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Treatment of Cytomegalovirus Optic Neuritis With Dihydroxy Propoxymethyl Guanine
Vol. 102, No.4
Letters to the Journal
Figure (Amano and associates). Punched-out, oval areas of choroidal atrophy. route to the eye for a number of neurotropic viruses.
References 1. Pavan-Langston, D.: Varicella-zoster ophthalmicus. Int. Ophthalmol. Clin. 15:171, 1975. 2. Ostler, H. 5., and Thygeson, P.: The ocular manifestations of herpes zoster, varicella, infectious mononucleosis, and cytomegalovirus disease. Surv. Ophthalmol. 21:148, 1976. 3. Naumann, G., Gass, J. D. M., and Font, R. L.: Histopathology of herpes zoster ophthalmicus. Am. J. Ophthalmol. 65:533, 1968. 4. O'Connor, G. R.: Herpes zoster uveitis. In Kraus-Mackiw, E., and O'Connor, G. R. (eds.): Uveitis. Pathophysiology and Therapy. New York, Thieme-Stratton, 1983, p. 56. 5. Lincoff, H. A., Wise, G. N., and Romaine, H. H.: Total detachment and reattachment of the retina in herpes zoster ophthalmicus. Am. J. Ophthalmol. 41:253, 1956.
533
Cytomegalovirus retinitis is a major cause of visual loss in the acquired immune deficiency syndrome.' Although concomitant peripapillary involvement is common, severe optic nerve involvement with obscuration of optic disk vessels is less frequent and accompanies advanced retinal disease. Seventeen patients with AIDS and cytomegalovirus retinitis have been treated with the antiviral drug, dihydroxy propoxymethyl guanine, with encouraging results.P" However, patients with documented optic nerve involvement had poor visual results despite dihydroxy propoxymethyl guanine treatment. We have examined a patient with cytomegalovirus retinitis with severe optic nerve disease and an afferent pupillary defect who showed improvement in visual acuity and optic nerve findings and reversal of the afferent pupillary defect after treatment with dihydroxy propoxymethyl guanine. In March 1986, a 32-year-old homosexual man with a history of Pneumocystis carinii pneumonia and positive blood cultures for Mycobacterium avium-intracel/ulare was examined for manifestations of disseminated cytomegalovirus disease (positive urine and buffy-coat cultures and cytomegalovirus adrenalitis). On April 17, the patient complained of decreasing vision in his left eye and on April 22 an ophthalmic evaluation disclosed a best corrected visual acuity of R.E.: 20/20 and L.E.: 20/400. There was a 2+ left afferent pupillary defect with 80% subjective red desaturation. There was no anterior reaction in either eye, but 1+ cells were noted in the anterior vitreous of the left eye. In the right eye, ophthalmoscopic findings were normal except for two cotton-
Treatment of Cytomegalovirus Optic Neuritis With Dihydroxy Propoxymethyl Guanine M. R. Robinson, M.D., B. W. Streeten, M.D., G. R. Hampton, M.D., E. C. Siebold, M.D., and C. Taylor-Findlay, B.S. Department of Ophthalmology, State University of New York Health Science Center. Inquiries to Barbara W. Streeten, M.D., Department of Pathology, State University of New York Health Science Center at Syracuse, Syracuse, NY 13210.
Fig. 1 (Robinson and associates). Pretreatment photograph shows severe cytomegalovirus optic neuritis with involvement of inferior retina.
October, 1986
AMERICAN JOURNAL OF OPHTHALMOLOGY
534
for the improved vision in our patient was his better initial visual acuity (20/400), whereas the other patients had visual acuities of counting fingers or worse. Further observations are necessary to explore the usefulness of this new therapeutic agent for cytomegalovirus retinal and optic nerve disease.
References
Fig. 2 (Robinson and associates). Fundus appearance 21 days after start of treatment shows marked decrease in optic nerve edema and more distinct optic disk margins.
wool spots. The left eye showed extensive inferior cytomegalovirus retinitis with sparing of the central macular area, and severe optic nerve involvement with obscuration of optic disk vessels (Fig. 1). The central visual loss was thought to be secondary to optic nerve involvement since the macula showed no edema on biomicroscopy. On April 26, dihydroxy propoxymethyl guanine treatment was started. The patient received 150 mg (2.5 mglkg of body weight) intravenously every eight hours. Cytomegalovirus was cultured from buffy-coat and urine. The patient noted subjective improvement in vision after seven days. On day 11, his visual acuity was R.E.: 20/20 and L.E.: 20/40. The left eye showed a 1 + afferent pupillary defect with less optic disk edema and improved visibility of optic disk vessels. The retina showed less hemorrhage and exudate. On day 21, visual acuity in the left eye was 20/30 +2 with no afferent pupillary defect and a subjective red desaturation of 30%. No new progression was noted, and atrophic retinal changes were seen in areas of previous active infection (Fig. 2). Cytomegalovirus cultures were negative by day 11, and on day 21 the patient was discharged on a regimen of maintenance therapy. Of the 17 previously described patients treated with dihydroxy propoxymethyl guanine for cytomegalovirus retinitis.P" three had documented optic nerve involvement.P-" All failed to show visual improvement. One patient had regression of the retinitis but poor vision because of optic atrophy. 2 A possible explanation 0
1. Palestine, A. G., Rodrigues, M. M., Macher, A. M., Chi-Chao, c.. Lane, H. c.. Fauci, A. 5., Masur, H., Longo, D., Reichert, C. M., Steis, R., Rook, A. H., and Nussenblatt, R. B.: Ophthalmic involvement in acquired immunodeficiency syndrome. Ophthalmology 91:1092, 1984. 2. Rosecan, L. R., Stahl-Bayliss, C. M., Kalman, C. M., and Laskin, O. L.: Antiviral therapy for cytomegalovirus retinitis in AIDS with dihydroxy propoxymethyl guanine. Am. J. Ophthalmol. 101:405, 1986. 3. Palestine, A. G., Stevens, G., Jr., Lane, H. c., Masur, H., Fujikawa, L. 5., Nussenblatt, R. B., Rook, A. H., Manischewitz, J., Baird, B., Megill, M., Quinnan, G., Gelmann, E., and Fauci, A. 5.: Treatment of cytomegalovirus retinitis with dihydroxy propoxymethyl guanine. Am. J. Ophthalmol. 101:95, 1986. 4. Felsenstein, D., D'Amico, D. J., Hirsch, M.S., Neumeyer, D. A., Cederberg, D. M., de Miranda, P., and Schooley, R. T.: Treatment of cytomegalovirus retinitis with 9-[2-hydroxy-1-(hydroxymethyl) ethoxymethyl] guanine. Ann. Intern. Med. 103:377, 1985. 5. Bach, M. c.. Bagwell, S. P., Knapp, N. P., Davis, K. M., and Hedstrom, P. 5.: 9-(l,3-Dihydroxy2-propoxymethyl) guanine for cytomegalovirus infections in patients with the acquired immunodeficiency syndrome. Ann. Intern. Med. 103:381, 1985.
Periorbital Cellulitis After Eyebrow Tweezing Michael S. Insler, M.D., and Susan Zatzkis, B. $. Department of Ophthalmology, Tulane University Medical School. Inquiries to Michael S. Insler, M.D., 1430 Tulane Avo, New Orleans, LA 70112.
Periorbital cellulitis is an acute spreading infection of the skin and subcutaneous tissues.P There is usually a history of trauma to
Letters to the Journal
Figure (Amano and associates). Punched-out, oval areas of choroidal atrophy. route to the eye for a number of neurotropic viruses.
References 1. Pavan-Langston, D.: Varicella-zoster ophthalmicus. Int. Ophthalmol. Clin. 15:171, 1975. 2. Ostler, H. 5., and Thygeson, P.: The ocular manifestations of herpes zoster, varicella, infectious mononucleosis, and cytomegalovirus disease. Surv. Ophthalmol. 21:148, 1976. 3. Naumann, G., Gass, J. D. M., and Font, R. L.: Histopathology of herpes zoster ophthalmicus. Am. J. Ophthalmol. 65:533, 1968. 4. O'Connor, G. R.: Herpes zoster uveitis. In Kraus-Mackiw, E., and O'Connor, G. R. (eds.): Uveitis. Pathophysiology and Therapy. New York, Thieme-Stratton, 1983, p. 56. 5. Lincoff, H. A., Wise, G. N., and Romaine, H. H.: Total detachment and reattachment of the retina in herpes zoster ophthalmicus. Am. J. Ophthalmol. 41:253, 1956.
533
Cytomegalovirus retinitis is a major cause of visual loss in the acquired immune deficiency syndrome.' Although concomitant peripapillary involvement is common, severe optic nerve involvement with obscuration of optic disk vessels is less frequent and accompanies advanced retinal disease. Seventeen patients with AIDS and cytomegalovirus retinitis have been treated with the antiviral drug, dihydroxy propoxymethyl guanine, with encouraging results.P" However, patients with documented optic nerve involvement had poor visual results despite dihydroxy propoxymethyl guanine treatment. We have examined a patient with cytomegalovirus retinitis with severe optic nerve disease and an afferent pupillary defect who showed improvement in visual acuity and optic nerve findings and reversal of the afferent pupillary defect after treatment with dihydroxy propoxymethyl guanine. In March 1986, a 32-year-old homosexual man with a history of Pneumocystis carinii pneumonia and positive blood cultures for Mycobacterium avium-intracel/ulare was examined for manifestations of disseminated cytomegalovirus disease (positive urine and buffy-coat cultures and cytomegalovirus adrenalitis). On April 17, the patient complained of decreasing vision in his left eye and on April 22 an ophthalmic evaluation disclosed a best corrected visual acuity of R.E.: 20/20 and L.E.: 20/400. There was a 2+ left afferent pupillary defect with 80% subjective red desaturation. There was no anterior reaction in either eye, but 1+ cells were noted in the anterior vitreous of the left eye. In the right eye, ophthalmoscopic findings were normal except for two cotton-
Treatment of Cytomegalovirus Optic Neuritis With Dihydroxy Propoxymethyl Guanine M. R. Robinson, M.D., B. W. Streeten, M.D., G. R. Hampton, M.D., E. C. Siebold, M.D., and C. Taylor-Findlay, B.S. Department of Ophthalmology, State University of New York Health Science Center. Inquiries to Barbara W. Streeten, M.D., Department of Pathology, State University of New York Health Science Center at Syracuse, Syracuse, NY 13210.
Fig. 1 (Robinson and associates). Pretreatment photograph shows severe cytomegalovirus optic neuritis with involvement of inferior retina.
October, 1986
AMERICAN JOURNAL OF OPHTHALMOLOGY
534
for the improved vision in our patient was his better initial visual acuity (20/400), whereas the other patients had visual acuities of counting fingers or worse. Further observations are necessary to explore the usefulness of this new therapeutic agent for cytomegalovirus retinal and optic nerve disease.
References
Fig. 2 (Robinson and associates). Fundus appearance 21 days after start of treatment shows marked decrease in optic nerve edema and more distinct optic disk margins.
wool spots. The left eye showed extensive inferior cytomegalovirus retinitis with sparing of the central macular area, and severe optic nerve involvement with obscuration of optic disk vessels (Fig. 1). The central visual loss was thought to be secondary to optic nerve involvement since the macula showed no edema on biomicroscopy. On April 26, dihydroxy propoxymethyl guanine treatment was started. The patient received 150 mg (2.5 mglkg of body weight) intravenously every eight hours. Cytomegalovirus was cultured from buffy-coat and urine. The patient noted subjective improvement in vision after seven days. On day 11, his visual acuity was R.E.: 20/20 and L.E.: 20/40. The left eye showed a 1 + afferent pupillary defect with less optic disk edema and improved visibility of optic disk vessels. The retina showed less hemorrhage and exudate. On day 21, visual acuity in the left eye was 20/30 +2 with no afferent pupillary defect and a subjective red desaturation of 30%. No new progression was noted, and atrophic retinal changes were seen in areas of previous active infection (Fig. 2). Cytomegalovirus cultures were negative by day 11, and on day 21 the patient was discharged on a regimen of maintenance therapy. Of the 17 previously described patients treated with dihydroxy propoxymethyl guanine for cytomegalovirus retinitis.P" three had documented optic nerve involvement.P-" All failed to show visual improvement. One patient had regression of the retinitis but poor vision because of optic atrophy. 2 A possible explanation 0
1. Palestine, A. G., Rodrigues, M. M., Macher, A. M., Chi-Chao, c.. Lane, H. c.. Fauci, A. 5., Masur, H., Longo, D., Reichert, C. M., Steis, R., Rook, A. H., and Nussenblatt, R. B.: Ophthalmic involvement in acquired immunodeficiency syndrome. Ophthalmology 91:1092, 1984. 2. Rosecan, L. R., Stahl-Bayliss, C. M., Kalman, C. M., and Laskin, O. L.: Antiviral therapy for cytomegalovirus retinitis in AIDS with dihydroxy propoxymethyl guanine. Am. J. Ophthalmol. 101:405, 1986. 3. Palestine, A. G., Stevens, G., Jr., Lane, H. c., Masur, H., Fujikawa, L. 5., Nussenblatt, R. B., Rook, A. H., Manischewitz, J., Baird, B., Megill, M., Quinnan, G., Gelmann, E., and Fauci, A. 5.: Treatment of cytomegalovirus retinitis with dihydroxy propoxymethyl guanine. Am. J. Ophthalmol. 101:95, 1986. 4. Felsenstein, D., D'Amico, D. J., Hirsch, M.S., Neumeyer, D. A., Cederberg, D. M., de Miranda, P., and Schooley, R. T.: Treatment of cytomegalovirus retinitis with 9-[2-hydroxy-1-(hydroxymethyl) ethoxymethyl] guanine. Ann. Intern. Med. 103:377, 1985. 5. Bach, M. c.. Bagwell, S. P., Knapp, N. P., Davis, K. M., and Hedstrom, P. 5.: 9-(l,3-Dihydroxy2-propoxymethyl) guanine for cytomegalovirus infections in patients with the acquired immunodeficiency syndrome. Ann. Intern. Med. 103:381, 1985.
Periorbital Cellulitis After Eyebrow Tweezing Michael S. Insler, M.D., and Susan Zatzkis, B. $. Department of Ophthalmology, Tulane University Medical School. Inquiries to Michael S. Insler, M.D., 1430 Tulane Avo, New Orleans, LA 70112.
Periorbital cellulitis is an acute spreading infection of the skin and subcutaneous tissues.P There is usually a history of trauma to