Picture Quiz Poll: A Brushfire in the Eye

nformation sourced from BMJ:

BMJ 2016;353:i3075
[Free full-text BMJ article PDF]

Endgames

Case Review

A brushfire in the eye

Mehnaz Khan, P Kumar Rao, Rajesh C Rao

Correspondence to: R C Rao rajeshr@med.umich.edu

[EXCERPTS]

A 44 year old man with untreated HIV infection was referred to the department of ophthalmology for routine screening of ocular disease. He reported non-compliance with highly active antiretroviral therapy (HAART) consisting of efavirenz, tenofovir, and emtricitabine, and his CD4 count was below 50×106 cells/L. He had no ocular problems at the time of presentation to his general practitioner.

His visual acuity was normal. Examination of the anterior structures of both eyes was unremarkable. Examination of the right eye identified a white annular edge of haemorrhagic retinitis in a brushfire pattern. The fundus of the left eye looked normal.


Fig 1 Fundus photograph of the right eye on presentation showing a white, annular leading edge of retinitis (white arrows) associated with haemorrhage (blue arrow) in a brushfire pattern.

What are the differential diagnoses for retinitis?

Retinitis can be secondary to viral, bacterial, fungal, and parasitic infections; autoimmune conditions; and cancer.

What is the diagnosis?

Cytomegalovirus retinitis.

What is the most common cause of blindness in this condition?

CMV retinitis of the posterior pole.

What are the available treatments and follow-up recommendations?

Intravenous ganciclovir, the oral prodrug valganciclovir, intravenous foscarnet, intravenous cidofovir, intravitreal injections of ganciclovir or foscarnet, or the ganciclovir intraocular implant (not currently available).

Patient outcome

After diagnosis, the patient was started on HAART and oral valganciclovir. In addition to regular follow-up for his retina care, he regularly visited an infectious disease specialist. Oral valganciclovir was stopped nearly a year after his initial visit when he achieved a CD4 count ≥100×106 cells/L, which was sustained during the follow-up period (two years after his first ophthalmic examination). During this time, the CMV retinitis evolved from a haemorrhagic form to an inactive retinal scar. The haemorrhages gradually resolved over two years, a subretinal band formed, and a demarcation line (the boundary between viable and scarred necrotic retina) appeared. His retinitis has not recurred.


Fig 2 Fundus photographs of the right eye during two years of treatment. The right eye was examined after initiation of highly active antiretroviral therapy and oral ganciclovir. The retinitis (white arrows) and haemorrhages (blue arrows) resolved over one week (A), six weeks (B), and at two years (C). A subretinal band formed at six weeks (B; [blue] arrowhead), and persisted at two years (C, blue arrowhead). At two years (C), a demarcation line (white arrows: boundary between viable and scarred, necrotic retina) formed in the place of the leading edge of the previous retinitis (A and B; white arrows)

Patient consent obtained.

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