Induction and maintenance therapy of cytomegalovirus central nervous system infection in HIV-infected patients.

OBJECTIVE: To evaluate the efficacy and safety of the foscarnet-ganciclovir combination in induction therapy (IT) and maintenance therapy (MT) for cytomegalovirus (CMV) central neurological disorders in HIV-infected patients. DESIGN: An open pilot non-comparative multicentre study. METHODS: Thirty-one patients with acute CMV encephalitis (CMVe) (n = 17) or CMV myelitis (CMVm) (n = 14) during the era before highly active antiretroviral therapy (HAART) received intravenous IT with foscarnet 90 mg/kg plus ganciclovir 5 mg/kg twice a day followed by MT. The primary endpoint was clinical efficacy, assessed at the end of the induction phase. RESULTS: The foscarnet-ganciclovir combination in IT resulted in a 74% (23 out of 31 patients) clinical improvement or stabilization. Eight patients did not respond clinically. Side-effects leading to drug discontinuation occurred in 10 patients during IT. Among the 23 patients who qualified for the maintenance phase, CMV disease progressed in 10, with a median time to the first relapse of 126 days (range 64-264 days). Overall, the median survival time was 3 months [95% confidence interval (CI), 2-4 months]. CONCLUSION: The combination of foscarnet and ganciclovir can safely be used for CMV central nervous system (CNS) infection, with an improvement or stabilization in 74% of patients. Life-long MT with this combination is recommended as long as the immune system is profoundly impaired.

Persistent hyperplastic primary vitreous and recessive oculo-dento-osseous dysplasia.

We report on a patient with oculo-dento-osseous dysplasia and bilateral persistence of the hyaloid system. Autosomal recessive inheritance may be the cause of this patient's condition since she was born to unaffected first-cousin parents. Ocular findings in the recessive variety of this syndrome seem to be more severe than those in the more common dominant form.

Penetration of tobramycin sulfate in the aqueous humor of the rabbit.

The intraocular penetration of tobramycin sulfate, a new aminoglycoside antibiotic, was evaluated in rabbits following subconjunctival injection. The mean tobramycin sulfate concentration in the aqueous humor 60 minutes after a single 5-mg dose was 5.5 mug/ml, as compared to a mean concentration of 6.7 mug/ml following a single 10-mg dose. These levels exceed the minimal inhibitory concentration (MIC) for most Pseudomonas species and a variety of other Gram-negative bacilli recovered from clinical infection. No anterior segment changes that may be attributed to the antibiotic could be demonstrated in the injected eye.

Intraocular penetration of sisomicin in rabbits.

The intraocular penetration of sisomicin, an aminoglycoside antibiotic, was studied in 47 normal rabbits following subconjunctival and/or intramuscular (IM) injections. Sisomicin levels were determined in the cornea and the aqueous humor of the injected eye as well as in the aqueous of the fellow eye by means of the cylinder-plate bioassay technique. When the IM route alone was used, the eye tissue concentrations remained negligible. One hour after subconjunctival injection, highly therapeutic sisomicin concentrations were achieved in the aqueous humor of both injected and fellow eyes, but the level dropped to very low concentrations 12 hours after the injection. The concomitant administration of sisomicin intramuscularly and subconjunctivally resulted in a significant delay of the clearance of sisomicin from the eye tissues. The use of the combined subconjunctival-IM regimen for administering aminoglycoside antibiotics needs further evaluation.

Intraocular pressure, cup-disc ratio, and steroid responsiveness in retinal detachment.

A review of the literature failed to indicate whether the high incidence of open angle glaucoma in patients with nontraumatic rhegmatogenous retinal detachment is due to common genetic determinants. The diurnal variation of intraocular pressure, the cup-disc C/D ratio, and the intraocular response to topically applied corticosteroids were studied in 30 subjects with unilateral, nontraumatic, rhegmatogenous retinal detachment. The results indicate that 20% of the subjects were high steroid responders and that 53% had a C/D ratio greater than 0.3. We shall discuss the relationship of these findings to the multifactorial inheritance of open angle glaucoma.

Penetration of intravenous moxalactam into human aqueous humor.

Intraocular penetration of moxalactam disodium, a new broad-spectrum oxa-beta-lactam antibiotic, was studied in 18 patients undergoing cataract surgery. The antibiotic was administered in a 2-g single dose by intravenous drip during a 20-minute period. After 40 to 230 minutes, moxalactam aqueous humor concentrations ranged from 1.1 to 5.0 micrograms/mL (mean, 2.3 micrograms/mL). The ratio of aqueous humor concentrations to concomitant serum concentrations ranged from 1.6% to 9.8%. The achievable aqueous moxalactam concentrations were well above the minimum inhibitory concentrations of most Gram-negative enteric bacilli but not of Pseudomonas and staphylococci.

Cloxacillin penetration.

We investigated the intraocular penetration of cloxacillin in 14 patients undergoing surgery for senile cataract after intramuscular and subconjunctival injections of the drug. No antibiotic level was detected in the aqueous humor when cloxacillin was administered intramuscularly in a dose that ranged between 1 and 4 g. With subconjunctival injection, therapeutically effective cloxacillin activity was detected in the aqueous humor only after a dose of 250 mg.

Crystalline retinopathy.

A 23-year-old woman had a chorioretinal dystrophy with retinal crystalline deposits, geographic areas of atrophy of the retinal pigment epithelium, choriocapillaris in the posterior pole, and fine pigment clumps in the midperiphery. Crystals were also observed in the periphery of the corneal stroma and epithelium. A diagnosis of crystalline retinopathy was made. Visual acuity and visual fields worsened over a two-year period. This is the first report of Bietti's crystalline retinopathy in the Middle East. The literature shows that corneal crystalline deposits are seen more frequently in Occidentals than in Orientals with this condition. Autosomal recessive inheritance with low gene frequency is favored in this disease, which has a worldwide distribution and in which a history of parental consanguinity is frequently observed.

Occipital cortical infarction complicating respiratory failure.

We describe the occurrence of bilateral occipital cortical infarction following respiratory failure in two patients of differing ages. The precipitating factors, clinical manifestations, and ophthalmologic findings also differed, but the hypoxic effects on the cortex were the same as evidenced by the CT scanning studies.

The role of cryotherapy in the management of early lesions of retinoblastoma.

Cryotherapy alone has destroyed as isolated retinoblastoma lesion in the fellow eye of a proven case of retinoblastoma. Follow-up for 14 months revealed no evidence of recurrence. Literature review has shown that cryotherapy has unique advantages in the treatment of retinoblastomas.

Ocular pulse in high myopia: a study of 40 eyes.

The ocular pulse amplitude of 20 myopic individuals (40 eyes) with refractive errors of -5.00 diopters and above was determined, using the Alcon Pneumatonograph. When compared to a group of normal individuals, the myopic group was found to have a significantly smaller mean ocular pulse amplitude but a significantly higher mean intraocular pressure. The importance of pulse-pressure relationship in the two groups is discussed.

Ocular abnormalities and renal disease: a review.

The eye is a mirror that reflects pathologic changes occurring in many organs. The present paper presents eye changes in renal disease including hereditary progressive nephritis, cystic disease of the kidney, cystinosis, and diffuse mesangial sclerosis. It also touches on these changes in some syndromes with major renal involvement.

The retinopathy of primary hyperoxaluria.

The ophthalmoscopic and fluorescein angiographic findings in a seven-year-old boy with primary hyperoxaluria presented. The retinal findings in this condition have been reported previously in only ten patients. The fluorescein pattern which is considered to be very suggestive was reported previously in only one patient. In this report, ocular oxalosis is discussed, and the crystalline retinopathies are briefly reviewed.