Cytomegalovirus retinitis in immunocompetent patients

Abstract

Purpose: : To report cases of cytomegalovirus (CMV) retinitis in immunocompetent patients

Methods: : Retrospective chart review of 7 patients with CMV retinitis who were immunocompetent.

Results: : Most patients in our series were above 60 years. Systemic comorbidities at presentation were DM, HTN, CRF, Cancer (Esophageal and Breast - both in remission at presentation), MS, Pemphigus, Prior history of Herpes Zoster. HIV serology was negative in all patients. 4 of the patients had intravitreal steroid and VEGF inhibitor injections in the preceding year in the affected eye.Most patients were initially misdiagnosed to have ARN for which they were on Valacyclovir for a variable period of time. All patients had anterior chamber and vitreous inflammation and retinitis. Many also had vascular attenuation or obliteration. All patients showed improvement in retinitis within weeks following therapy with intravitreal foscarnet/ganciclovir and systemic valganciclovir. 2 patients had recurrences 1 month and 2 months after stopping valganciclovir therapy. Both the patients were started on a second round of systemic valganciclovir therapy but it had to be stopped because of systemic side effects. One of these patients had a valganciclovir implant and has had no recurrences in the subsequent 2 years. The other patient developed a recurrence in both eyes at different time intervals after stopping the second round of systemic valganciclovir. She had intravitreal ganciclovir implants placed in both eyes and did not develop any recurrences of CMV retinitis, but developed CMV viremia and CMV pneumonia later. One patient was initially started on systemic valganciclovir which he stopped due to a skin rash and intravitreal ganciclovir implant was inserted; his retinitis remains quiescent for 2 years following the implant. The other patients are on systemic valganciclovir and have no recurrences while on systemic therapy.

Conclusions: : CMV retinitis usually occurs in immunocompromised patients, however it can occur in immunocompetent patients. Most of these patients have systemic comorbidities and some have preceding intravitreal steroid and VEGF inhibitor injections which may cause subclinical immunossuppression. CMV Retinitis in this subgroup responds well to CMV therapy however since there is no obvious immunosuppression, optimum duration of therapy is unknown and needs to be individualized to each patient.

Keywords: cytomegalovirus • retinitis