J Korean Ophthalmol Soc.  2016 Feb;57(2):316-323. 10.3341/jkos.2016.57.2.316.

Safety and Efficacy of Intravitreal Ganciclovir Injections More than 10 Times for Cytomegalovirus Retinitis

• Jang KH
• Heo JW

• KMID: 2213675
• DOI: http://doi.org/10.3341/jkos.2016.57.2.316

Abstract

PURPOSE
To study the treatment outcomes in patients who were administered multiple intravitreal ganciclovir injections more than 10 times alone without systemic anti-cytomegalovirus therapy for cytomegalovirus retinitis.
CASE SUMMARY
A 64-year-old man who underwent immunosuppressive therapy after thymectomy due to an invasive thymoma and pure red-cell aplasia, a 60-year-old woman who underwent chemotherapy after diagnosis of diffuse large B-cell lymphoma, a 49-year-old man with a history of bone marrow transplantation due to acute myeloid leukemia, a 29-year-old woman with dermatomyositis treated with oral steroids and cyclosporine, and a 47-year-old woman who received intravitreal dexamethasone implant injections, intravitreal and subtenon steroid injections due to Behcet's disease were diagnosed with cytomegalovirus retinitis. All patients showed systemic complications such as pancytopenia after systemic anti-cytomegalovirus therapy, and therefore, they were administered multiple intravitreal ganciclovir injections alone. Best-corrected visual acuities improved in all patients, except in one case, where viral lesions were observed in the fovea. Retinal hemorrhaging and infiltrative lesions decreased in all patients. No severe complication was observed during the injection and in the follow-up period.
CONCLUSIONS
Multiple intravitreal ganciclovir injections alone can be used as a treatment modality for cytomegalovirus retinitis to avoid the systemic side effects of systemic anti-cytomegalovirus therapy.

Keyword

Cytomegalovirus retinitis; Intravitreal ganciclovir injection; Multiple intravitreal ganciclovir injection

MeSH Terms

Adult
Bone Marrow Transplantation
Cyclosporine
Cytomegalovirus Retinitis*
Cytomegalovirus*
Dermatomyositis
Dexamethasone
Diagnosis
Drug Therapy
Female
Follow-Up Studies
Ganciclovir*
Humans
Intravitreal Injections
Leukemia, Myeloid, Acute
Lymphoma, B-Cell
Middle Aged
Pancytopenia
Red-Cell Aplasia, Pure
Retinaldehyde
Steroids
Thymectomy
Thymoma
Visual Acuity
Cyclosporine
Dexamethasone
Ganciclovir
Retinaldehyde
Steroids

Figure

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  Figure 1. Fundus photographs of left eye in case 1 patient. (A) Photograph showing whitish opaque lesions at the temporal side of retina. (B) Photograph of the same patients showing decreased lesion after intravitreal ganciclovir injection (cataract developing after the ganciclovir injection blocks the clear image).

• 

  Figure 2. Fundus photographs of both eye in case 2 patient. (A) Fundus photograph showing whitish retinal lesion and retinal hemorrhages along the inferior vascular arcade. (B) After intravitreal ganciclovir injection, the retinal lesion and hemorrhages were dimin-ished leaving a few white scars. (C) A whitish retinal lesion was spotted at inferior side of macula in the left eye. (D) Retinal lesion was disappeared leaving small retinal atrophy.

• 

  Figure 3. Fundus photographs of right eye in case 3 patient. (A) Fundus photograph showing whitish retinal lesion and vascular sheathing along the inferior vascular arcade. (B) Retinal lesion was disappeared after intravitreal ganciclovir injection leaving multiple chorioretinal atrophy.

• 

  Figure 4. Fundus photographs of right eye in case 4 patient. (A) Fundus photograph showing whitish retinal lesions mixed with hemorrhages along the superior vascular arcade. (B) Fundus photograph showing healed lesion and hemorrhages after intravitreal ganciclovir injection.

• 

  Figure 5. Fundus photographs of rignt eye in case 5 patient. (A) Fundus photograph showing multiple whitish retinal lesions and hemorrhage at peripheral retinal of all quadrants and peripheral laser markings after diagnostic vitrectomy. (B) Retinal lesions and hemorrhage was decreased after intravitreal ganciclovir injection.

Reference

1). Teoh SC, Wang PX, Wong EP. The epidemiology and incidence of cytomegalovirus retinitis in the HIV population in Singapore over 6 years. Invest Ophthalmol Vis Sci. 2012; 53:7546–52.

2). Gallant JE, Moore RD, Richman DD, et al. Incidence and natural history of cytomegalovirus disease in patients with advanced human immunodeficiency virus disease treated with zidovudine. The Zidovudine Epidemiology Study Group. J Infect Dis. 1992; 166:1223–7.

3). Miao H, Tao Y, Jiang YR, Li XX. Multiple intravitreal injections of ganciclovir for cytomegalovirus retinitis after stem-cell transplantation. Graefes Arch Clin Exp Ophthalmol. 2013; 251:1829–33.

4). Saidel MA, Berreen J, Margolis TP. Cytomegalovirus retinitis after intravitreous triamcinolone in an immunocompetent patient. Am J Ophthalmol. 2005; 140:1141–3.

5). Langner-Wegscheider BJ, Mura M, et al. Intravitreal ganciclovir in the management of non-AIDS-related human cytomegalovirus retinitis. Can J Ophthalmol. 2010; 45:157–60.

6). Teoh SC, Ou X, Lim TH. Intravitreal ganciclovir maintenance injection for cytomegalovirus retinitis: efficacy of a low-volume, intermediate-dose regimen. Ophthalmology. 2012; 119:588–95.

7). Foscarnet-Ganciclovir Cytomegalovirus Retinitis Trial: 5. Clinical features of cytomegalovirus retinitis at diagnosis. Studies of ocular complications of AIDS Research Group in collaboration with the AIDS Clinical Trials Group. Am J Ophthalmol. 1997; 124:141–57.

8). Kuppermann BD, Petty JG, Richman DD, et al. Correlation between CD4+ counts and prevalence of cytomegalovirus retinitis and human immunodeficiency virus-related noninfectious retinal vasculopathy in patients with acquired immunodeficiency syndrome. Am J Ophthalmol. 1993; 115:575–82.

9). Lalezari J, Lindley J, Walmsley S, et al. A safety study of oral valganciclovir maintenance treatment of cytomegalovirus retinitis. J Acquir Immune Defic Syndr. 2002; 30:392–400.

10). Jung D, Dorr A. Single-dose pharmacokinetics of valganciclovir in HIV- and CMV-seropositive subjects. J Clin Pharmacol. 1999; 39:800–4.

11). Mortality in patients with the acquired immunodeficiency syndrome treated with either foscarnet or ganciclovir for cytomegalovirus retinitis. Studies of Ocular Complications of AIDS Research Group, in collaboration with the AIDS Clinical Trials Group. N Engl J Med. 1992; 326:213–20.

12). Morbidity and toxic effects associated with ganciclovir or foscarnet therapy in a randomized cytomegalovirus retinitis trial. Studies of ocular complications of AIDS Research Group, in collaboration with the AIDS Clinical Trials Group. Arch Intern Med. 1995; 155:65–74.

13). Agarwal A, Kumari N, Trehan A, et al. Outcome of cytomegalovirus retinitis in immunocompromised patients without Human Immunodeficiency Virus treated with intravitreal ganciclovir injection. Graefes Arch Clin Exp Ophthalmol. 2014; 252:1393–401.

14). Choopong P, Tesavibul N, Rodanant N. Crystallization after intravitreal ganciclovir injection. Clin Ophthalmol. 2010; 4:709–11.

15). Kwun YK, Chae JB, Ham DI. Cinical manifestations and prognosis of cytomegalovirus retinitis. J Korean Ophthalmol Soc. 2010; 51:203–9.