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N. J. London, N. Tun, M. Kyaw Kyaw, F. Smithuis, D. Heiden; Mortality and a CMV Retinitis Strategy for Resource-Poor Settings. Invest. Ophthalmol. Vis. Sci. 2010;51(13):2913.
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Description of a three year pilot program of CMV retinitis management by non-ophthalmologists in a resource-poor setting of SE Asia (Myanmar). The program consists of systematic screening of all high-risk patients (CD4 < 100) by AIDS clinicians using indirect ophthalmoscopy, and treatment with intravitreal ganciclovir. MSF/H provides Antiretroviral Therapy (ART) for approximately two-thirds of all patients receiving ART in Myanmar. Prior to this program, CMV retinitis had never been treated in Myanmar, and this program still represents the only treatment available for patients with CMV retinitis in Myanmar.
Descriptive data were collected on the scope of clinical activities. Mortality for the Yangon project HIV/AIDS patients was analyzed, with regard to the association with active CMV retinitis. All patients were treated with ART by standard protocols.
Between November 2006 and September 2009, eight primary care AIDS clinicians were trained in indirect ophthalmoscopy and diagnosis of CMV retinitis, and six were also trained in intravitreal injection. Systematic screening of all high-risk patients (CD4 less than 100) was carried out at five separate AIDS clinics throughout Myanmar. A total of 891 new patients (1782 eyes) were screened, with an average CD4 cell count of 38 cells/uL. Of 1782 total eyes screened, 16% (287) were diagnosed with CMV retinitis, and 76 patients (36%) had bilateral disease. Patients with active retinitis were treated with weekly intravitreal ganciclovir (1,300+ injections). On Kaplan-Meyer analysis, there was a significantly higher mortality for patients with active CMV retinitis (n=70) compared to those without CMV retinitis (n=473) (p=0.026). Proportional hazards (Cox) regression analysis showed no significant relationship between survival and gender, presence of WHO stage IV disease, CD4 < 100 cells/uL, or age under 15 years.
A strategy of management of CMV retinitis at the primary care level by AIDS clinicians is feasible in resource-poor settings. AIDS clinicians can become skilled in indirect ophthalmoscopy, diagnosis of CMV retinitis, and intravitreal injection. Although local treatment of retinitis is effective, well accepted, and low cost, this treatment strategy by itself is not medically sufficient in light of the higher mortality in patients with active CMV retinitis. Systemic treatment should be the standard of care. Oral valganciclovir is an essential drug for patients with CMV retinitis, and must be made affordable and widely available immediately.
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