J Korean Ophthalmol Soc.  2019 Jan;60(1):85-90. 10.3341/jkos.2019.60.1.85.

A Case of Cytomegalovirus Retinitis Following Intravitreal Dexamethasone Implant in an Immunocompetent Patient with Uveitis

• Kim I
• Lee J

• KMID: 2431845
• DOI: http://doi.org/10.3341/jkos.2019.60.1.85

Abstract

PURPOSE
We report a case of cytomegalovirus (CMV) retinitis following placement of an intravitreal dexamethasone implant in an immunocompetent patient diagnosed with non-infectious uveitis.
CASE SUMMARY
A 60-year-old woman was referred to our hospital for recurrent anterior uveitis. Fundus examination and fluorescein angiography showed dense vitritis, but no definite retinal infiltration. After laboratory examinations, the patient was diagnosed with non-infectious panuveitis. Uveitis was much improved after the patient started taking oral steroid medication. However, the patient complained of systemic side effects from the oral steroids. Medication was stopped, and an intravitreal dexamethasone implant was fitted to address worsening inflammation. Two months later, perivascular retinal infiltration developed and vitritis recurred. Viral retinitis was suspected, and the patient underwent diagnostic vitrectomy adjunctive with intravitreal ganciclovir injection. Polymerase chain reaction of vitreous fluid confirmed the diagnosis of CMV retinitis. The patient has remained inflammation-free for more than 20 months after vitrectomy, single ganciclovir injection, and 2 months of oral valganciclovir medication.
CONCLUSIONS
This is a case report of CMV retinitis following placement of an intravitreal dexamethasone implant in an immunocompetent patient without any risk factors or previous history of immunosuppression. Potential risk factors for CMV retinitis should be evaluated and careful follow-up should be performed when intravitreal dexamethasone injections are unavoidable for the treatment of non-infectious uveitis.

Keyword

Cytomegalovirus retinitis; Dexamethasone; Ganciclovir; Uveitis; Vitrectomy

MeSH Terms

Cytomegalovirus Retinitis*
Cytomegalovirus*
Dexamethasone*
Diagnosis
Female
Fluorescein Angiography
Follow-Up Studies
Ganciclovir
Humans
Immunosuppression
Inflammation
Middle Aged
Panuveitis
Polymerase Chain Reaction
Retinaldehyde
Retinitis
Risk Factors
Steroids
Uveitis*
Uveitis, Anterior
Vitrectomy
Dexamethasone
Ganciclovir
Retinaldehyde
Steroids

Figure

• 

  Figure 1 A 60-year-old woman with no previous medical history presented with visual disturbance of the left eye. (A) Fundus examination showed dense vitritis without retinal infiltration. (B) Fluorescein angiography showed diffuse retinal vascular leakage and disc leakage. (C) After 3 weeks of oral steroid treatment, vitritis was improved. (D–E) Compared to the initial optical coherence tomography (OCT) image (D), OCT image 3 weeks after treatment (E) showed improvement of media opacity and normal retinal structure at macula.

• 

  Figure 2 Intravitreal dexamethasone implantation was performed for the recurrence of vitritis after oral steroid tapering. (A) Fundus examination showed the recurrence of vitritis after oral steroid tapering. (B) After 2 weeks of intravitreal dexamethasone implant, vitritis was improved. (C) After 2 months of dexamethasone implant, perivascular retinal infiltrations were newly developed and vitritis was aggravated. (D) Fluorescein angiography showed occlusive vasculopathy and vasculitis, which suggest the possibility of viral retinitis.

• 

  Figure 3 Images of post-vitrectomy with endolaser photocoagulation and intravitreal ganciclovir injection. (A) Fundus examinations 2 weeks after vitrectomy showed improved vitritis and retinal infiltration. (B) Fluorescein angiography at postoperative 2 months showed much improved vascular leakage. (C) Fundus photography 20 months after vitrectomy showed inflammation-free vitreous and retina and stable laser scars. (D–E) Optical coherence tomography at two weeks (D) and 20 months (E) after vitrectomy show normal retinal structure at macula.

Reference

1. Port AD, Orlin A, Kiss S, et al. Cytomegalovirus retinitis: a review. J Ocul Pharmacol Ther. 2017; 33:224–234.

2. Ufret-Vincenty RL, Singh RP, Lowder CY, Kaiser PK. Cytomegalovirus retinitis after fluocinolone acetonide (Retisert) implant. Am J Ophthalmol. 2007; 143:334–335.

3. Delyfer MN, Rougier MB, Hubschman JP, et al. Cytomegalovirus retinitis following intravitreal injection of triamcinolone: report of two cases. Acta Ophthalmol Scand. 2007; 85:681–683.

4. Vannozzi L, Bacherini D, Sodi A, et al. Cytomegalovirus retinitis following intravitreal dexamethasone implant in a patient with central retinal vein occlusion. Acta Ophthalmol. 2016; 94:e158–e160.

5. Zaborowski AG. Cytomegalovirus retinitis following intravitreal triamcinolone acetonide in a patient with chronic uveitis on systemic immunosuppression. Ocul Immunol Inflamm. 2013; 21:148–149.

6. Furukawa M, Kumagai K, Ogino N, et al. Cytomegalovirus retinitis after intravitreous triamcinolone treatment of a vitrectomized eye in an immunocompetent patient. Retin Cases Brief Rep. 2007; 1:205–207.

7. Park YS, Byeon SH. Cytomegalovirus retinitis after intravitreous triamcinolone injection in a patient with central retinal vein occlusion. Korean J Ophthalmol. 2008; 22:143–144.

8. Saidel MA, Berreen J, Margolis TP. Cytomegalovirus retinitis after intravitreous triamcinolone in an immunocompetent patient. Am J Ophthalmol. 2005; 140:1141–1143.

9. Vertes D, Snyers B, De Potter P. Cytomegalovirus retinitis after low-dose intravitreous triamcinolone acetonide in an immunocompetent patient: a warning for the widespread use of intravitreous corticosteroids. Int Ophthalmol. 2010; 30:595–597.

10. Myung JS, Aaker GD, Kiss S. Treatment of noninfectious posterior uveitis with dexamethasone intravitreal implant. Clin Ophthalmol. 2010; 4:1423–1426.

11. Fassbender Adeniran JM, Jusufbegovic D, Schaal S. Common and rare ocular side-effects of the dexamethasone implant. Ocul Immunol Inflamm. 2017; 25:834–840.

12. Bae SH, Kim TW, Chung H, Heo JW. Cytomegalovirus retinitis after intravitreal bevacizumab injection in an immunocompetent patient. Korean J Ophthalmol. 2013; 27:61–63.

13. Olson DJ, Parhiz AT, Wirthlin RS. Reactivation of latent toxoplasmosis following dexamethasone implant injection. Ophthalmic Surg Lasers Imaging Retina. 2016; 47:1050–1052.

14. DeRussy BM, Aylward MA, Fan Z, et al. Inhibition of cytomegalovirus infection and photothermolysis of infected cells using bioconjugated gold nanoparticles. Sci Rep. 2014; 4:5550.