title: Chronic retinal necrosis: cytomegalovirus necrotizing retinitis associated with panretinal vasculopathy in non-HIV patients.
abstract: OBJECTIVE
  To characterize a unique cytomegalovirus (CMV)-associated retinopathy in patients with limited immune dysfunction.
  
  
  METHODS
  Retrospective observational case series. CMV was confirmed as the pathogenic agent via polymerase chain reaction analysis of aqueous or vitreous humor samples or via immunohistochemical analysis of retinal biopsy specimens.
  
  
  RESULTS
  Five non-HIV patients with granular necrotizing retinitis, vitritis, and severe occlusive vasculopathy were identified. Patient histories all suggested a basis for limited immune dysfunction including advanced age (n = 4), diabetes mellitus (n = 4), and noncytotoxic immunotherapy (n = 3). Diagnosis of CMV retinitis was delayed in all cases and patients received either no antiviral therapy (n = 2) or incorrect antiviral therapy (n = 3) for presumed herpes simplex/varicella zoster-related acute retinal necrosis. Retinitis subsequently regressed in all cases with introduction of systemic ganciclovir/valganciclovir (n = 5) and/or intravitreal foscarnet (n = 2). Four of five patients developed neovascularization because of extensive retinal ischemia.
  
  
  CONCLUSIONS
  The clinical expression of CMV-associated retinopathy is strongly related to immune status. In patients with limited immune dysfunction, a mixed clinical picture of intraocular inflammation with panretinal occlusive vasculopathy, more characteristic of acute retinal necrosis, and peripheral slowly progressive granular retinitis, more characteristic of classic CMV retinitis, is observed. Recognition of this atypical clinical presentation, which the authors term chronic retinal necrosis, should prompt molecular testing for CMV to determine the appropriate antiviral therapy. Consideration should also be given to prophylactic panretinal photocoagulation in such eyes, given the high risk of neovascular complications.
authors.affiliation: *Department of Ophthalmology and Visual Sciences, University of Michigan, W.K. Kellogg Eye Center, Ann Arbor, Michigan; †Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota; ‡Department of Ophthalmology, Mount Sinai School of Medicine, New York, New York; and §Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts.
authors.forename: Eric W
authors.initials: EW
authors.lastname: Schneider
authors.forename: Susan G
authors.initials: SG
authors.lastname: Elner
authors.forename: Frederik J
authors.initials: FJ
authors.lastname: van Kuijk
authors.forename: Naomi
authors.initials: N
authors.lastname: Goldberg
authors.forename: Ronni M
authors.initials: RM
authors.lastname: Lieberman
authors.forename: Dean
authors.initials: D
authors.lastname: Eliott
authors.forename: Mark W
authors.initials: MW
authors.lastname: Johnson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000998:Antiviral Agents / Q000627:therapeutic use; D001082:Aqueous Humor / Q000821:virology; D018791:CD4 Lymphocyte Count; D002908:Chronic Disease; D003587:Cytomegalovirus / Q000235:genetics / Q000302:isolation & purification; D017726:Cytomegalovirus Retinitis / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D004279:DNA, Viral / Q000032:analysis; D004359:Drug Therapy, Combination; D005260:Female; D017245:Foscarnet / Q000627:therapeutic use; D015774:Ganciclovir / Q000031:analogs & derivatives / Q000627:therapeutic use; D018023:HIV Seronegativity; D006801:Humans; D008297:Male; D008875:Middle Aged; D009336:Necrosis; D016133:Polymerase Chain Reaction; D015861:Retinal Neovascularization / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy; D031300:Retinal Vasculitis / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D012171:Retinal Vessels / Q000473:pathology*; D012189:Retrospective Studies; D015866:Uveitis, Posterior / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy; D000077562:Valganciclovir; D014822:Vitreous Body / Q000821:virology
chemical_list: D000998:Antiviral Agents; D004279:DNA, Viral; D017245:Foscarnet; D000077562:Valganciclovir; D015774:Ganciclovir