Fundus autofluorescence changes in cytomegalovirus retinitis

Abstract

Purpose: The purpose of this study was to describe fundus autofluorescence imaging features of cytomegalovirus (CMV) retinitis and to correlate fundus autofluorescence features with clinical activity.

Methods: A retrospective case series was undertaken to evaluate nine eyes of six patients with active CMV retinitis. Patients were evaluated with a comprehensive ophthalmic examination, fundus autofluorescence imaging, and fundus photography. Oral valganciclovir, intravitreal ganciclovir, intravitreal foscarnet, or an ganciclovir implant was administered as clinically indicated.

Results: In all nine eyes with active CMV retinitis, a hyperautofluorescent signal on fundus autofluorescence imaging was correlated spatially with the border of advancing CMV retinitis. Stippled areas of alternating hyperautofluorescence and hypoautofluorescence were observed in regions of retinal pigment epithelium atrophy from prior CMV retinitis. In three eyes with subtle CMV reactivation, a hyperautofluorescent border was helpful in the detection and localization of active CMV retinitis. In another patient, diffuse, punctate hyperautofluorescence after intravitreal ganciclovir and foscarnet was a concern for medication-related toxicity.

Conclusion: Fundus autofluorescence imaging was valuable in highlighting areas of active CMV retinitis in all patients in this series, including two patients with subtle clinical features. Fundus autofluorescence may be useful as an adjunctive imaging modality for the detection of CMV activity and aid in our understanding of the structural changes during episodes of CMV retinitis.

Figure 1

Fundus photographs and corresponding FAF images of new-onset CMV retinitis in two HIV-positive patients. Fundus photograph of a 32 year-old male patient shows full-thickness retinitis in the inferonasal quadrant of the right eye (A). The FAF image demonstrated hyperautofluorescence at the posterior border of the zone of retinitis with mottled hyper- and hypoautofluorescence anterior to the advancing border in areas of clinically atrophic RPE (B). In a 35 year-old female patient with HIV and CNS lymphoma, a hemorrhagic retinitis is seen (C) and FAF imaging shows hyperautofluorescence at the posterior border of the active retinitis with a swath of hypoautofluorescence corresponding to hemorrhage, retinal edema, and full-thickness retinitis (D). Mottled hyper- and hypoautofluorescence are seen anterior to this area of active disease, corresponding to RPE atrophy seen in the fundus photograph.

Figure 2

Fundus photograph of the posterior pole of a HIV-positive patient with macular CMV retinitis (A) and corresponding FAF image (B) shows hypoautofluorescence with surrounding halo of hyperautofluorescence (asterisk), which corresponded to hemorrhage, retinal infiltration and retinal edema. A stippled area of hyper- and hypoautofluorescence is observed superonasal to the fovea (yellow arrow) in a smaller, non-contiguous area of active CMV retinitis. Two weeks following intravitreal foscarnet and ganciclovir, the area of active CMV retinitis has decreased (C) and the FAF image shows that the region of hypoautofluorescence has changed to an area with both hyper- and hypoautofluorescent signal (D, asterisk). Interestingly, widespread hyperautofluorescent stippling is seen on FAF imaging, which was not apparent clinically (D). At 6 months follow-up after ganciclovir implantation, the CMV retinitis has resolved (E), however, diffuse and persistent FAF abnormalities are seen, possible related to medication toxicity (F).

Figure 3

Fundus photograph OS of a HIV-positive patient with CMV retinitis involving superotemporal macula with a serous retinal detachment (A) and corresponding FAF image showing hypoautofluorescence with a faint halo of hyperautofluorescence in the zone of hemorrhagic retinitis and retinal edema (B). Hyperautofluorescent stippling is also seen temporally (asterisk), and corresponds to a linear streak of advancing infection. Following intravitreal ganciclovir and foscarnet injections, the CMV retinitis began to resolve (C) with a corresponding decrease in the density of the hypoautofluorescence at the superotemporal arcade (D). The prior area of linear hyperautofluorescence now shows linear hyper- and hypoautofluorescence (asterisk). Clinically, this area of CMV retinitis is also resolving and has been replaced by punctate hemorrhages suggestive of small-vessel injury during the resolution phase of the disease.

Figure 4

Fundus photograph of 73 year-old patient with large granular leukemia and a history of prophylactic valganciclovir shows subtle retinal whitening at he border of prior CMV retinitis and RPE atrophy (A, white arrows). FAF imaging reveals hyperautofluorescence in the area of the CMV retinitis recurrence (B, white arrows), which was confirmed by PCR testing. A 67-year-old patient who was status post lung transplantation and on multiple immunosuppressive medications and prophylactic valganciclovir complained of new floaters in both eyes. Fundus photography showed retinal whitening at the posterior border in the area of prior CMV retinitis (C, yellow arrows). FAF imaging highlighted this border of active CMV retinitis with hyperautofluorescence corresponding to the area of CMV retinitis recurrence (yellow arrows, D). PCR testing confirmed the presence of CMV DNA and led to the institution of valganciclovir at higher treatment doses.