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Grand Ward Round

Grand Ward Round. Tan Tock Seng Hospital The Eye Institute 05/07/07. History. 66 year old Indian Female Past medical hx: SLE dx 2000 - f/u TTSH RAI. - Had recent IV cyclophosphamide 800mg x 6 doses last 6 months.

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Grand Ward Round

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  1. Grand Ward Round Tan Tock Seng Hospital The Eye Institute 05/07/07

  2. History 66 year old Indian Female Past medical hx: • SLE dx 2000 - f/u TTSH RAI. - Had recent IV cyclophosphamide 800mg x 6 doses last 6 months. - Also on oral prednisolone previously on 30 mg bd, reduced to 40 mg om in feb 07 in view of CMV gastritis. • Type II diabetes on OHGA • Hypertension • Hyperlipidaemia

  3. History Was seen in eye clinic for on 22/06/07 for follow-up on: • Left BRVO s/p sectoral laser in NUH 3-4 yrs ago 2) SLE not on plaquenil, on steroids • Right Phaco/IOL in Mar 06 • Left macular scar

  4. Examination • Visual acuity Right eye: 6/12 Left eye: CF 1 feet. • GAT • Anterior segment examination Right eye: PCIOL, cornea clear, AC deep quiet, retrolental vitreal cells ++ Left eye: NS 2+, AC and retrolental quiet 19 18

  5. Differential diagnosis • Posterior uveitis ? Cause - CMV retinitis - toxoplasmosis/ TB/ sarcoidosis/ syphilis • Acute retinal necrosis • SLE related retinal occlusive vasculopathy • Masquerade syndromes

  6. Periphlebitis Sarcoidosis Syphilis Pars planitis Sickle cell retinopathy Behcet disease Arteritis Giant cell arteritis Polyarthritis nodosum SLE ARN Behcet disease Retinal Vasculitis

  7. Investigation • Full blood counts, renal panel, liver function tests normal • ESR 52 • CD4/ CD8 Panel - CD 4 count 22 (25-50) - CD4/ CD8 Ratio 0.46 (0.50 – 2.50) • Vitreous tap for TB negative, for tetraplex unfortunately insufficient specimen.

  8. Treatment • Working diagnosis at this point in times likely CMV retinitis Treatment: • Retinal laser barrier to right eye on day of admission. • Intravitreal Ganciclovir 2mg/0.04 ml was given post vitreous tap. • Sytemic IV ganciclovir 350mg bd • G. PF Q1H RE • G homatropine 2% bd RE

  9. Post Barrier Laser treatement

  10. Progress • Referred to RAI - suggest reduce prednisolone to 15 mg om. • Patient had involvement of left eye on day 2 of admission. - 2 isolated areas of retinitis in the supero-temporal region. - Intravitreal ganciclovir 2mg/0.04ml given BE on 25/06/07. • VA remains fairly similar in both eyes with no worsening.

  11. Progress ID suggests: If cost is not an issue… i) Induction therapy: IV ganciclovir 5mg/kg bd followed by oral valganciclovir 900mg bd (21d) 72 hrs after starting IV therapy. -> cost $6000 per month! ii) Following induction, need maintenance therapy to prevent relapse. Dose valganciclovir at 900mg/day. • Decision to stop maintenance therapy will be dependent on clinical response. • *In HIV pts who cannot afford oral valganciclovir or IV ganciclovir, they will do well on intravitreal ganciclovir only for maintenance therapy i.e. until no evidence of active infection.* • Discussed with family, decision made for intravitreal ganciclovir only for maintenance therapy.

  12. Literature review Clinical Characteristics and Outcomes of Cytomegalovirus Retinitis in Persons without Human Immunodeficiency Virus infection Am J Ophthalmol. 2004 Sep;138(3):338-46

  13. Literature review • Aim: To describe the characteristics and outcomes of patients with CMV retinitis in the absence of HIV infection • Methods: Retrospective cohort study of 18 patients (30 eyes) between 1984 and 2003 in a tertiary centre

  14. Literature review • 5/18 patients receiving immunosuppresive therapy for autoimmune disease • 11/30 eyes (37%) VA of 6/15 or worse • 12 patients (67%) had bilateral involvement, 10 at initial presentation and develop on f/u.

  15. Literature review

  16. Literature review • Results: • Clinical characteristic retinitis of CMV patients without HIV similar to those with HIV. -necrotizing retinitis, often with intraretinal haemorrhage, with either granular or oedematous borders • Rates of visual loss to 20/50 (6/15) 17% per eye-year Rates of visual loss to 20/200 (6/60) 14% per eye-year • Incidence of RD 3.7% per eye-year • With reduction of immunosuppressives, 10 patients (56%) who discontinued anti-CMV therapy remained free of retinitis progression.

  17. Conclusion • CMV retinitis patients without HIV had a similar clinical course similar to that in patients with AIDS treated with HAART - except RD incidence lower • Substantial number of patients no longer required long term anti-CVM therapy after adjustment of immunomodulatory therapy.

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