Comparison of treatment regimens for cytomegalovirus retinitis in patients with AIDS in the era of highly active antiretroviral therapy

Ophthalmology. 2013 Jun;120(6):1262-70. doi: 10.1016/j.ophtha.2012.11.023. Epub 2013 Feb 16.

Abstract

Purpose: To describe the outcomes of different treatment approaches for cytomegalovirus (CMV) retinitis in the era of highly active antiretroviral therapy (HAART).

Design: Prospective cohort study, the Longitudinal Study of the Ocular Complications of AIDS.

Participants: A total of 250 patients with CMV retinitis and a CD4+ T-cell count <100 cells/μl (n = 221) at enrollment or incident retinitis (n = 29) during cohort follow-up.

Methods: The effects of systemic therapy (vs. intraocular therapy only) on systemic outcomes and the effect of intraocular therapies (ganciclovir implants, intravitreal injections) on ocular outcomes were evaluated.

Main outcome measures: Mortality, CMV dissemination, retinitis progression, and treatment side effects.

Results: Regimens containing systemic anti-CMV therapy were associated with a 50% reduction in mortality (adjusted hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.3-0.7; P = 0.006), a 90% reduction in new visceral CMV disease (adjusted HR, 0.1; 95% CI, 0.04-0.4; P = 0.004), and among those with unilateral CMV retinitis at presentation, an 80% reduction in second eye disease (adjusted HR, 0.2; 95% CI, 0.1-0.5; P = 0.0005) when compared with those using only intraocular therapy (implants or injections). Compared with systemic treatment only, regimens containing intravitreal injections had greater rates of retinitis progression (adjusted HR, 3.4; P = 0.004) and greater visual field loss (for loss of one half of the normal field, adjusted HR, 5.5; P < 0.01). Intravitreal implants were not significantly better than systemic therapy (adjusted HR for progression, 0.5; P = 0.26; adjusted HR for loss of one half of the visual field, 0.5; P = 0.45), but the sample size was small. Hematologic and renal side effect rates were similar between those groups with and without systemic anti-CMV therapy. The rate of endophthalmitis was 0.017 per eye-year (EY) (95% CI, 0.006-0.05) among those treated with intravitreal injections and 0.01 per EY (95% CI, 0.002-0.04) among those treated with an implant.

Conclusions: In the HAART era, systemic anti-CMV therapy, while there is immune compromise, seems to provide benefits in terms of longer survival and decreased CMV dissemination.

Financial disclosure(s): Proprietary or commercial disclosure may be found after the references.

Publication types

  • Comparative Study
  • Multicenter Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • AIDS-Related Opportunistic Infections / drug therapy*
  • AIDS-Related Opportunistic Infections / immunology
  • AIDS-Related Opportunistic Infections / physiopathology
  • Adult
  • Antiretroviral Therapy, Highly Active*
  • Antiviral Agents / administration & dosage*
  • CD4 Lymphocyte Count
  • Cytomegalovirus Retinitis / drug therapy*
  • Cytomegalovirus Retinitis / physiopathology
  • Drug Implants
  • Female
  • Follow-Up Studies
  • Ganciclovir / administration & dosage*
  • Ganciclovir / analogs & derivatives
  • Humans
  • Intravitreal Injections
  • Male
  • Middle Aged
  • Prospective Studies
  • T-Lymphocytes / immunology
  • Valganciclovir
  • Visual Acuity / physiology
  • Visual Fields / physiology

Substances

  • Antiviral Agents
  • Drug Implants
  • Valganciclovir
  • Ganciclovir