Immune recovery uveitis in HIV patients with cytomegalovirus retinitis in the era of HAART therapy—a 5-year study from Singapore

Abstract

BackgroundThe aim of this study is to analyse the clinical features of HIV patients with cytomegalovirus retinitis (CMVR) developing immune recovery uveitis (IRU) while on highly active antiretroviral therapy (HAART) and to identify the risk factors, visual outcomes and complications of IRU.ResultsMajority (n = 26, 86.7 %) of patients were male, with 76.7 % (n = 23) of patients having bilateral disease. Twenty-seven eyes (50.9 %) had both anterior uveitis and vitritis. The median CD4 at IRU was 210 cells/μL (IQR 140–279), with 86.7 % having CD4 >100 cells/μL. The median duration from initiation of HAART to IRU was significantly different between those <50 years old (median 763 days, IQR 174–1872 days) and those ≥50 years old (median 161 days, IQR 84.5–278 days). Fourteen eyes (26.4 %) had loss of one or more Snellen lines visual acuity at 6 months while the rest maintained or improved vision. Complications developed in 21 eyes, with cataract (66.7 %), glaucoma and ocular hypertension (33.3 %) being the most common. The risk of complications was associated with the absolute difference in CD4 counts at IRU and at HAART commencement (p = 0.041). Age was also negatively associated with the duration from HAART to IRU (p = 0.005, Spearman’s rho coefficient = −0.503).ConclusionsIt is common to have both anterior uveitis and vitritis in IRU. There was a positive association between the increase in CD4 from HIV to IRU diagnoses and the risk of developing complications. Younger patients appeared to develop IRU later than older patients after HAART, suggesting that long-term follow-ups are essential for these patients.

Cytomegalovirus Retinitis in HIV and Non-HIV Individuals

“…Immune reconstitution inflammatory syndrome (IRIS) is a phenomenon where increased inflammation is observed in HIV patients who are on ART during the initial weeks of treatment. This exaggerated reactivation of the immune system can lead to worsening reaction to CMV [19,51,98]. Immune recovery uveitis (IRU) is the predominant form of ocular immune reconstitution syndrome [98][99][100].…”

“…This exaggerated reactivation of the immune system can lead to worsening reaction to CMV [19,51,98]. Immune recovery uveitis (IRU) is the predominant form of ocular immune reconstitution syndrome [98][99][100]. IRU can result in visual loss from macula edema, retinal neovascularization and cataracts, in the absence of active CMV disease [99,100].…”

A lymphoma patient with Cytomegalovirus retinitis and post‐autologous hematopoietic cell transplantation immune reconstitution uveitis: A case report and review of the literature

“…To our knowledge, this is the first report of IRU in a patient with lymphoma after autologous HCT. There are two case reports of IRU following allogeneic HCT for other lymphoproliferative disorders . In both cases, IRU occurred following neutrophil engraftment and/or when immunosuppression was tapered.…”

Viral retinitis: diagnosis and management in the era of biologic immunosuppression: A review

“…In the majority of immunosuppressed patients the inflammatory response will be mild and therefore corticosteroids can be withheld. As the immunocompromised state resolves, patients may experience an immune reconstitution uveitis manifesting as severe anterior uveitis, vitritis, and macular oedema leading to a deterioration in vision . When this occurs, use of local and systemic corticosteroids should be considered to reduce the inflammatory response and prevent further ocular damage.…”