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Acyclovir
5%
2/39
Ganciclovir
79%
31/39
Observation
3%
1/39
Pentamidine
8%
3/39
Trimethoprim-sulfamethoxazole
Select Answer to see Preferred Response
This patient likely has cytomegalovirus (CMV) retinitis in the setting of acquired immunodeficiency syndrome (AIDS) as demonstrated by the presence of opportunistic infections (oral thrush indicating a candidal infection), vision loss, and characteristic retinal findings (white, fluffy retinal necrosis with overlying retinal hemorrhages). CMV retinitis is treated with both intravenous and intravitreal ganciclovir (in addition to antiretroviral therapy (ART)). CMV retinitis is caused by CMV and predominantly occurs in people with immunosuppression (patients with AIDS). Common symptoms include decreased vision, floaters, blurred vision, or photopsia (flashes of light) but may be variable depending on the location and size of the lesions. The retinitis classically presents as fluffy retinal infiltrates and hemorrhagic necrotizing retinitis that follows the vasculature, which creates the “scrambled eggs and ketchup” picture. Full-thickness necrosis of the retina can eventually lead to retinal detachment, vitritis (inflammation of the vitreous), and rarely, inflammation of the anterior chamber (indicated by cell and flare in the anterior chamber). Diagnosis is often made clinically, and treatment involves systemic and intravitreal ganciclovir along with treatment of the underlying AIDS. Port et al. studied the incidence and treatment of CMV retinitis. The authors found that widespread implementation of ART has decreased the incidence of CMV retinitis among AIDS patients, and has improved visual outcomes in those affected. The authors recommend that all patients should be monitored for sight-threatening complications of CMV retinitis that require specific interventions, including retinal detachment and immune recovery uveitis.Figure/Illustration A is a fundus photo showing fluffy-white exudates (arrows) and perivascular hemorrhage (chevron) characteristic of CMV retinitis.Incorrect Answers: Answer 1: Acyclovir is indicated in patients with necrotizing herpetic retinopathy, which can appear similar to CMV retinitis. However, patients often have a rapidly progressive course with significant inflammation in the anterior chamber, which is not the case here. In addition, HSV-associated retinitis often occurs in the elderly population who are immunocompetent. Answer 3: Observation and ART is the usual course of action for patients with HIV retinopathy, which is the most common ocular manifestation of HIV infection. The most notable finding is the cotton wool spot, which can be distinguished from infectious retinitis by its small size and lack of significant hemorrhage. Answer 4: Pentamidine is one of the treatments for pneumocystis choroiditis, which presents with deep orange lesions that generally do not affect vision. This patient has significant visual loss resulting in a relative afferent pupillary defect. Answer 5: Trimethoprim-sulfamethoxazole (TMP-SMX) is one of the first-line treatments for toxoplasmosis, which can cause necrotizing retinitis similar to that of CMV retinitis. Ocular toxoplasmosis presents with necrotizing retinitis with associated vitreous and anterior chamber inflammation. The presence of chorioretinal scarring (with surrounding pigmentation) can effectively differentiate this disease from CMV retinitis. Bullet Summary: Ganciclovir is the treatment for cytomegalovirus retinitis.
5.0
(4)
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