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Long-Term Results of Oral Valganciclovir for Treatment of Anterior Segment Inflammation Secondary to Cytomegalovirus Infection

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Long-Term Results of Oral Valganciclovir for Treatment of Anterior Segment Inflammation Secondary to Cytomegalovirus Infection Clinical Ophthalmology Dovepress open access to scientific and medical research Open Access Full Text Article ORIGINAL RESEARCH Long-term results of oral valganciclovir for treatment of anterior segment inflammation secondary to cytomegalovirus infection Victoria WY Wong Background: The purpose of this study was to assess the efficacy of oral valganciclovir in the Carmen KM Chan treatment of anterior segment inflammation caused by cytomegalovirus (CMV) infection. Dexter YL Leung Methods: Consecutive patients with anterior segment inflammation due to CMV causing Timothy YY Lai anterior uveitis or corneal endotheliitis treated with oral valganciclovir were reviewed. Diagnosis of CMV infection was confirmed by polymerase chain reaction of the aqueous aspirate prior Department of Ophthalmology and Visual Sciences, The Chinese to commencement of oral valganciclovir. All patients were treated with an oral loading dose University of Hong Kong, Hong Kong of 900 mg valganciclovir twice daily for at least 2 weeks, followed by an additional 450 mg Eye Hospital, Hong Kong, valganciclovir twice-daily maintenance therapy. Changes in visual acuity, intraocular pressure People’s Republic of China (IOP), use of antiglaucomatous eye drops, and recurrence were analyzed. For personal use only. Results: Thirteen eyes of 11 patients were followed for a mean of 17.2 months. Two patients had bilateral corneal endotheliitis. All eyes had absence of anterior segment inflammation within 3 weeks after treatment. Following treatment, the mean logMAR visual acuity improved significantly from 0.58 at baseline to 0.37 at the last follow-up (P = 0.048). The mean IOP and number of antiglaucomatous eye drops also decreased significantly (P = 0.021 and P = 0.004, respectively). Five (38.5%) eyes had recurrence of anterior uveitis after valganciclovir was stopped and required retreatment with oral valganciclovir. Conclusion: Oral valganciclovir appeared to be effective in controlling CMV anterior uveitis, resulting in visual improvement and IOP reduction following control of inflammation. However, despite the initial clinical response in all cases, recurrence after cessation of oral valganciclovir could occur. Clinical Ophthalmology downloaded from https://www.dovepress.com/ by 147.8.230.105 on 09-Sep-2020 Keywords: cytomegalovirus infection, inflammation, anterior uveitis, endotheliitis, ocular hypertension, antiviral, valganciclovir Introduction In recent years, with the increasing use of polymerase chain reaction (PCR) for the detection of viruses in intraocular fluids, cytomegalovirus (CMV) infection is increasingly recognized as an important cause of anterior segment inflammation in immunocompetent individuals.1–5 Clinical features of CMV anterior segment inflammation in immunocompetent individuals include increased intraocular pressure (IOP), Correspondence: Timothy YY Lai Department of Ophthalmology and Visual with anterior chamber inflammation like Posner-Schlossmann syndrome, iris Sciences, The Chinese University of atrophy with nodular endothelial changes similar to Fuchs uveitis syndrome, and Hong Kong, Hong Kong Eye Hospital, corneal endotheliitis with coin-shaped keratic precipitates with or without corneal 147K Argyle Street, Kowloon, Hong Kong SAR, China edema.6–10 Systemic and ocular antiviral therapies with ganciclovir are the main Tel +852 2762 3134 treatment options for CMV anterior segment inflammation.4,5,10–12 Valganciclovir, Fax +852 2715 9490 Email [email protected] the prodrug of ganciclovir, is also available for convenient oral dosing instead of submit your manuscript | www.dovepress.com Clinical Ophthalmology 2012:6 595–600 595 Dovepress © 2012 Wong et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article http://dx.doi.org/10.2147/OPTH.S30476 which permits unrestricted noncommercial use, provided the original work is properly cited. Powered by TCPDF (www.tcpdf.org) 1 / 1 atrophy. chamber cells, presence of keratic precipitates, inflammationand iris on clinical examination, such antiglaucomatousas drugs,anterior and details of anterior segment baseline and final visual IOP acuity, measurements, use of with thetenetsofDeclarationHelsinki. accordance in performed was study The weeks. 6 least at for maintenance therapy of 450 valganciclovir 900 All patients received a loading dose of oral valganciclovir internal organ transplantation or connective tissue disease. on systemic chemotherapy or immunosuppressantswith human immunodeficiency virusfor infection, and those patients included criteria Exclusion endotheliitis. corneal or Posner-Schlossmann syndrome, Fuchs uveitis syndrome, confirmed with clinical features of CMV infection together CMV anterior segment inflammationwas defined as PCR- minimum follow-up duration of 6 treatment between June 2007 and Augustsegment 2010inflammation withwho a received oralvalganciclovir anterior CMV with patients immunocompetent consecutive all of notes case The Kong. Hong Hospital, Eye Kong Hong The study was a case retrospective series carried out at the Materials andmethods ganciclovir. intravenous et Wong 596 inflammation with corneal endotheliitis presented in both ( study the in included were patients 11 from eyes 13 of total A Baseline demographics Results significant. consideredasstatistically was Chi-squared test or Fisher Exact test. A the using performed was variables categorical of comparison performed using the Wilcoxon Canada). sign-rankedComparisons oftest (StatPlus:Mac continuousand 2009,variables AnalystSoft wereInc, by Vancouver,descriptive BC, summarized are patients the statisticsof characteristics Demographic using statisticalStatistical analysis software segment inflammation. segment of oral valganciclovir in the treatment efficacy long-term the of evaluate to was CMVstudy our of purpose anterior the treatment of CMV anterior segment inflammation. The the short-termevaluated outcome in of oral valganciclovir Table The main outcome measures of the study included mg twice daily for at least two weeks, followed by 1). Two patients had bilateral CMV anterior segment segment anterior CMV bilateral had patients Two 1). al Dove manuscript submit your press | 13,14 www.dovepress.co Most previous studies have only only have studies previous Most m For personal use only. months were reviewed. P value of mg twice daily , 0.05 Table 1 Demographics and clinical findings of 11 patients with cytomegalovirus and anterior segment inflammation treated with oral valganciclovir Clinical Ophthalmology downloaded from https://www.dovepress.com/ by 147.8.230.105 on 09-Sep-2020 Patient Gender/ Diagnosis Prior Follow-up Duration of Recurrence Interval between Baseline Final Lines Baseline Final age surgery duration maintenance recurrence and VA VA changed IOP IOP (months) therapy stopping valganciclovir (mmHg) (mmHg) (months) therapy (months) 1 (OD) M/60 Endotheliitis PK, Trab 38 36 Yes 4 20/70 20/800 -12 21 14 1 (OS) M/60 Endotheliitis PK, Trab 38 36 No N/A 20/800 20/70 +12 8 9 2 (OD) F/50 Endotheliitis None 13 3.5 No N/A 20/100 20/40 +4 30 12 2 (OS) F/50 Endotheliitis None 13 3.5 No N/A 20/30 20/20 +2 12 16 3 M/57 Endotheliitis Trab 24 2 No N/A 20/1600 20/20 +18 16 17 4 M/59 FUS None 12 2 Yes 4 20/25 20/20 +1 27 7 Clinical Ophthalmology 2012:6 5 F/50 FUS Trab 6 2.5 No N/A 20/25 20/25 +1 8 8 6 M/49 FUS None 15 2.5 No N/A 20/100 20/20 +7 15 8 7 M/48 PSS None 6 3.5 No N/A 20/70 20/25 +4 21 17 8 F/39 PSS None 17 2.5 Yes 1 20/30 20/30 +0 23 16 9 M/58 PSS Phaco, Trab 23 3.5 No N/A 20/70 20/800 -12 18 6 10 M/28 PSS None 6 7 Yes 2 20/20 20/18 +1 11 11 Dove 11 M/70 PSS Phaco 29 27 Yes 1 20/70 20/25 +4 28 11 press Abbreviations: M, male; F, female; PSS, Posner-Schlossmann syndrome; FUS, Fuchs uveitis syndrome; PK, penetrating keratoplasty; Trab, trabeculectomy; Phaco, phacoemulsification; VA, visual acuity; IOP, intraocular pressure; N/A, not applicable. Powered by TCPDF (www.tcpdf.org) 1 / 1 Dovepress Valganciclovir for anterior segment inflammation eyes at the same time. The mean age of the patients at the valganciclovir and recurrence of anterior segment inflam- commencement of valganciclovir treatment was 51.6 ± 10.8 mation was 2 (range 1–4) months. Two of these patients had (range 28–70) years, and there were eight males and three repeat aqueous tap and both were found to be positive for females. All patients were of Chinese ethnicity. Diagnoses CMV PCR. All patients were resumed on oral valganciclovir included Posner-Schlossmann syndrome in five (45.4%) following recurrence of anterior segment inflammation. Three patients, Fuchs uveitis syndrome in three (27.3%) patients, patients remained on valganciclovir at the last follow-up, two and corneal endotheliitis in three (27.3%) patients. for prevention of IOP rise in Posner-Schlossmann syndrome All patients had aqueous aspiration performed prior and one for prevention of graft failure in corneal endothe- to commencement of valganciclovir, and the PCR of the liitis. Eight eyes underwent subsequent surgery during the aqueous fluid was positive for CMV DNA and negative for follow-up period, including trabeculectomy in three eyes, herpes simplex virus and herpes zoster virus DNA. At time combined phacoemulsification and trabeculectomy in two of starting oral valganciclovir, the mean ± standard deviation eyes, phacoemulsification and endothelial keratoplasty in one logMAR visual acuity of the 13 eyes was 0.58 ± 0.57 eye, and phacoemulsification in one eye. (Snellen equivalent 20/76; range 0.0–1.8 logMAR units). The mean baseline IOP was 18.3 ± 7.4 (range 8–30) mmHg Changes in visual acuity and the eyes were on a median three (range 0–4) types of and intraocular pressure antiglaucomatous eye drops prior to treatment with oral At the last follow-up, the mean logMAR visual acuity valganciclovir. Four (36.3%) patients were also on oral aceta- was 0.37 (Snellen equivalent 20/47). There was a signifi- zolamide for IOP control. Other topical medications used cant improvement in the level of visual acuity at the last- by the patients at presentation included 1% prednisolone follow-up compared with baseline (Wilcoxon sign-ranked acetate eye drops in seven patients, 0.5% loteprednol eta- test, P = 0.048).
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