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Answers: 2009 Series -  December 8, 2009 Lecture 4 of 52  NEXT»

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QOW120809_1A QOW120809_1B

A 29-year-old Caucasian male comes in complaining of floaters and blurry vision in the right eye over the last month. The patient admits to being an IV drug abuser.

1. What is the MOST LIKELY diagnosis in this case?

b -- cytomegalovirus (CMV)

This young patient is an intravenous drug abuser, which is a risk factor for HIV.  The most common opportunistic ocular infection in HIV patients is CMV retinitis.  This usually presents when the CD4 count drops below 50 cells/mm3.  About 40% of patients present with bilateral disease.  The fundus examinations show the characteristic retinal whitening and hemorrhages seen in CMV retinitis.

2. Which of the following treatments is felt to have a survival benefit for this patient?

d -- Ganciclovir given IV

Systemic therapy is felt to have a survival benefit in patients with CMV retinitis because of the treatment of extraocular CMV disease.  It also offers treatment to the contralateral eye.   Because some patients are not able to tolerate systemic therapy secondary to medication side effects (i.e. neutropenia, renal failure, etc), local therapy may be indicated.

3. How would you best treat a rhegmatogenous retinal detachment in this situation?

d -- PPV and silicone oil

One complication of CMV retinitis is that it can lead to a rhegmatogenous retinal detachment.  Retinal detachments secondary to CMV retinitis are difficult to repair because of the extent of retinal necrosis and retinal holes involved.  Often not only are there multiple retinal holes present, but also the holes are located posteriorly.  Thus, a scleral buckle alone would not be adequate treatment.  It is felt that PPV with long-term silicone oil tamponade would be the best treatment in this situation.


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