ diagnosed 3 days ago that refers left eye cloudiness since 3 weeks ago. Patient refers (-) eye pain, (-) photophobia, (-) flashlights, (-) diplopia, (-) secretions, (-) redness. Patient currently admitted to Internal Medicine service due to bronchitis and episode of right sided extremities weakness.

  4. History • Eye history: None • Surgeries: C-Section (x2) • Childhood: (+)VZV, (+)Measles • Systemic history: HIV, episodes of bronchitis • Family history: BA, CAD, DM, HIV

  5. SLE

  6. DFE - OD Right Eye

  7. DFE - OS Left Eye

  8. Differential Diagnosis • Cytomegalovirus (CMV) Retinitis • Progressive Outer Retinal Necrosis (PORN) • Acute Retinal Necrosis (ARN) • Toxoplasmosis Retinitis • HIV Retinitis • Syphilis Retinitis

  9. CMV Retinitis • Progressive hemorrhagic necrotizing retinitis involving all retinal layers • 15-40% of patients who develops AIDS • 90% of infectious retinopathies in AIDS patients • CD4 count <50 cells/mm3 • 40% bilateral at presentation

  10. CMV Retinitis • Symptoms • Often asymptomatic • Floaters • Photopsia • Scotomas

  11. CMV Retinitis • Findings • Well circumscribed necrotizing retinitis • Indolent • Fulminant • Mild AC and vitreous reaction

  12. CMV Retinitis • Indolent • Limited to the periphery • Appearing more granular with less hemorrhage

  13. CMV Retinitis • Fulminant • Can involve the macula • Thick, yellow-white necrosis • Greater degree of intraretinal hemorrhage • Vascular sheating

  14. CMV Retinitis

  15. CMV Retinitis • Pathology • Infected retinal cells are markedly enlarged, then necrotic, finally atrophic • Large owl’s eye intranuclear lesions

  16. CMV Retinitis • Treatment • HAART – Most important • Systemic – 2 weeks induction • Ganciclovir • Valganciclovir • Foscarnet • Cidofovir • Intraocular • Ganciclovir implant • Intravitreal foscarnet

  17. PORN • Devastating condition caused by an aggressive variant of VZV • Second most common retina infection in AIDS

  18. PORN • Symptoms • Painless rapidly progressive visual loss • Unilateral (74%), then bilateral (70%)

  19. PORN • Findings • Multifocal, deep, yellow-white, retinal infiltrates with minimal vitritis. • Rapid confluence, full thickness retinal necrosis • Early macular involvement • Vasculitis not prominent

  20. Treatment Combination of foscarnet and ganciclovir Poor response to antivirals Prognosis 67% become NLP within 4 weeks RD in 90% PORN

  21. ARN • Acute self-limited confluent peripheral necrotizing retinitis due to infection with VZV, HSV, or rarely CMV • Usually immunocompetent individuals • 33% Bilateral (BARN), immunosupressed

  22. ARN • Symptoms • Rapid onset of ocular/periocular pain • Pain on eye movement • Redness • Photophobia • Floaters • Decreased vision • Constriction of visual field

  23. ARN • Findings • Anterior granulomatous uveitis and vitritis are universal • Peripheral retinal periarteritis and multifocal, deep, yellow white, retinal infiltrates

  24. ARN • Findings • Gradual confluence of the lesions and the development of full thickness retinal necrosis • Posterior pole usually spare until late • Optic disc edema • Choroidal thickening • Retinal hemorrhages

  25. ARN • Pathology • Necrosis from virally induced cytolysis • Arteriolar and choriocapillaris occlusion • Necrotic cells sloughs into vitreous • Large areas devoid of retina

  26. Treatment Acyclovir IV Famcyclovir Systemic steroids Aspirin Prognosis Fellow eye usually develops ARN within 4 weeks Rhegmatogenous RD (65-90%) ARN

  27. Toxoplasmosis • Most common cause of infectous retinitis in immunocompetent individuals • Active retinitis usually associated with anterior uveitis.

  28. Toxoplasmosis • Findings • Inactive chorioretinal scar in posterior pole • Active white fluffy lesion adjacent to old scar with granulomatous uveitis and vitritis • White spots along arteries (Kyrieleis’ plaques)

  29. Toxoplasmosis • Findings in AIDS • Head CT may show ring-enhancing lesions • Minimal AC reaction and vitritis • Bilateral, multifocal, discrete foci or extensice confluent areas of retinits • Pre-existing scars are absent

  30. Toxoplasmosis • Pathology • Round Toxoplasma cysts • Chronic granulomatous choroiditis

  31. Toxoplasmosis

  32. Toxoplasmosis • Treatment • Clindamycin • Sulphadiazine • Pyrimethamine • Folinic acid • Systemic steroids

  33. HIV Retinopathy • Microangiopathy in up to 50% of HIV-infected individuals • Asymptomatic, nonprogressie

  34. HIV Retinopathy • Findings • Cotton wool spots • Roth spots • Hemorrhages • Microaneurysms • Treatment • None

  35. Literature Review • Causes of Vision Loss in CMV Retinitis. Thome et al. Ophthalmology Vol 113, Num 8, August 2006 • Zone I involvement and CMV-related retinal detachment remain common causes of vision loss despite HAART. • Longstanding CMV retinitis and immune recovery uveitis are also at risk for visual impairment owing to the development of cataract and CME.

  36. Literature Review • Outcomes Associated with Ganciclovir Implants in AIDS-Related CMV Retinitis. Kappel et al. Vol 113, Num 4, April 2006 • Complications specifically associated with ganciclovir implants can occur many years after implantation procedure • Poor outcomes were associated with: • disease factors (size and activity of lesions) • lack of HAART • lack of HAART associated immune reconstitution

  37. Literature Review • Treatment of CMV retinitis in AIDS patients with intravitreal ganciclovir. Ausayakhun S et al. J Med Assoc Thai. 2005 Nov;88 Suppl 9. • 568 treated eyes • VA remained stable in 343 (60%) • Improved VA in 76 (13%) • Decreased in 149 (26%) • 33 retinal detachments • 6 intravitreal hemorrhages • 6 endophthalmitis • 2 cataract

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