CMV Retinitis Increases Cataract Risk in Patients With AIDS

Troy Brown

August 03, 2012

August 3, 2012 — Cytomegalovirus (CMV) retinitis is associated with an increased absolute and relative risk for cataract in patients with AIDS, according to a study published online July 31 in Ophthalmology. The risk is highest for patients older than 60 years and for eyes that have had detached retina repair using silicone oil.

John H. Kempen, MD, PhD, and colleagues analyzed data from patients enrolled in the Longitudinal Study of Ocular Complications of AIDS, a prospective cohort study of patients from 19 AIDS ophthalmology centers in the United States.

Dr. Kempen is an associate professor of ophthalmology and epidemiology, the director of the Ocular Inflammation Service at the Scheie Eye Institute/Department of Ophthalmology, the director of Ophthalmic Epidemiology and International Ophthalmology, and senior scholar at the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania School of Medicine in Philadelphia.

The researchers analyzed data from a total of 729 eyes of 489 individuals diagnosed with CMV retinitis to determine the prevalence and incidence of cataract in patients with CMV retinitis and AIDS. Patients were seen initially and quarterly thereafter for ophthalmologic evaluation.

"Cataract historically has not been thought of as an issue in the setting of AIDS, but was identified as the second leading cause of visual loss in our cohort of AIDS patients in a previous paper, so we wanted to look into it more. The risk for eyes with CMV retinitis was so different than for eyes without CMV retinitis that we wanted to look at it separately," said Dr. Kempen in an e-mail interview with Medscape Medical News.

Tamara Vrabec, MD, an ophthalmologist at Geisinger Medical Center in Danville, Pennsylvania, and a clinical correspondent for the American Academy of Ophthalmology, also commented on the study in an e-mail interview with Medscape Medical News. "Kempen et al. have provided an excellent analysis of factors related to cataract development in persons with CMV retinitis. Several [factors], including age and duration of disease, are not modifiable and will continue to contribute to the development of cataract in those affected persons, especially as [highly active antiretroviral therapy] continues to prolong life expectancy."

Cataract Prevalence Higher With CMV Retinitis

At the time of the first study visit after CMV retinitis diagnosis, patients with bilateral CMV retinitis had more than twice the likelihood of having a cataract that was visually significant or of having undergone cataract surgery in at least 1 eye than patients with unilateral CMV retinitis (32% vs 15%; OR, 2.74; 95% confidence interval [CI], 1.76 - 4.26).

Of the 205 patients with bilateral CMV retinitis at this point in the study, 139 (68%) were without cataract, 36 (17%) had a unilateral cataract, and 30 (15%) had bilateral cataracts. Of the 284 patients with unilateral CMV retinitis, 242 (85%) were without cataract, 38 (13%) had cataract in the eye with CMV retinitis only, and 4 (1.4%) had bilateral cataracts. None of the patients with unilateral cataract had cataract in the CMV retinitis-free eye.

Cataract was approximately 11 times more frequent in eyes with CMV retinitis than in those without CMV retinitis (15% vs 1.4%; P < .0001).

Thirty-five patients initially had unilateral CMV retinitis and developed it in the second eye during the follow-up period. Of these patients, none of the eyes that developed CMV retinitis during follow-up had cataract at diagnosis, but 6 of the contralateral eyes with CMV retinitis were diagnosed with a cataract initially (0% vs 17%; P < .041).

The cataract prevalence was higher in study group patients with CMV retinitis than in the population-based cohort.

After adjusting for confounding factors, the predominant risk factors for cataract prevalence in this cohort were prior retinal detachment and a larger area of retinal involvement with CMV retinitis (adjusted OR [aOR] for lesions 25% - 49%, 6.521 [95% CI, 3.30 - 12.88]; aOR for lesions ≥50%, 8.53 [95% CI, 3.91 - 18.60]).

The association between prior retinal detachment and cataract was much stronger if silicone oil was used for the repair (aOR, 19.73; 95% CI, 7.47 - 52.07) than if it was not (aOR, 2.32; 95% CI, 0.83 - 6.47). Overall, the odds of cataract were increased 8.25-fold (95% CI, 4.12 - 16.50) in eyes with prior retinal detachment.

Other factors associated with increased odds of having cataract at the time of presentation were higher age (especially among patients aged 60 years or older compared with patients younger than 40 years: aOR, 11.77; 95% CI, 2.28 - 60.65), longer duration of CMV retinitis (aOR, 1.39 per year; 95% CI, 1.22 - 1.59 per year), and the presence of anterior segment inflammatory signs (aOR, 2.46; 95% CI, 1.29 - 4.67).

A CMV retinitis border that was currently active was associated with decreased odds of cataract at the time of presentation (aOR, 0.26; 95% CI, 0.07 - 0.93).

Cataract Incidence Higher With CMV Retinitis

A total of 591 (81%) phakic eyes (419 patients) were cataract-free at the initial study visit, with at least 1 follow-up visit conducted for 521 (88%) eyes and a median follow-up time of 1.99 eye-years (range, 0.15 - 9.36 eye-years). There were 5961 anticipated visits during this period, of which 5148 (86%) were completed. Out of 1566 eye-years at risk of developing cataract, 145 cataracts were identified (rate, 8.1 per 100 eye-years; 95% CI, 6.7 - 10.0 per 100 eye-years).

Overall, history of retinal detachment was associated with a 5.04-fold (95% CI, 3.45 - 7.37) increased risk for cataract (without silicone oil repair: adjusted HR [aHR], 2.90 [95% CI, 1.73 - 4.87]; with silicone oil repair: aHR, 10.37 [95% CI, 6.51 - 16.52]).

Patients with a large area of retinitis involvement had a many-fold higher risk for cataract. This association was stronger than expected and was not eliminated by adjustment for ganciclovir implants or cidofovir. After adjusting for confounding factors, neither therapy had a major effect on cataract risk.

CMV retinitis lesions that were larger (aHR for lesions 25% - 49%, 2.30 [95% CI, 1.51 - 3.50]; aHR for lesions ≥50%, 3.63 [95% CI, 2.18 - 6.04]) were associated with progressively increased cataract risk.

Anterior chamber inflammatory signs were associated with a doubled risk for cataract (aHR, 2.27; 95% CI, 1.59 - 3.25). This association was stronger than those found with identification of either immune recovery uveitis or vitreous inflammatory signs.

"[T]he magnitude of the association of cataract with large lesion size was much stronger than the association with inflammation, and that association persisted after adjustment for observed inflammatory findings and diagnosis with immune recovery uveitis," the authors write.

Cataract presence in the contralateral eye was also associated with an increased risk for incident cataract (aHR, 2.52; 95% CI, 1.74 - 3.66).

In patients with CMV retinitis and AIDS, the cataract risk is several-fold higher than in persons of comparable age in the general population. After adjustment for age, cataract prevalence among CMV retinitis cases was higher than that found in a population-based sample (P < .0001). The prevalence of cataract increased with age (aOR, 11.77 [95% CI, 2.28 - 60.65] for age 60 years vs younger than 40 years) and longer period of retinitis (aOR, 1.36 per year; 95% CI, 1.20 - 1.54 per year).

Preventing CMV Retinitis and the Advancement of Lesions

"There appear to be many pathways by which CMV retinitis or its complications lead to cataract," Dr. Kempen told Medscape Medical News. "Prevention of CMV retinitis and prevention of advancement of CMV lesions are key goals of clinical management, which have many benefits to patients, which include reducing the risk of cataract," he added.

Early detection of CMV retinitis is important, explained Dr. Vrabec. "HIV+ patients with CD4+ counts less than 50 cells/mL are at highest risk.... Individuals with CD4+ counts less than 50 cells/mL and their primary physicians or infectious disease consultants should be aware of the importance of dilated retinal evaluation. Routine screening at 3-month intervals with dilated fundus examination has been recommended.... Patients should also be educated about symptoms that may indicate [CMV retinitis], including floaters, blurred vision or scotoma," she added.

Dr. Vrabec also explained that it is important to select the proper surgical approach to retinal detachments in these patients.

"All CMV related retinal detachments are not alike. Factors which must be considered in determining the surgical approach include whether or not the macula is detached, whether or not active retinitis is present, the extent and location of active and inactive disease, and the location of all retinal breaks. The alternatives to silicone oil injection, which include vitrectomy with gas (which also carries risk of cataract formation), scleral buckle without vitrectomy, laser demarcation (a noninvasive office procedure), and rarely pneumatic retinopexy may or may not be appropriate in every detachment," Dr. Vrabec said.

The authors have disclosed no relevant financial relationships. Dr. Vrabec has published on the use of demarcation laser as an alternative to silicone oil injection in CMV-related retinal detachments.

Ophthalmology. Published online July 31, 2012. Abstract

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