CMV retinitis as a cause of retinal detachment in HIV infection immune status stages diagnosis and comprehensive surgical treatment

Title : CMV retinitis as a cause of retinal detachment in HIV infection immune status stages diagnosis and comprehensive surgical treatment

Abstract:

At present, the world continues to face the HIV infection pandemic, which is naturally accompanied by an increasing number of patients with various complications of this disease. Among the causes of blindness in HIV?infected patients, retinal detachment ranks third — after cytomegalovirus (CMV) chorioretinitis and cataracts. It is particularly concerning that retinal detachment often results from CMV chorioretinitis, significantly worsening the visual prognosis.

This situation underscores the urgent need to develop a comprehensive approach to treating retinal detachment in CMV retinitis in the context of HIV infection. The main goal is to minimize the risks of recurrence of both retinal detachment and CMV retinitis.

Clinical Case: Patient S., 35?years old. Her main complaints:

• progressive decrease in visual acuity of the right eye;
• complete absence of object vision in the left eye.

Medical history:

• HIV infection since 2012;
• at admission — stage?4B, phase of unstable remission;
• since August?2023 — antiretroviral therapy (Dolutegravir, Lamivudine, Tenofovir);
• generalized cytomegalovirus infection (ongoing maintenance anti?CMV therapy);
• CMV chorioretinitis in both eyes (of unknown duration).

Local status:

• Left eye: visual acuity — 0; outcome of CMV chorioretinitis, optic nerve atrophy.
• Right eye: visual acuity — 0.1; inferior retinal detachment (reaching the macular area), multiple chorioretinal lesions.

Diagnostic procedures at the preoperative stage: Analysis of the CD4/CD8 lymphocyte ratio in blood.

1. Determination of viral load (number of HIV and cytomegalovirus copies).
2. Collection of intraocular fluid from the anterior chamber to detect cytomegalovirus copies.
3. Intravitreal administration of ganciclovir (according to Pershin?B.?S.’s method) — concurrently with intraocular fluid sampling.

Laboratory findings:

• HIV viremia — 3?288?copies/mL;
• CD4/CD8 lymphocyte ratio — 0.23;
• PCR for CMV in blood — not detected;
• PCR for CMV in the anterior chamber fluid — not detected.

Interpretation of results: The patient’s immune system is significantly depleted due to prolonged HIV replication, which increases the risk of endophthalmitis after surgery. The absence of CMV copies in blood and intraocular fluid indicates a low risk of CMV retinitis recurrence for at least 1?month. This allows for surgical treatment of retinal detachment without additional intravitreal administration of antiviral drugs during the operation.

Surgical Treatment: The patient underwent combined surgery: vitrectomy with cataract phacoemulsification and intraocular lens (IOL) implantation.

Surgical course:

• a linear retinal tear was identified along the edge of the chorioretinal scar in the paramacular area (it was concealed by a bubble of detached retina, creating a false impression of «pseudo?exudative» retinal detachment);
• subretinal fluid was drained through the tear;
• endolaser photocoagulation of the retina was performed;
• silicone was injected.???????

Results: One and three months after the surgery: the retinal layers are apposed; no signs of chorioretinitis activation or proliferative vitreoretinopathy; corrected visual acuity — 0.4. The patient is under dynamic observation.

Plans for further management:

• In 6?months after surgery — planned removal of silicone (if the intraocular situation remains stable).
• Prior to silicone removal — additional blood testing for CMV copies.
• If CMV copies are detected: intensification of antiviral therapy and delay of silicone removal.
• If no CMV copies are found: silicone removal without additional intravitreal administration of antiviral drugs.???????

Conclusions: The presented clinical case demonstrates that a comprehensive approach to the treatment of rhegmatogenous retinal detachment in the setting of CMV retinitis with HIV infection enables:

• effective stabilization of the retinal condition;
• reduction of the risk of retinal detachment recurrence;
• minimization of the likelihood of CMV retinitis recurrence.

This approach combines thorough preoperative diagnostics, individualized medical support, and well?considered surgical tactics, collectively improving the visual prognosis for this category of patients

Biography:

Anna Rusanovskaya, MD, PhD, is an ophthalmologist in the Ophthalmology Department of the Moscow State Budgetary Healthcare Institution "Moscow Clinical Research Center, Hospital No. 52, Moscow Department of Healthcare." She is a member of the Russian Society of Ophthalmologists, the European Society of Cataract and Refractive Surgeons, and the European Society of Vitreoretinal Surgeons. She holds the highest qualification category. Specializes in vitreoretinal surgery for complications of diabetic retinopathy, rhegmatogenous retinal detachment, macular surgery, IOL dislocations, etc.