Internal Medicine

0521779407-10 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:44

858 Intraocular Infection

➣Intravitreal foscamet and intravenous acyclovir. May also use

intravitreal ganciclovir. Adjust acyclovir dose for reduced renal

function.

■Ocular toxoplasmosis

➣Bactrim DS BID. Add pyrimethamine, clindamycin, and pred-

nisone for recurrences threatening optic nerve or macula or

for marked vitreal inflammation. Folinic acid twice weekly to

reduce complications of pyrimethamine. Bactrim contraindicted

in patients with sulfa allergy.

■CMV

➣systemic ganciclovir, foscarnet or valganciclovir. Consider gan-

ciclovir implant. Reduce systemic immunosuppression.

➣Bone marrow suppression is major complication of ganciclovir.

➣Renal toxicity is major complication of foscamet.

■Systemic therapy of TB, Bartonella and Lyme as indicated

follow-up

■Bacterial & fungal endophthalmitis:

➣Daily for first 3–7 days, reduced frequency thereafter depending

on response

■Acute retinal necrosis:

➣Two or three times a week initially, weekly for next month

■Ocular toxoplasmosis:

➣Every 2–3 weeks

■CMV:

➣2 weeks after induction therapy, every 4–8 weeks thereafter,

depending on response to therapy and CD4 count

complications and prognosis

■Prognosis is guarded for bacterial and fungal endophthalmitis, but

rapid recognition and response will usually result in visual acuity

better than 20/80. Complications include cataract, glaucoma and

retinal detachment.

Prognosis for acute retinal necrosis syndrome is also guarded.

Most cases treated solely with systemic antivirals end up with vision

worse than 20/400. However, treatment with intravitreal antivi-

rals can significantly improve results. Complications include retinal

detachment (common), cataract, persistent vitreal opacification.

Cases of ocular toxoplasmosis usually do quite well unless there

is involvement of the optic nerve or macula. Major complication is

retinal scarring.