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CMV still common with Hart? How do you prevent it?
Jul 9, 2003

Dear experts,

How do you explain this article on CMV visual loss being common in Hart era, does this often still occur with individuals using Hart? What can one do to prevent this from occuring to themselves. Thanks.

Bart

CMV-related visual loss remains common in HAART era

Last Updated: 2003-06-30 13:28:12 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Depending on immune recovery status, visual loss related to cytomegalovirus retinitis can often occur in HIV-infected individuals treated with highly active antiretroviral therapy (HAART), according to a report in the July British Journal of Ophthalmology.

Inflammatory sequelae and visual loss have complicated healed CMV retinitis in the setting of immune recovery following HAART, the authors explain, but long-term visual outcomes have not been systematically assessed.

Dr. William Freeman from University of California San Diego in La Jolla, California, and associates determined the long-term visual outcome of 63 HAART-treated AIDS patients (90 eyes) with extramacular CMV retinitis in relation to immune failure or immune recovery with or without immune recovery uveitis (IRU).

Twenty-one of 48 patients (26 eyes) who achieved immune recovery developed IRU, the report indicates.

Patients with immune recovery but without IRU had the lowest incidence of ocular sequelae, the authors report, whereas the highest incidence occurred in patients with immune recovery and IRU.

Also, the highest rate of cataract formation (84) occurred in eyes with IRU, the results indicate, while the lowest incidence was seen in eyes without IRU in immune-recovery patients.

Similarly, moderate visual loss was most likely to develop in eyes with immune recovery and subsequent IRU, the researchers note, and severe visual loss was significantly associated with retinal detachment.

"We attribute our findings to the high incidence of intraocular inflammation secondary to HAART induced immune recovery uveitis in the setting of healed CMV retinitis," the authors conclude. "In the HAART era, vision loss is still common in CMV retinitis patients."

Br J Ophthalmol 2003;87:853-855.

Response from Dr. Wohl

The visual loss that Dr. Freeman and his colleagues describe is due to the (hyper)activity of the immune system following HIV therapy and not to CMV itself.

It is thought that as the immune system improves with HIV therapy it reacts to some remaining remnants of CMV in the eye. If you look for actual live CMV virus in the eyes of these patients you don't find it.

This is a major problem and we do not know how to prevent it. It may be that people treated with the CMV drug cidofovir may be at more risk for some eye problems but this is not conclusively demonstrated.

The good news is that CMV retinitis, once common, has now become very rare due to HIV therapy. But, among those who have had CMV eye disease and then start HIV meds there is a real risk of an immune related problem developing. Many have had some success at controlling their immune related disease with steroids delivered into the eye and surgery. DW



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