Valganciclovir Therapy for Immune Recovery Uveitis Complicated by Macular Edema

Abstract

Abstract: : Purpose: To test the hypothesis that low level CMV replication may be responsible for persistent antigen presentation in the eyes of patients with immune recovery uveitis and that treatment with a potent anti-CMV regimen may reduce the inflammation and improve vision in patients with immune recovery uveitis and vision loss from angiographically proven macular edema. Methods: A prospective open label cross over controlled drug study. Five patients with angiographically documented chronic macular edema due to immune recovery uveitis were studied. Four patients were previously unresponsive to periocular steroid injections. Two patients had prior surgery for chronic macular edema (one associated with an epiretinal membrane). Baseline fluorescein angiograms, best-corrected ETDRS visions, and lymphoproliferative T-cell function assays were obtained and repeated after three months of oral valganciclovir therapy (900 mg daily) and again 3 months after withdrawal of therapy. Results: The mean number of letters of improvement in the treatment phase was 9.4 (p=0.0448, paired t-test, one-way). Angiograms were graded and 3 of 5 patients showed treatment benefit with reduction of macular edema. One patient’s studies were limited by vitritis, which made the detection of macular edema difficult, but the vitritis was reduced after the treatment phase. One patient did not show treatment benefit of reduction of macular edema. Of the 3 patients with treatment benefit, one patient had rebound increase in macular edema after the withdrawal phase. There was no evidence that the CMV lymphoproliferative response was affected by the valganciclovir, suggesting that if the valganciclovir is suppressing residual CMV replication, it is not reducing the cellular immune response to CMV. Conclusion: This open label cross over study suggests a possible benefit of oral valganciclovir to treat macular edema in immune recovery uveitis. The cohort is small and the treatment benefit mild; a larger prospective double masked study should be considered to further explore the hypothesis that anti-CMV treatment may be useful in immune recovery vitritis.

Keywords: cytomegalovirus • AIDS/HIV • clinical (human) or epidemiologic studies: tre