Cystoid macular oedema and cytomegalovirus retinitis in patients with HIV disease treated with highly active antiretroviral therapy

Background-Although cystoid macular oedema (CMO) is a rare cause of visual loss in AIDS related cytomegalovirus (CMV) retinitis, nine cases are report ed of CMO occurring in HIV infected patients with a prior diagnosis of CMV who were receiving highly active antiretroviral therapy (HAART). Methods-Medical and ophthalmological records of nine AIDS patients with ina ctive CMV retinitis were retrospectively analysed. Ophthalmic examination d ata, laboratory findings, and the systemic antiviral treatment were studied . Ophthalmic examination included visual acuity, anterior chamber flare mea sured with the laser flare cell meter (LCFM),vitreous haze quantification a ccording to the Nussenblatt grading system, and fluorescein angiography. Results-Nine HIV infected patients, eight men and one woman, mean age 39 ye ars (range 29-53 years) presented with inactive CMV retinitis and CMO. On f luorescein angiography, CMO was present only in eyes (14 eyes) with signs o f previous CMV retinitis. CMV retinitis was inactive in all of them. Visual acuity ranged from 20/200 to 20/30. In 10 eyes with CMV retinitis, anterio r chamber flare measured with the LCFM ranged from 18.5 to 82 photons/ms (m ean 35.42 ph/ms). A significant vitreous inflammation (1.5+) was observed i n eight eyes. All patients had been treated with anti-CMV drugs for a mean period of 18 months (range 12-36 months). All nine patients received HAART with a combination of two nucleotide analogue reverse transcriptase inhibit ors and one protease inhibitor for a mean period of 14 months (range 9-18 m onths). The HIV viral load was below detectable levels (<200 copies/ml) in eight patients and low (3215 copies/ml) in one. At the time of CMO, the med ian CD4+ lymphocyte count was 232 cells x 10(6)/l (range 99-639). Conclusion-In AIDS patients, the usual absence of intraocular inflammation in eyes affected by CMV retinitis has been tentatively explained by the pro found cellular immunodeficiency. In these patients, treated with HAART, CD4 + counts were increased for several months (mean 14 months). In their eyes, CMV retinitis was associated with significant ocular inflammation and CMO. These findings could be related to the restoration of immune competence af ter HAART as recently shown.