Ocular OI

Question 1

In who do new cases of CMVR occur?

Answer 1

Late diagnosis, poor adherence, poor tolerance of treatment, failure of ART

Question 2

What are the symptoms of CMVR?

Answer 2

In people with CD4 <50

Affects one eye first and without treatment other eye becomes affected

Floaters, blind spots, blurred vision, sudden decrease in vision

Question 3

Who should be screened for CMVR and how frequently?

Answer 3

Dilated indirect ophthalmoscope at 3 monthly intervals in patients with CD4 <50

Question 4

How is CMVR diagnosed?

Answer 4

Clinical diagnosis
Urgent ophthalmology review to confirm

Question 5

What counts as progression of CMVR?

Answer 5

Extension by 750um along 750m-wide front

Question 6

For who is treatment of CMVR indicated?

Answer 6

Incident cases
Progression or reaction of pre existing CMVR

Question 7

Benefits of treatment of CMVR

Answer 7

Limits progression and reduces risk of blinding complications - retinal detachment, macular involvement

Prophylaxis for unaffected eye

Question 8

What can be given to patients not tolerating systemic CMVR therapy?

Answer 8

Intravitreal injections or implants

Question 9

How is CMVR treated?

Answer 9

Induction - 2-4 weeks
Maintainence period with lower dose until CD4 sustained >100

Question 10

What is the preferred treatment for CMVR?

Answer 10

Oral valganciclovir preferred option - 900mg BD in induction, OD for maintenance

Question 11

What should be given if oral therapy for CMVR not tolerated or issues regards adherence?

Answer 11

Induction - IV ganciclovir 5mg/kg bd, iv foscarnet 90mg/kg bd, weekly cidofovir 5mg/kg

Maintenance - iv ganciclovir 5mg/kg OD or 6mg/kg/day for 5 days of week, iv foscarnet 90mg/kg od daily or 120mg/kg for 5 days of week. Fortnightly cidofovir.

Question 12

What monitoring is needed for people on IV ganciclovir, foscarnet or cidofovir?

Answer 12

All iv options can cause significant toxicities - renal and electrolyte abnormalities, bone marrow suppression

Question 13

What to do if treatment for CMVR fails with oral valganciclovir?

Answer 13

Dose increase
Add implant or intravitreal ganciclovir
Intravitreal foscarnet is an alternative option or switch to foscarnet or cidofovir

Question 14

What to consider if CMVR treatment with implant fails?

Answer 14

Implants do not release ganciclovir steadily so may have ceased to release active drug

Question 15

Is cidofovir safe in pregnancy?

Answer 15

Men - do not father a child during or within 3/12 of cidofovir treatment

Women - do not get pregnant during or for 1 month after treatment

Question 16

Does CMV associated IRIS happen when ARVs are started?

Answer 16

May occur up to many months later

Most common presentation vitritis and most likely if large retinal lesions at baseline
Immune recovery uveitis also may occur - seen at CD4 50-150 - resolves as CD4 continues to rise

Question 17

Treatment for CMV IRIS

Answer 17

Coordination between HIV team and ophthalmology team
Often requires corticosteroids either systemically or periocularly

Question 18

When should ARVs be started in context of CMVR

Answer 18

‘Promptly’

Question 19

How should ocular syphilis be treated in HIV+ patients?

Answer 19

As for neurosyphilis -

14/7 procaine penicillin 1.8mu-2.4 mu im plus probenecid 500mg po qds
Benzylpenicillin 1.8-2.4g iv 4hrly for 14/7

Alternatives
Doxy 200mg BD 28/7
Amoxicillin plus probenecid
Ceftriaxone 2g im or iv for 10-14/7

40-60mg prednisolone od for 3/7 starting 24hrs before

Question 20

How is ocular toxoplasma diagnosis?

Answer 20

Usually on clinical suspicion
Toxoplasma dna detected on pcr of intraocular fluids
Plasma and intraocular fluid antitoxoplasma antibody levels

Question 21

What is the classical appearance of ocular toxoplasmosis?

Answer 21

Focus of retinochoroiditis adjacent to chorioretinal scar from previous infestation
Overlying vitreous haze and cellular response
Atypical presentations can include multiple large or bilateral lesions

Question 22

How does ocular toxoplasmosis occur?

Answer 22

Reactivation of pre or post natal infection
Occurs at an earlier stage than CMV retinitis

Question 23

What is the treatment for ocular toxoplasmosis?

Answer 23

Systemic therapy - sulphadiazine and pyrimethamine have good efficacy but issues with toxicity and DDI may limit long term use
Atovaquone also used with success

Maintenance therapy until ‘good immune recovery’ with HAART

Question 24

What extra investigation needed if a patient has ocular toxoplasma infection?

Answer 24

MRI head to rule out cerebral disease

Question 25

Symptoms of varicella zoster virus retinitis

Answer 25

Rapidly progressive visual loss occurring unilaterally initially
Progrsssive full thickness retinal necrosis with confluent lesions spreading inwards from retinal periphery
Immunocompromised patients may experience early macular involvement with no vitrifis

Question 26

What occular syndromes can be caused by varicella zoster virus?

Answer 26

Progressive outer retinal necrosis syndrome (PORN)
Acute retinal necrosis syndrome (ARN)

ARN typically VZV in older patients, can be caused by HSV in younger patients

Question 27

Possible complications of VZV retinitis

Answer 27

Retinal detachment, ischaemic optic neuropathy from vascular occlusion or optic nerve inflammation and macular involvement

Question 28

Diagnosis of VZV retinitis

Answer 28

Vitreous sampling and analysis

Question 29

Prognosis for VZV retinitis

Answer 29

Often disappointing - bling within weeks from macular involvement and complications such as retinal detachment

Question 30

Treatment of VZV retinitis

Answer 30

Cidofovir probably drug of choice with or without addition of Intravitreal ganciclovir or foscarnet

Iv ganciclovir alone or in combo with foscarnet and intravitreal ganciclovir/foscarnet have been used to halt progression