Setting:

Medical Retina service, Moorfields Eye Hospital NHS Foundation Trust. London, UK.

Purpose:

To describe a CMV retinitis in a patient with long standing inmunosuppresive treatment after liver transplant, and the therapeutic challenges of this case. We report a 74 year old man with previous liver transplant 20 years ago due to a Autoinmune Hepatitis who attended eye casualty complaining of floaters and blurred vision in his left eye. The patient was on low grade immunosuppressive theraphy consisting in 5 mg of oral Prednisolone and Micofenolate mofetil (MM) 1gr bd. The visual acuity was 6/36 in both eyes, intraocular pressure was normal in RE and 28 mm hg in the LE. Anterior segment was quiet in BE. On fundoscopy the RE showed just macular atrophy, the left eye had moderate vitritis, superior area of retinitis and macular atrophy. Differential diagnosis of HSV retinitis (ARN), toxoplasmasis and CMV retinitis was done. After taking AC and vitreous taps for PCR, we decided to inject intravitreal Foscarnet 2.4 mg in 0.1 ml . Valacyclovir 2g tds orally was initiated. After five days we received the results of vitreous tap being positive to CMV. Then valacyclovir was changed to Valgancyclovir 900 mg bd and other intravitreal injection of Foscarnet was done. Visual acuity remained unchanged and not progression of the retinitis was seen during that time. After 8 weeks the dose of Valgancyclovir was reduced to 450 mg bd, he has been with the same dose for more than a year, when he developed a episode of CMV viraemia and needed intravenous Foscarnet and MM was stopped. Currently the patient is with 5 mg of oral Prednisolone, and no signs of retinitis, he has developed an area of superior retinal atrophy.

Conclusion:

CMV retinitis is a devastating ocular disease, that is most commonly seen in patient with AIDS, but could occur in any patient on immunosuppressive theraphy, as in transplanted patients. The management in these cases could be very complicated as they need the inmunosuppresors in order to avoid organ rejection so the option would be to reduce that theraphy or maintain a long term antiviral treatment to avoid recurrences and CMV viraemia.

Contact Details:

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