eMedicine Specialties > Ophthalmology > Retina

Retinitis, CMV: Differential Diagnoses & Workup

Author: Michael Altaweel, MD, FRCS(C), Associate Professor, Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health
Coauthor(s): Matthew D Reed, MD, Fellow, Department of Ophthalmology and Visual Sciences, University of Wisconsin Clinical Science Center
Contributor Information and Disclosures

Updated: Apr 18, 2006

Differential Diagnoses

Herpes Simplex
Herpes Zoster
HIV
Toxoplasmosis

Workup

Laboratory Studies

  • The CD4 count is a marker of immune dysfunction in patients infected with HIV. Patients may be asymptomatic with CMV retinitis; therefore, ophthalmic screening frequency is based on CD4 count.
    • CD4 >50 cells/mL - Little risk; screening examination every 6 months if CD4 50-100 cells/mL; screen yearly if CD4 >100 cells/mL
    • CD4 <50 cells/mL - Up to 35% incidence of CMV retinitis; median time to diagnosis of CMV retinitis is 13 months; screen every 3 months
    • The above screening regimen was used prior to the routine use of HAART. The frequency of examinations likely will be modified by assessing viral load, result of CMV DNA capture, CD4 count, and response to treatment.
  • CMV DNA capture
    • A polymerase chain reaction (PCR) test can be qualitative or quantitative. Specimens can be obtained from blood buffy coat, semen, or urine. Detection of CMV in the blood by DNA PCR is most predictive of developing CMV disease. Patients with AIDS who test positive will have more than a 60% chance of developing CMV end-organ disease.
    • Responders to ganciclovir prophylaxis convert to PCR negative with treatment. Compared to nonresponders, survival is increased 2.4 times at 12 months.
  • Viral load: Increased viral load can be a predictor of development of CMV end-organ disease.
  • HIV test
  • Complete blood count (CBC) with differential is important in evaluation for causes of immunosuppression and in assessment for side effects of ganciclovir use.
  • Blood urea nitrogen (BUN) and creatinine baseline assessment and serial measurements are used to evaluate for side effects of foscarnet or cidofovir use.

Imaging Studies

  • Ultrasound is used for evaluation of retinal detachment, particularly if vitritis obscures adequate fundus visualization.
  • Fluorescein angiogram - Assessment for areas of ischemia
  • Chest x-ray - Assessment for concurrent Pneumocystis pneumonia

Other Tests

  • Fluorescent treponemal antibody absorption (FTA-ABS) test or microhemagglutination-Treponema pallidum (MHA-TP) - Serologic testing for infection with syphilis, a differential diagnosis for CMV retinitis
  • Serum toxoplasma titer - Differential diagnosis for retinitis with vitritis

Procedures

  • Ganciclovir implant
    • This intravitreal implant releases ganciclovir at a steady state for up to 8 months.
    • The implant provides treatment of CMV retinitis in 1 eye only. No systemic effect occurs.
    • The initial implant usually is placed in the inferotemporal quadrant. It may be visualized through a dilated pupil.
    • Possible complications include vitreous hemorrhage, retinal detachment, hypotony, and endophthalmitis.
    • After 8 months, if still required, a second implant may be placed. The first implant can be left in place or removed.
  • Fomivirsen implant: Fomivirsen is not used as a primary therapy but is approved for cases not responding to other therapies.
  • Vitreoretinal surgery
    • Retinal detachment repair is required in 5-50% of patients with CMV retinitis (depending on the trial).
    • Multiple small holes in several areas of the retina are often responsible for the retinal detachment. These occur at the junction of healthy and necrotic retina.
    • Primary repair with vitrectomy, air-fluid exchange, endolaser, and silicone oil tamponade has improved surgical outcome.
  • Laser photocoagulation: Small peripheral retinal detachments can be repaired with laser photocoagulation.
  • Intravitreal injections of ganciclovir, foscarnet, or cidofovir
    • These injections offer high levels of intraocular drug for short periods of time.
    • They are useful in acute vision-threatening cases when rapid drug delivery is needed prior to instituting longer term therapy.
    • Risks of intravitreal injection include hemorrhage, RD, and endophthalmitis.

Histologic Findings

The healthy retina is sharply demarcated from infected retinal cells, which show edema, pathognomonic cytomegalic inclusions, and few surrounding inflammatory cells (consistent with a compromised immune response). Infected cells lyse, leaving an area of full-thickness necrosis and releasing virus particles that infect adjacent retinal cells. The histopathology correlates well with the clinical picture of a posteriorly advancing edge of active disease with formerly active areas undergoing necrosis, scarring, and atrophy.

Staging

CMV retinitis is described by the stage and zone of involvement.

  • Stage
    • Active retinitis - 3 general patterns
      1. Hemorrhagic - Large areas of retinal hemorrhage on a background of whitened, necrotic retina
      2. Brush fire - Yellow-white margin of slowly advancing retinitis at the border of atrophic retina
      3. Granular - Found in the periphery; focal white granular lesions without associated hemorrhage
    • Necrotic stage - End result of all patterns of active retinitis is the progression to necrosis. Retinal tears or holes can develop in these areas.
  • Zone of involvement
    • Zone 1 - Within 1500 µm of the optic nerve or 3000 µm of the fovea
    • Zone 2 - From zone 1 to equator, at vortex vein ampullae
    • Zone 3 - From zone 2 to the ora serrata
  • Zone 2 and 3 are the most common sites of initial retinal involvement.
  • Progression - Spread of retinitis usually is along the leading edge, although skip lesions can occur. Progression occurs at a rate of 250-350 µm per week if untreated.

More on Retinitis, CMV

Overview: Retinitis, CMV
Differential Diagnoses & Workup: Retinitis, CMV
Treatment & Medication: Retinitis, CMV
Follow-up: Retinitis, CMV
Multimedia: Retinitis, CMV
References
[ CLOSE WINDOW ]

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Further Reading

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Keywords

cytomegalovirus retinitis, CMV retinitis

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Contributor Information and Disclosures

Author

Michael Altaweel, MD, FRCS(C), Associate Professor, Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health
Michael Altaweel, MD, FRCS(C) is a member of the following medical societies: American Academy of Ophthalmology and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

Matthew D Reed, MD, Fellow, Department of Ophthalmology and Visual Sciences, University of Wisconsin Clinical Science Center
Disclosure: Nothing to disclose.

Medical Editor

Vytautas A Pakainis, MD, Chief of Ophthalmology, Dorn Veterans Administration Medical Center, Professor of Ophthalmology, Ophthalmology, University of South Carolina School of Medicine
Vytautas A Pakainis, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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