12/28/2023 0 Comments Normal retina vs cmv retinitis![]() ![]() Dx: Dx made clinically, confirmatory tests rarely necessary.DDx: acute retinal necrosis ( HSV or VZV), progressive outer retinal necrosis ( VZV), toxoplasmosis, syphilis, cotton-wool spots, metastatic Candida or other fungal endophthalmitis, intraocular lymphoma, tuberculosis.Risk greatest in patients with large areas of CMV retinitis. CMV Immune reconstitution inflammatory reaction ( IRIS): usually causes uveitis or vitritis with viral suppression after starting ART in patients with very low CD4 count.Retinal detachment may occur in areas of necrosis. Spectrum of clinical findings: (1) Fulminant/granular retinitis: hemorrhagic retinal necrosis, often with perivascular sheathing (may be present in retina away from area of necrosis) rarely mis-Dx’d (2) Indolent/granular retinitis: minimal or no hemorrhage and no perivascular sheathing more commonly misdiagnosed (3) Mixed features can be present (4) Dry, granular-appearing border characteristic (5) Lesions may be single or multiple, unilateral or bilateral (6) Full-thickness retinal necrosis with irreversible loss of function in affected tissue (7) Mild anterior chamber and vitreous inflammatory reaction usually present fine keratic precipitates typical no posterior synechiae.Zone 3 (anterior to imaginary circle connecting ampulla of vortex veins). Zone 2 (peripheral to zone 1 but posterior to zone 3) not considered immediately vision-threatening direct ophthalmoscopy in well-dilated pupil can image retina into mid-periphery of zone 2. Location of retinitis: Zone 1 (posterior, often visible with direct ophthalmoscopy) within 1500 mu (~1 disc diameter) of optic disc or 3000 mu of fovea considered immediately vision-threatening.Clinical course: relentless progression of retinitis in untreated pts: 24 microns/day (range 0-164).Cataract and macular edema are most common causes of visual loss in patients with immune recovery uveitis.In HAART era, detachment rate has decreased, but remains similar among those with CD4 < 50. 50% will have detachment in ≥1 eye at 1 yr after Dx of CMV-R without immune recovery 33% of eyes will suffer detachment. Greater risk in eyes with larger lesions and with lesions involving vitreous base anteriorly. Causes of visual loss: central macular (foveal) necrosis (irreversible) optic neuritis (occasionally reversible) macular edema (occasionally reversible) retinal detachment (surgically treatable).50% w/ unilateral retinitis develop contralateral involvement within 6 mos if untreated. Bilateral involvement at time of Dx in 35%.Sx: (1) often none (15-50% asymptomatic) (2) floaters, photopsias, blind spots, distortion (blind spots % distortion especially if macula involved) (3) no pain, redness, photophobia.survival after Dx w/ CMV-R 8.5-12 mos in pre-HAART era. Retinitis comprises 80-90% of end-organ CMV disease. Most common cause of visual loss in AIDS and most common ocular disease when CD4 CMV retinitis (CMV-R) occurred in ~30% AIDS pts pre-HAART (with CD4 ![]()
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