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Editor,—Cytomegalovirus (CMV) retinitis affects 12%–46%1-3 of individuals with AIDS and is frequently bilateral. The current management of CMV retinitis includes systemic anti-CMV therapy, local intravitreal injections of ganciclovir or foscarnet, and, more recently, intravitreal sustained release ganciclovir implant (Vitrasert) (Fig 1). High dose intravenous ganciclovir or foscarnet is effective in suppressing viral replication in the short term but breakthrough infection is common during the maintenance phase with up to 50% of patients experiencing recurrent disease.4-6 Implantation can be done as primary therapy at the time of CMV retinitis diagnosis or as salvage therapy once the conventional treatment has failed. We describe our experience using Vitrasert as salvage treatment in patients with AIDS related recurrent CMV retinitis.
Data on patients with CMV retinitis treated with Vitrasert implants at two centres, Edinburgh and Belfast, were analysed retrospectively. Twenty five Vitrasert devices were implanted in 16 eyes of 11 patients between August 1995 and May 1997. Before implantation all patients showed recurrent CMV retinitis despite systemic treatment with ganciclovir and/or foscarnet, had central line sepsis, or were intolerant of these medications. The median post-implantation follow up time was 7 months (range 1–15 months). Following the diagnosis of CMV retinitis, median life survival of four patients now dead was 19.5 months (range 4–24), for seven surviving patients this period at the time of writing was 12 months (range 8–22). The median time interval between CMV retinitis diagnosis and initial implantation was 9 months (range 1–19). The median time interval for retinitis progression following first implantation was 6 months (range 2–13).
Post-implantation anti-CMV systemic treatment in the form of oral ganciclovir was continued at a reduced dose in eight (73%) patients and discontinued in three (27%) patients who received bilateral implantation and showed no clinical evidence of extraocular CMV disease. At the last follow up following implantation 13 (82%) eyes remained within one line of their preoperative visual acuity and three (18%) eyes had loss of 2 lines. A final visual acuity of 6/18 or more was retained in 56% eyes. Complications of the implant include mild vitreous haemorrhage in four eyes, cystoid macular oedema in three eyes, moderate anterior uveitis in one eye, and non-progressive macula on nasal rhegmatogenous retinal detachment in one eye, 6 months following implantation.
In this relatively small study the median time interval for retinitis progression was 6 months, similar to a previous study reported by Marxet al.7 However, in an earlier study8 done in patients with newly diagnosed CMV retinitis, this period was reported to be 7.5 months. Therefore, this preliminary study has shown that the intravitreal ganciclovir implant is effective as salvage treatment in recurrent CMV retinitis in the majority of patients. It avoids the need for repeated intravitreal injections and associated frequent hospital visits, provides a longer period of disease control, and may be used to retain useful vision in majority of patients helping to improve their quality of life. Although the implants are effective in controlling local CMV disease, systemic anti-HIV and anti-CMV therapy should be continued to prevent extraocular disease. The longer term efficacy and complications of this procedure should be studied prospectively in those individuals who fail “conventional therapies”.