Retinal detachment associated with AIDS-related cytomegalovirus retinitis: risk factors in a resource-limited setting

Michael Yen, Jenny Chen, Somsanguan Ausayakhun, Paradee Kunavisarut, Pornpattana Vichitvejpaisal, Sakarin Ausayakhun, Choeng Jirawison, Jessica Shantha, Gary N Holland, David Heiden, Todd P Margolis, Jeremy D Keenan, Michael Yen, Jenny Chen, Somsanguan Ausayakhun, Paradee Kunavisarut, Pornpattana Vichitvejpaisal, Sakarin Ausayakhun, Choeng Jirawison, Jessica Shantha, Gary N Holland, David Heiden, Todd P Margolis, Jeremy D Keenan

Abstract

Purpose: To determine risk factors predictive of retinal detachment in patients with cytomegalovirus (CMV) retinitis in a setting with limited access to ophthalmic care.

Design: Case-control study.

Methods: Sixty-four patients with CMV retinitis and retinal detachment were identified from the Ocular Infectious Diseases and Retina Clinics at Chiang Mai University. Three control patients with CMV retinitis but no retinal detachment were selected for each case, matched by calendar date. The medical records of each patient were reviewed, with patient-level and eye-level features recorded for the clinic visit used to match cases and controls, and also for the initial clinic visit at which CMV retinitis was diagnosed. Risk factors for retinal detachment were assessed separately for each of these time points using multivariate conditional logistic regression models that included 1 eye from each patient.

Results: Patients with a retinal detachment were more likely than controls to have low visual acuity (odds ratio [OR], 1.24 per line of worse vision on the logMAR scale; 95% confidence interval [CI], 1.16-1.33) and bilateral disease (OR, 2.12; 95% CI, 0.92-4.90). Features present at the time of the initial diagnosis of CMV retinitis that predicted subsequent retinal detachment included bilateral disease (OR, 2.68; 95% CI, 1.18-6.08) and lesion size (OR, 2.64 per 10% increase in lesion size; 95% CI, 1.41-4.94).

Conclusion: Bilateral CMV retinitis and larger lesion sizes, each of which is a marker of advanced disease, were associated with subsequent retinal detachment. Earlier detection and treatment may reduce the likelihood that patients with CMV retinitis develop a retinal detachment.

Copyright © 2015 Elsevier Inc. All rights reserved.

Figures

Figure. Risk of retinal detachment in patients…
Figure. Risk of retinal detachment in patients with the acquired immunodeficiency syndrome (AIDS) and cytomegalovirus retinitis, stratified by most anterior zone of retinal involvement
Patients are grouped by the most anterior zone occupied by the lesion, with cases of retinal detachment (+RD) on the left and controls without retinal detachment (-RD) on the right. The zones represented by each pair of columns are shown in the key above the figure, with each colored box corresponding to the color of the bar.

References

    1. Jabs DA, Van Natta ML, Holbrook JT, et al. Longitudinal study of the ocular complications of AIDS: 1. Ocular diagnoses at enrollment. Ophthalmology. 2007;114(4):780–6.
    1. Jabs DA. Ocular manifestations of HIV infection. Trans Am Ophthalmol Soc. 1995;93:623–83.
    1. Deayton JR, Wilson P, Sabin CA, et al. Changes in the natural history of cytomegalovirus retinitis following the introduction of highly active antiretroviral therapy. AIDS. 2000;14(9):1163–70.
    1. Jacobson MA, Stanley H, Holtzer C, Margolis TP, Cunningham ET. Natural history and outcome of new AIDS-related cytomegalovirus retinitis diagnosed in the era of highly active antiretroviral therapy. Clin Infect Dis. 2000;30(1):231–3.
    1. Yust I, Fox Z, Burke M, et al. Retinal and extraocular cytomegalovirus end-organ disease in HIV-infected patients in Europe: a EuroSIDA study, 1994-2001. Eur J Clin Microbiol Infect Dis. 2004;23(7):550–9.
    1. Sugar EA, Jabs DA, Ahuja A, et al. Incidence of cytomegalovirus retinitis in the era of highly active antiretroviral therapy. Am J Ophthalmol. 2012;153(6):1016–24. e5.
    1. Heiden D, Ford N, Wilson D, et al. Cytomegalovirus retinitis: the neglected disease of the AIDS pandemic. PLoS Med. 2007;4(12):e334.
    1. Ford N, Shubber Z, Saranchuk P, et al. Burden of HIV-related cytomegalovirus retinitis in resource-limited settings: a systematic review. Clin Infect Dis. 2013;57(9):1351–61.
    1. Ausayakhun S, Watananikorn S, Ittipunkul N, Chaidaroon W, Patikulsila P, Patikulsila D. Epidemiology of the ocular complications of HIV infection in Chiang Mai. J Med Assoc Thai. 2003;86(5):399–406.
    1. Ausayakhun S, Keenan JD, Ausayakhun S, et al. Clinical features of newly diagnosed cytomegalovirus retinitis in northern Thailand. Am J Ophthalmol. 2012;153(5):923–931. e1.
    1. Pathanapitoon K, Ausayakhun S, Kunavisarut P, et al. Blindness and low vision in a tertiary ophthalmologic center in Thailand: the importance of cytomegalovirus retinitis. Retina. 2007;27(5):635–40.
    1. Sudharshan S, Kaleemunnisha S, Banu AA, et al. Ocular lesions in 1,000 consecutive HIV-positive patients in India: a long-term study. J Ophthalmic Inflamm Infect. 2013;3(1):2.
    1. Gharai S, Venkatesh P, Garg S, Sharma SK, Vohra R. Ophthalmic manifestations of HIV infections in India in the era of HAART: analysis of 100 consecutive patients evaluated at a tertiary eye care center in India. Ophthalmic Epidemiol. 2008;15(4):264–71.
    1. Thorne JE, Jabs DA, Kempen JH, et al. Causes of visual acuity loss among patients with AIDS and cytomegalovirus retinitis in the era of highly active antiretroviral therapy. Ophthalmology. 2006;113(8):1441–5.
    1. Raina J, Bainbridge JW, Shah SM. Decreased visual acuity in patients with cytomegalovirus retinitis and AIDS. Eye (Lond) 2000;14(Pt 1):8–12.
    1. Irvine AR, Lonn L, Schwartz D, Zarbin M, Ballesteros F, Kroll S. Retinal detachment in AIDS: long-term results after repair with silicone oil. Br J Ophthalmol. 1997;81(3):180–3.
    1. Tangmonkongvoragul C, Ausayakhun S. Causes of visual acuity loss among HIV-infected patients with cytomegalovirus retinitis in the era of highly active antiretroviral therapy in Chiang Mai University Hospital. J Med Assoc Thai. 2012;95(Suppl 4):S129–35.
    1. Kunavisarut P, Bijlsma WR, Pathanapitoon K, Patikulsila D, Choovuthayakorn J, Rothova A. Proliferative vitreoretinopathy in human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy. Am J Ophthalmol. 2010;150(2):218–22.
    1. Jabs DA, Enger C, Haller J, de Bustros S. Retinal detachments in patients with cytomegalovirus retinitis. Arch Ophthalmol. 1991;109(6):794–9.
    1. Freeman WR, Friedberg DN, Berry C, et al. Risk factors for development of rhegmatogenous retinal detachment in patients with cytomegalovirus retinitis. Am J Ophthalmol. 1993;116(6):713–20.
    1. Rhegmatogenous retinal detachment in patients with cytomegalovirus retinitis: the Foscarnet-Ganciclovir Cytomegalovirus Retinitis Trial. The Studies of Ocular Complications of AIDS (SOCA) Research Group in Collaboration with the AIDS Clinical Trials Group (ACTG). Am J Ophthalmol. 1997;124(1):61–70.
    1. 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(12):2232–9.
    1. Kempen JH, Jabs DA, Dunn JP, West SK, Tonascia J. Retinal detachment risk in cytomegalovirus retinitis related to the acquired immunodeficiency syndrome. Arch Ophthalmol. 2001;119(1):33–40.
    1. Holland GN, Buhles WC, Jr., Mastre B, Kaplan HJ. A controlled retrospective study of ganciclovir treatment for cytomegalovirus retinopathy. Use of a standardized system for the assessment of disease outcome. UCLA CMV Retinopathy. Study Group. Arch Ophthalmol. 1989;107(12):1759–66.
    1. Schneider CA, Rasband WS, Eliceiri KW. NIH Image to ImageJ: 25 years of image analysis. Nat Methods. 2012;9(7):671–5.
    1. Weinberg DV, Holbrook JT, Hubbard LD, et al. Clinician versus reading center assessment of cytomegalovirus retinitis lesion size. Ophthalmology. 2005;112(4):559–66.
    1. Holland GN, Vaudaux JD, Jeng SM, et al. Characteristics of untreated AIDS-related cytomegalovirus retinitis. I. Findings before the era of highly active antiretroviral therapy (1988 to 1994). Am J Ophthalmol. 2008;145(1):5–11.
    1. Ausayakhun S, Yuvaves P, Ngamtiphakom S, Prasitsilp J. Treatment of cytomegalovirus retinitis in AIDS patients with intravitreal ganciclovir. J Med Assoc Thai. 2005;88(Suppl 9):S15–20.
    1. Engstrom RE, Jr., Holland GN. Local therapy for cytomegalovirus retinopathy. Am J Ophthalmol. 1995;120(3):376–85.
    1. Holland GN, Vaudaux JD, Shiramizu KM, et al. Characteristics of untreated AIDS-related cytomegalovirus retinitis. II. Findings in the era of highly active antiretroviral therapy (1997 to 2000). Am J Ophthalmol. 2008;145(1):12–22.
    1. Jabs DA, Van Natta ML, Kempen JH, et al. Characteristics of patients with cytomegalovirus retinitis in the era of highly active antiretroviral therapy. Am J Ophthalmol. 2002;133(1):48–61.
    1. Nolan W, Mitchell S. Do all patients with CMV retinitis require life long anti-CMV therapy? Br J Ophthalmol. 1998;82(7):844–5.
    1. Jouan M, Saves M, Tubiana R, et al. Discontinuation of maintenance therapy for cytomegalovirus retinitis in HIV-infected patients receiving highly active antiretroviral therapy. AIDS. 2001;15(1):23–31.
    1. Wohl DA, Kendall MA, Owens S, et al. The safety of discontinuation of maintenance therapy for cytomegalovirus (CMV) retinitis and incidence of immune recovery uveitis following potent antiretroviral therapy. HIV Clin Trials. 2005;6(3):136–46.
    1. Orellana J, Teich SA, Friedman AH, Lerebours F, Winterkorn J, Mildvan D. Combined short- and long-term therapy for the treatment of cytomegalovirus retinitis using ganciclovir (BW B759U). Ophthalmology. 1987;94(7):831–8.
    1. McCluskey P, Grigg J, Playfair TJ. Retinal detachments in patients with AIDS and CMV retinopathy: a role for laser photocoagulation. Br J Ophthalmol. 1995;79(2):153–6.
    1. Vrabec TR. Laser photocoagulation repair of macula-sparing cytomegalovirus-related retinal detachment. Ophthalmology. 1997;104(12):2062–7.
    1. Davis JL, Hummer J, Feuer WJ. Laser photocoagulation for retinal detachments and retinal tears in cytomegalovirus retinitis. Ophthalmology. 1997;104(12):2053–60. discussion 2060-1.
    1. Althaus C, Loeffler KU, Schimkat M, Hudde T, Sundmacher R. Prophylactic argon laser coagulation for rhegmatogenous retinal detachment in AIDS patients with cytomegalovirus retinitis. Graefes Arch Clin Exp Ophthalmol. 1998;236(5):359–64.
    1. Resnikoff S, Felch W, Gauthier TM, Spivey B. The number of ophthalmologists in practice and training worldwide: a growing gap despite more than 200,000 practitioners. Br J Ophthalmol. 2012;96(6):783–7.
    1. Estopinal CB, Ausayakhun S, Ausayakhun S, et al. Access to ophthalmologic care in Thailand: a regional analysis. Ophthalmic Epidemiol. 2013;20(5):267–73.
    1. Tun N, London N, Kyaw MK, et al. CMV retinitis screening and treatment in a resource-poor setting: three-year experience from a primary care HIV/AIDS programme in Myanmar. J Int AIDS Soc. 2011;14:41.
    1. Ausayakhun S, Skalet AH, Jirawison C, et al. Accuracy and reliability of telemedicine for diagnosis of cytomegalovirus retinitis. Am J Ophthalmol. 2011;152(6):1053–1058. e1.
    1. Shah JM, Leo SW, Pan JC, et al. Telemedicine screening for cytomegalovirus retinitis using digital fundus photography. Telemed J E Health. 2013;19(8):627–31.
    1. Yen M, Ausayakhun S, Chen J, et al. Telemedicine diagnosis of cytomegalovirus retinitis by nonophthalmologists. JAMA Ophthalmol. 2014;132(9):1052–8.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe