Yale Medicine-Ophthalmology

Improving the odds, and quality of life, for AIDS patients

In surveys, fear of vision loss has ranked consistently as the leading quality-of-life concern among people living with AIDS—and with good reason. Among the opportunistic infections that often accompany the disease is a blinding disorder known as cytomegalovirus retinitis. One in four patients with AIDS develops CMV retinitis, which attacks and destroys the retina and leads to irreversible loss of sight if left untreated.

A decade ago, the only treatment for this form of viral retinitis was daily intravenous therapy, an expensive and unpleasant ordeal that carried with it the serious side-effects of kidney toxicity and reduced immune function—less than ideal for patients with HIV.

That picture has brightened somewhat since the introduction of new medications and surgical interventions during the past several years. Yale is among a handful of centers evaluating a new delivery system for the antiviral agent ganciclovir, one of a half-dozen drugs now available to treat CMV retinitis. Concentrated into tiny pellets in slow-release form, ganciclovir is implanted into the vitreous cavity of the eye, where it bathes the retina for as long as eight months before the implant procedure must be repeated.

Although the implant is effective in the majority of patients, says Ray Gariano, M.D., Ph.D., chief of the retinal service at Yale, it can cause retinal detachment or bleeding in the eye. Some patients develop resistance to the drug while others, with no systemic agent working against CMV, are left vulnerable elsewhere in the body, especially in the colon and lungs.

Even without the implant, retinal detachment occurs frequently among patients with CMV. Ophthalmologists are now able to correct the condition by surgically removing a portion of the vitreous humor at the back of the eye and replacing it with clear, silicone oil. The oil pushes the retina back against the inside wall of the eye and holds it in place. In 80 percent of the surgeries, the retina remains in place, and the patient’s vision is improved.

“Despite the fact that we have these options, none is perfect,” Dr. Gariano says. “We’re always looking for less toxic, more effective anti-CMV medications than have been studied in the past.”

One encouraging note is that with the partial success of a new generation of AIDS medications, better immune function has begun to offset the incidence of viral retinitis. Nowhere is this more apparent than among the youngest AIDS patients. Of 70 children with congenital HIV followed at Yale during the past three years, none has shown signs of viral retinitis.

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