CMV Retinitis

CMV Retinitis
SYMPTOMS Decreased central vision, Metamorphopsia, Visual field loss, Scotomas, Floaters, Flashes
There is strong correlation between symptoms of flashes and floaters in a patient with AIDS and the presence of CMV retinitis
SIGNS Mild anterior uveitis, Mild posterior uveitis, Posterior synechiae, Mild vitritis, Yellow-white fluffy and/or granular lesions adjacent to retinal vessels and associated with intraretinal hemorrhages (represents a full thickness retinal necrosis), Retinal edema, Retinal breaks, Retinal detachments, Cystoid macular edema, Optic nerve edema
Typically retinal signs will start in the periphery but will eventually end up involving the posterior pole
WORK-UP Pupils, Full eye exam with dilated retinal exam, Gonioscopy, OCT analysis of the macula, OCT analysis of the optic nerve, OCT-Angiography, Fluorescein Angiography, Indocyanine Green Angiography, Fundus Autofluorescence, Fundus photos, Infrared photos, B-scan ultrasound, Watzke-Allen test, Macular photostress test, Amsler grid
TREATMENT Refer to PCP ASAP for treatment of AIDS and improvement of CD4 count
Give take home Amsler grid in order to monitor for change
If patient presents with an anterior uveitis with or without posterior synechiae, the patient should be started on a topical steroid (Prednisolone acetate or Durezol) and a topical cycloplegic (refer to retinal specialist ASAP as patient will have retinal complications as well)
If patient presents with any evidence of CMV retinitis, refer to retinal specialist ASAP for further evaluation and treatment
FOLLOW-UP Patient should be monitored very closely every month while on treatment for CMV retinitis
Once the patient is no longer being treated by a retinal specialist and the retina/macula/optic nerve are stable, the patient should be seen back every 3-4 months
ADDITIONAL LAB | TESTS Viral load, CD4 count, CBC with differential, Polymerase chain reaction analysis of the vitreous and aqueous (most likely will be done by the retinal specialist)
ETIOLOGY The cytomegalovirus is an opportunistic infection that affects the retinal vasculature and spreads to the retinal tissue. CMV retinitis occurs in patients with AIDs and typically when the CD4 count is less than 50
DIFFERENTIAL DX HIV retinopathy, Ocular toxoplasmosis, Ocular syphilis, Acute retinal necrosis, Progressive outer retinal necrosis
NOTES Lesions that look like cotton wool spots but enlarge in size are highly suspicious for early CMV retinitis (especially in patients that are immunocompromised)
Despite improvement in therapeutics, patients with CMV retinitis end up still having a high mortality rate
CMV Retinitis: Fundus photo demonstrating extensive full thickness retinal necrosis