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Use of the Ganciclovir Implant for Treating Cytomegalovirus Retinitis Secondary to Immunosuppression After Bone Marrow Transplantation
immunocompetent patients.4 Bilateral chorioretinitis caused by herpes simplex virus that manifests as multifocal choroiditis without vascular sheathing or hemorrhages has also been reported.5 In this case, polymerase chain reaction positivity is an interesting laboratory finding. Although positive polymerase chain reaction results cannot clarify whether a particular condition is caused by the manifestations of primary viral infection or recrudescent viral infection, there is strong evidence from the clinical manifestations and the course of the disease in our patient to correlate frosted branch angiitis with herpes simplex virus infection. The superior fundus location of the angiitis is difficult to explain, but it may be attributed to the early administration of acyclovir and methylprednisolone. This case shows that the use of molecular diagnos tic modalities in clinical practice may assist in diag nosing patients with atypical retinal vascular inflam matory diseases. REFERENCES 1. Ito Y, Nakano M, Kyu N, Takeushi M. Frosted branch angiitis in a child. Jpn J Clin Ophthalmol 1976;30:797-803. 2. Spaide RF, Vitale AT, Toth IR, Oliver JM. Frosted branch angiitis associated with cytomegalovirus retinitis. Am J Oph thalmol 1992;113:522-528. 3. Cunningham ET, Short GA, Irvine AR, Duker JS, Margolis TP. Acquired immunodeficiency syndrome-associated herpes simplex virus retinitis: clinical description and use of a polymerase chain reaction-based assay as a diagnostic tool. Arch Ophthalmol 1996;114:834-840. 4. Lewis ML, Gulbertson W W , Post JD, Miller D, Kokame GT, Dix RD. Herpes simplex virus type 1: a cause of the acute retinal necrosis syndrome. Ophthalmology 1989;96:875-878. 5. Grutzmacher RD, Henderson D, McDonald PJ, Coster DJ. Herpes simplex chorioretinitis in a healthy adult. Am J Ophthalmol 1983;96:788-796.
Use of the Ganciclovir Implant for Treating Cytomegalovirus Retinitis Secondary to Immunosuppression After Bone Marrow Transplantation P. F. McAuliffe, BS, M. James Hall, MD, H. Castro-Malaspina, MD, and M.-H. Heinemann, MD PURPOSE: To report a case in which we treated cytomegalovirus retinitis using an intravitreal ganciclovir sustained-release device in a patient negative for the human immunodeficiency virus, 702
with a history of myeloproliferative syndrome with myelofibrosis and profound immunosuppression after allogeneic bone marrow transplantation. METHODS: Case report. Review of medical rec ords and fundus photographs. RESULTS: After the ganciclovir device was im planted, the cytomegalovirus retinitis did not progress, and visual acuity improved. We removed the device 9 months after implantation. CONCLUSIONS: The ganciclovir sustained-re lease device may be useful for treating cytomegalo virus retinitis in patients without the acquired immunodeficiency syndrome who are profoundly immunosuppressed and fail conventional intrave nous therapy. If immune suppression is of limited duration, the device can be removed.
C
YTOMEGALOVIRUS RETINITIS AFFECTS AS MANY AS
40% of patients with acquired immunodeficiency syndrome,1 and it is a less common complication of chemotherapy and organ transplantation. 2 A 57-yearold woman diagnosed with myeloproliferative syn drome and myelofibrosis who was serologically nega tive for the human immunodeficiency virus had persistent and severe immunodeficiency after alloge neic bone marrow transplantation from an unrelated donor. Fourteen days after transplantation, the patient developed cytomegalovirus viremia that was treated with intravenous foscarnet after initial ganciclovir treatment failed. Seven months later, the patient complained of decreased vision in her right eye, which she described as a "veil." Best-corrected visual acuity was RE, 20/50. Examination of the fundus disclosed peripheral, feathery-white necrotizing reti nitis in the right eye. The superior lesions involved less than 10% of the retina in zones 2 and 3, outside the vascular arcades (Figure 1). Despite systemic foscarnet therapy that included a 2-week induction period, cytomegalovirus retinitis progressed. One month after diagnosing cytomegalovirus retinitis, we surgically implanted a ganciclovir susAccepted for publication Dec 13, 1996. Department of Ophthalmology, The New York Hospital, Cornell Medical Center (P.F.M., M.J.H., M.-H.H.); Bone Marrow Transplant Service (H.C.-M.) and Ophthalmology Service, Department of Surgery (M.-H.H.), Memorial Sloan-Kettering Cancer Center. Inquiries to M.-H. Heinemann, MD, Department of Ophthalmology, The New York Hospital, Cornell Medical Center, Starr 811, 525 E 68 St, New York, NY 10021; fax: (212) 746-8377.
AMERICAN JOURNAL OF OPHTHALMOLOGY
MAY
1997
Figure 1. Active cytomegalovirus retinitis in the right eye at the visit before insertion of the ganciclovir sustained-release device.
followed up the patient for 3 months, during which time cytomegalovirus did not progress. It has been our experience that ganciclovir devices can be left in the eye for prolonged periods without side effects. However, over time, complications such as implant extrusion and granulomatous inflamma tion related to the sutures and device are known to occur.4 Our patient's symptoms, as well as her improv ing level of immune competence, prompted us to remove the depleted implant. After removal, we found the implant to be devoid of ganciclovir.5 At the time of removal, our patient's CD4+ lymphocyte level was 75 cells/(xl, slightly above the level (50 cells/(xl or less) at which infection by cytomegalovirus usually occurs. While the patient's lymphocyte subset num bers improved after the unrelated-donor bone marrow transplantation, the functional activity of these cells remained abnormal, as assessed by response to non specific (phytohemagglutinin, concanavalin A) and specific (bacterial, fungal, and viral) mitogens. How ever, the patient's improving immune status was sufficient to prevent recurrence of cytomegalovirus retinitis. The ganciclovir sustained-release device may play a role in treating carefully selected patients with cyto megalovirus retinitis complicating illnesses other than HIV infection who either do not respond to or are intolerant of systemic antiviral therapy. REFERENCES
Figure 2. Eight months after pars plana insertion of the ganciclovir sustained-release device into the right eye, retinitis remained inactive.
tained-release device into the right eye without com plication.3 Two weeks postoperatively, visual acuity returned to 20/25, and the lesions became quiescent. Six weeks after implantation, foscarnet therapy was stopped because of dose-limiting renal toxicity and catheter-associated sepsis. During a period of 8 months, the cytomegalovirus retinitis lesions in the right eye remained inactive, and no new lesions were observed (Figure 2). Nine months postoperatively, the patient complained of irritation and discomfort upon eye movement, and the implant was removed. After performing an uncomplicated removal, we VOL.123, No. 5
1. Hoover DR, Saah AJ, Bacellar H, et al. Clinical manifestations of AIDS in the era of Pneumocystis prophylaxis: multicenter AIDS cohort study. N Engl J Med 1993;329:1922-1926. 2. Rahhal FM, Rosberger DF, Polsky B, Thoron L, Heinemann M.-H. Cytomegalovirus retinitis in a patient with a nor mal helper T-cell (CD4) count. Arch Ophthalmol 1993;111: 1325-1326. 3. Martin DF, Parks D], Mellow SD, et al. Treatment of cytomegalovirus retinitis with an intraocular sustained-release ganciclovir implant. Arch Ophthalmol 1994;112:1531-1539. 4. Morley MG, Duker JS, Ashton P, Robinson MR. Replacing ganciclovir implants. Ophthalmology 1995;102:388-392. 5. Charles NC, Steiner GC. Ganciclovir intraocular implant: a clinicopathologic study. Ophthalmology 1996;103:416-421.
Sarcoidosis Manifesting as Uveitis and Menometrorrhagia Mark D. Sherman, MD, Keith J. Pince, MD, and Shirin M. Farahmand, MD PURPOSE: To report a rare systemic manifestation
BRIEF REPORTS
703
Use of the Ganciclovir Implant for Treating Cytomegalovirus Retinitis Secondary to Immunosuppression After Bone Marrow Transplantation P. F. McAuliffe, BS, M. James Hall, MD, H. Castro-Malaspina, MD, and M.-H. Heinemann, MD PURPOSE: To report a case in which we treated cytomegalovirus retinitis using an intravitreal ganciclovir sustained-release device in a patient negative for the human immunodeficiency virus, 702
with a history of myeloproliferative syndrome with myelofibrosis and profound immunosuppression after allogeneic bone marrow transplantation. METHODS: Case report. Review of medical rec ords and fundus photographs. RESULTS: After the ganciclovir device was im planted, the cytomegalovirus retinitis did not progress, and visual acuity improved. We removed the device 9 months after implantation. CONCLUSIONS: The ganciclovir sustained-re lease device may be useful for treating cytomegalo virus retinitis in patients without the acquired immunodeficiency syndrome who are profoundly immunosuppressed and fail conventional intrave nous therapy. If immune suppression is of limited duration, the device can be removed.
C
YTOMEGALOVIRUS RETINITIS AFFECTS AS MANY AS
40% of patients with acquired immunodeficiency syndrome,1 and it is a less common complication of chemotherapy and organ transplantation. 2 A 57-yearold woman diagnosed with myeloproliferative syn drome and myelofibrosis who was serologically nega tive for the human immunodeficiency virus had persistent and severe immunodeficiency after alloge neic bone marrow transplantation from an unrelated donor. Fourteen days after transplantation, the patient developed cytomegalovirus viremia that was treated with intravenous foscarnet after initial ganciclovir treatment failed. Seven months later, the patient complained of decreased vision in her right eye, which she described as a "veil." Best-corrected visual acuity was RE, 20/50. Examination of the fundus disclosed peripheral, feathery-white necrotizing reti nitis in the right eye. The superior lesions involved less than 10% of the retina in zones 2 and 3, outside the vascular arcades (Figure 1). Despite systemic foscarnet therapy that included a 2-week induction period, cytomegalovirus retinitis progressed. One month after diagnosing cytomegalovirus retinitis, we surgically implanted a ganciclovir susAccepted for publication Dec 13, 1996. Department of Ophthalmology, The New York Hospital, Cornell Medical Center (P.F.M., M.J.H., M.-H.H.); Bone Marrow Transplant Service (H.C.-M.) and Ophthalmology Service, Department of Surgery (M.-H.H.), Memorial Sloan-Kettering Cancer Center. Inquiries to M.-H. Heinemann, MD, Department of Ophthalmology, The New York Hospital, Cornell Medical Center, Starr 811, 525 E 68 St, New York, NY 10021; fax: (212) 746-8377.
AMERICAN JOURNAL OF OPHTHALMOLOGY
MAY
1997
Figure 1. Active cytomegalovirus retinitis in the right eye at the visit before insertion of the ganciclovir sustained-release device.
followed up the patient for 3 months, during which time cytomegalovirus did not progress. It has been our experience that ganciclovir devices can be left in the eye for prolonged periods without side effects. However, over time, complications such as implant extrusion and granulomatous inflamma tion related to the sutures and device are known to occur.4 Our patient's symptoms, as well as her improv ing level of immune competence, prompted us to remove the depleted implant. After removal, we found the implant to be devoid of ganciclovir.5 At the time of removal, our patient's CD4+ lymphocyte level was 75 cells/(xl, slightly above the level (50 cells/(xl or less) at which infection by cytomegalovirus usually occurs. While the patient's lymphocyte subset num bers improved after the unrelated-donor bone marrow transplantation, the functional activity of these cells remained abnormal, as assessed by response to non specific (phytohemagglutinin, concanavalin A) and specific (bacterial, fungal, and viral) mitogens. How ever, the patient's improving immune status was sufficient to prevent recurrence of cytomegalovirus retinitis. The ganciclovir sustained-release device may play a role in treating carefully selected patients with cyto megalovirus retinitis complicating illnesses other than HIV infection who either do not respond to or are intolerant of systemic antiviral therapy. REFERENCES
Figure 2. Eight months after pars plana insertion of the ganciclovir sustained-release device into the right eye, retinitis remained inactive.
tained-release device into the right eye without com plication.3 Two weeks postoperatively, visual acuity returned to 20/25, and the lesions became quiescent. Six weeks after implantation, foscarnet therapy was stopped because of dose-limiting renal toxicity and catheter-associated sepsis. During a period of 8 months, the cytomegalovirus retinitis lesions in the right eye remained inactive, and no new lesions were observed (Figure 2). Nine months postoperatively, the patient complained of irritation and discomfort upon eye movement, and the implant was removed. After performing an uncomplicated removal, we VOL.123, No. 5
1. Hoover DR, Saah AJ, Bacellar H, et al. Clinical manifestations of AIDS in the era of Pneumocystis prophylaxis: multicenter AIDS cohort study. N Engl J Med 1993;329:1922-1926. 2. Rahhal FM, Rosberger DF, Polsky B, Thoron L, Heinemann M.-H. Cytomegalovirus retinitis in a patient with a nor mal helper T-cell (CD4) count. Arch Ophthalmol 1993;111: 1325-1326. 3. Martin DF, Parks D], Mellow SD, et al. Treatment of cytomegalovirus retinitis with an intraocular sustained-release ganciclovir implant. Arch Ophthalmol 1994;112:1531-1539. 4. Morley MG, Duker JS, Ashton P, Robinson MR. Replacing ganciclovir implants. Ophthalmology 1995;102:388-392. 5. Charles NC, Steiner GC. Ganciclovir intraocular implant: a clinicopathologic study. Ophthalmology 1996;103:416-421.
Sarcoidosis Manifesting as Uveitis and Menometrorrhagia Mark D. Sherman, MD, Keith J. Pince, MD, and Shirin M. Farahmand, MD PURPOSE: To report a rare systemic manifestation
BRIEF REPORTS
703