Intravitreal sustained‐release ganciclovir implants for severe bilateral cytomegalovirus retinitis after stem cell transplantation

Abstract

ABSTRACT.Purpose: To describe the treatment of cytomegalovirus (CMV) retinitis with intravitreal sustain-release ganciclovir devices in a 16-year-old patient in third remission of acute lymphoblastic leukemia after stem cell transplantation. Methods: The patient received a stem cell transplant from an unrelated bone marrow donor after which he contracted a serious CMV infection manifested in the lungs and retinae. His immune system at this time was almost completely depleted. Implantation of a sustained-release ganciclovir device was performed in both eyes when retinitis progressed in spite of aggressive antiviral intravenous treatment.

Cytomegalovirus Retinitis in an ALL Child on Exclusive Chemotherapy Treated Successfully With Intravitreal Ganciclovir Alone

“…Among the immunosuppressed states, it has been reported frequently in children with acquired immunodeficiency syndrome but has been rarely reported in other immunosuppressive conditions. 1 In pediatric age group, acute lymphoblastic leukemia (ALL) is the most common hematologic malignancy and second most common malignancy overall in children forming the second most common cause of immunosuppression after acquired immunodeficiency syndrome. 2 In children with ALL on exclusive chemotherapy without hematopoietic stem cell transplantation, CMV retinitis has been reported in only 1 case in the literature.…”

Immune reconstitution complicated by CMV retinitis in a pediatric patient who underwent haploidentical CD34+-selected hematopoietic stem cell transplant for acute lymphoblastic leukemia

“…In some reports, the most important differences with respect to adults were the timing of diagnosis of CMV retinitis, the occurrence being as early as day +42, +63, and +81 post-grafting in pediatric patients, and the temporal association with CMV reactivation or CMV disease involving other organs [17,18].…”

Cytomegalovirus retinitis in children and adolescents with acute leukemia following allogeneic hematopoietic stem cell transplantation

“…Three drugs are currently available for therapy of CMVR: GCV, PFA, and cidofovir. GCV and PFA, both intravenously and as intravitreous injections, are first‐line therapies for CMVR, while the risk of GCV myelotoxicity as observed in four patients of the published cases and in one of the presented cases might have prevented its use in favor of PFA . In almost all published cases, antiviral treatment of CMVR was implemented, in 85% consisting of GCV, in two‐thirds administered systemically; PFA was given to 55% of patients.…”

“…Intravitreal administration of antiviral drugs provides higher targeted drug concentrations compared to systemic therapy and allows to avoid systemic drug‐induced toxicity and resistance . As VGCV is highly effective for providing short‐term anti‐CMV coverage, the indications for intravitreal injections may be limited to short‐term use in the presence of severe neutropenia and/or progressive CMVR when sight is immediately threatened . Noteworthy, repetitive injections expose immunocompromised patients to serious complications such as endophthalmitis and represent a significant treatment burden, particularly for pediatric patients .…”