Vitreous Polymerase Chain Reaction Research Articles

The impact of polymerase chain reaction (PCR) on diagnosis and management of infectious uveitis at a tertiary care facility

BackgroundPolymerase Chain Reaction (PCR) is a well-accepted adjunct in the management of infectious uveitis. In turn, few reports in the literature have evaluated how PCR then impacts patient care. This study aims to evaluate the impact of PCR sampling on diagnosis and treatment of infectious uveitidies at a large tertiary care facility.Main bodyThis is a retrospective, observational study of patients with aqueous and vitreous PCR samples obtained from 2014 to 2019. The study was undertaken at a single institution. At least one follow up visit following results of PCR testing was required for inclusion. If a patient had multiple PCR samples taken, only the first sample was included. The patients were divided into three categories based on pre-sampling diagnosis. A chi-square test was used to analyze the data. 108 cases were available for analysis. PCR did not change diagnosis or management in any of the cases where pre-sampling diagnosis carried a high clinical suspicion for negative PCR. Overall, the results of PCR testing had a more significant impact on diagnosis in those cases where pre-sampling diagnosis was unknown versus those where it was confirmatory in nature, thus presumed to be related to an infectious entity tested by PCR (74% vs. 29%, p = 0.00006). The rate of treatment change based on PCR was similar between those cases where there was a high clinical suspicion for positive PCR and those where pre-sampling diagnosis was unknown (32% vs. 33%, p = 0.95). Further analyzing specimens separately depending on source of sample, this pattern persisted for aqueous samples, with PCR showing a more significant impact on diagnosis in those cases where the diagnosis was unknown versus those where sampling was confirmatory (86% vs. 31%, p = 0.00004). The rate of change in treatment between the two groups was similar (35% vs. 31%, p = 0.79). Vitreous samples followed a similar pattern with a higher rate of diagnosis change for those cases where pre-sampling diagnosis was unknown and a similar rate in treatment change between the two groups, however this did not reach statistical signifigance (44% vs. 25%, p = 0.28; 27% vs. 33%, p = 0.74).ConclusionThere is no well-defined algorithm as to when to employ PCR testing in uveitis. As expected, in our experience, it has the largest impact on diagnosis when the diagnosis is unknown, however even when confirmatory in nature, it continues to impact patient management.

Atypical toxoplasmic retinochoroiditis in patients with malignant hematological diseases

In immunocompromised patients, toxoplasmosis may have atypical presentation with bilateral, extensive or multifocal involvement. We report a case series of atypical toxoplasmic retinocoroiditis in patients with malignant hematological diseases who are usually immunosuppressed. Four patients were diagnosed of atypical toxoplasmic retinochoroiditis, all of them had immunosuppression (100%) and half of them (50%) had received a bone marrow transplant. The polymerase chain reaction for toxoplasma was positive in 75% of cases, and in one case (25%) the diagnosis was made with clinical and serological criteria. One patient presented ocular toxoplasmosis despite being on prophylactic treatment with atovaquone. Patients with atypical ocular toxoplasmosis and hematological diseases are generally immunocompromised, but they do not always have history of a bone marrow transplant. The presentation may be due to a primary infection or a reactivation of the disease. The aqueous humor and/or vitreous polymerase chain reaction allow confirming the diagnosis to perform a proper treatment.

Simultaneous amplification of herpes simplex virus type 2 and Epstein–Barr virus in an immunocompetent host with acute retinal necrosis

Acute retinal necrosis (ARN) is an ocular inflammatory disease characterized by panuveitis and retinal vasculitis. Herpes virus is strongly associated with ARN and can often be detected by polymerase chain reaction (PCR) of vitreous samples. The authors report a case of ARN associated with herpes simplex virus-2 (HSV-2) and Epstein–Barr virus (EBV) in an immunocompetent host. A 72-year-old man with a history of herpes zoster ophthalmicus presented with sudden vision loss in the left eye in the setting of hypertensive anterior uveitis and severe vitreous inflammation. ARN was diagnosed and antiviral and steroid treatment was initiated. Vitritis improved 1 week later and foci of retinal necrosis with occlusive vasculitis were observed. Three days later, a rhegmatogenous retinal detachment developed. Pars plana vitrectomy with retinopexy was performed and a vitreous PCR test was positive for both HSV-2 and EBV. Despite retinal reattachment, visual acuity did not improve. Prophylactic antiviral therapy was continued for the fellow eye. The coexistence of more than one virus in the ARN context is exceedingly rare and might be associated with poor visual outcomes.

Acute Retinal Necrosis Multicenter Case Series: Prognostic Indicators and Treatment Outcomes

Purpose: The purpose of this article is to report the prognostic associations of acute retinal necrosis (ARN), determine the diagnostic utility of aqueous vs vitreous polymerase chain reaction (PCR), and describe outcomes of antiviral, corticosteroid, antithrombotic, and laser retinopexy treatment. Methods: A retrospective, nonrandomized case series was conducted. Primary outcomes included final visual acuity (VA), severe VA loss (≥1.00 log of the minimum angle of resolution [logMAR] [Snellen equivalent, <20/200]), and retinal detachment (RD). Results: Fifty eyes of 46 patients were diagnosed with ARN. Varicella-zoster and herpes simplex viruses were the viral etiology in 29 and 16 eyes, respectively. Five were diagnosed on clinical criteria. Intravenous acyclovir was administered in 90% of eyes. Neither induction therapy for ≥13 days ( P = .692) nor intravitreal medication ( P = .203) decreased the incidence of severe vision loss. Maintenance antiviral medication was administered in 96% of eyes (50% received >13 weeks). At final follow-up, 40% of eyes had severe vision loss (range, –0.08 to +3.0 logMAR [Snellen, 20/17-no perception of light]). Forty-six percent developed RD. Relative afferent pupillary defect (RAPD), zone and extent of retinitis, and RD were prognostic of final VA. Antithrombotic therapy was administered in 25/50 eyes and was associated with lower incidence of severe VA loss ( P = .027) and better final VA ( P = .040). Laser retinopexy was performed in 40% of eyes with no significant effect on RD incidence ( P = .901) or severe VA loss ( P = .451). Conclusions: ARN has a high incidence of RD and poor visual outcomes. Aqueous humor PCR is the first-line diagnostic investigation. Prognostic indicators include RD, RAPD, zone, and extent of retinitis. Induction antiviral medication is appropriate for at least 12 days. Antithrombotic medication is associated with improved outcomes. Laser retinopexy does not reduce the incidence of RD.

Multifocal Toxoplasma Retinochoroiditis in a Nonimmunosuppressed Elderly Patient: Case Report and Brief Review of the Literature

Purpose To raise awareness of ophthalmologists that toxoplasmosis should be considered in the differential diagnosis of multifocal or diffuse necrotizing retinitis in nonimmunosuppressed elderly patients. Methods Interventional case report with serial color fundus photographs, indocyanine green angiography, fluorescein angiography, optical coherence tomography, and chorioretinal biopsy histology. Results A 77-year-old, nonimmunosuppressed man developed extensive multifocal retinochoroiditis with scattered focal hemorrhages and significant vitreous haze. This case posed a significant diagnostic challenge mimicking viral retinitis. Vitreous polymerase chain reaction and chorioretinal biopsy confirmed the diagnosis of toxoplasma retinochoroiditis. Conclusions As demonstrated in this case, toxoplasmosis should be considered as a cause of multifocal and/or diffuse necrotizing retinitis in elderly patients even in the absence of obvious systemic immunosuppression.

Cytomegalovirus retinitis in an immunocompetent pregnant woman

Cytomegalovirus (CMV) is a herpes virus that causes a wide spectrum of diseases. One of the most important clinical manifestations of CMV is retinitis which occurs often in immunocompromised patients and is a serious and sight‑threatening condition. The diagnosis is made clinically based on ophthalmologic examination but in equivocal situations can be confirmed by aqueous or vitreous polymerase chain reaction (PCR) testing. Here, we report one case of CMV retinitis in a pregnant woman without any obvious immunodeficiency that started with mononucleosis like syndrome at first and followed by retinal involvement. The disease was diagnosed by ophthalmologists and confirmed by aqueous PCR. The patient was treated with ganciclovir. Our opinion is that pregnancy and its mild cellular immunity can probably be considered as a cause of CMV retinitis in this patient. Keywords: Cytomegalovirus , immunocompetency, pregnancy, retinitis

Cytomegalovirus Retinitis in Chinese Patients of non-Hodgkin Lymphoma with Normal CD4 Counts

Objective: To manifested the clinic features in two cases of cytomegalovirus(CMV) retinitis in Chinese patients of non-Hodgkin lymphoma with normal CD4 counts. Methods: Two patients with non-Hodgkin lymphoma presented with floaters and vision reduction in affected eyes. The patient underwent eye examination and blood investigation, and vitreous was extracted for CMV-DNA polymerase chain reaction (PCR). The patient was treated with intravenous and intravitreal ganciclovir. Results: Funduscopy showed typical yellow and white lesions in the retina of affected eyes. Blood investigation showed HIV(-), CMV- IgG (+) IgM (-),and CD4 T-cell counts more than 300 cells/ul. CMV DNA PCR(+) of vitreous sample supported the diagnosis of CMV retinitis. Retinitis regressed after the treatment of ganciclovir. Conclusions: CMV retinitis occurred in non-HIV disease such as non-Hodgkin lymphoma with normal CD4 counts. These cases showed CMV-DNA PCR of vitreous may be a good marker for CMV retinitis and intravitreal ganciclovir may be an effective treatment.

Epstein-barr infection of the retina: case report and review of the literature.

The purpose of this study is to describe a presumed case of Epstein-Barr virus (EBV) infection of the retina in a 65-year-old female with sudden bilateral vision loss. Diagnostic vitreous biopsy of the left eye was performed to test for EBV and other known infectious causes of retinitis and evaluate vitreous cells. Serologic EBV testing was positive. Vitreous polymerase chain reaction viral DNA testing was positive for EBV, but negative for herpes-simplex virus, varicella-zoster virus, cytomegalovirus, and toxoplasma gondii. Histopathologic analysis of vitreous cells revealed atypical lymphocytes. Epstein-Barr virus may be a cause of retinal disease. Awareness of this severe ocular complication may enable prompt diagnosis and treatment of future cases, and promote greater investigation into its disease prevalence.

Cytomegalovirus (CMV) retinitis activity is accurately reflected by the presence and level of CMV DNA in aqueous humor and vitreous.

To evaluate the potential of ocular and systemic specimens to provide markers of active cytomegalovirus (CMV) retinitis, we examined the relationship between virologic and clinical aspects of CMV infections in AIDS patients with CMV retinitis. CMV polymerase chain reaction (PCR) analysis of 74 aqueous humor and vitreous specimens indicated that ocular specimens can provide accurate markers to differentiate active and inactive CMV retinitis (aqueous or vitreous PCR, P<.001). Moreover, these markers were superior to extraocular measures, including plasma PCR (P=.08) and blood and urine CMV cultures (P=.05). A direct correlation was identified between the quantity of CMV DNA in aqueous humor or vitreous specimens and the corresponding surface area of active CMV retinitis (r2=.69 and.44, respectively). Thus, qualitative and quantitative PCR-based analyses of aqueous humor can provide valuable markers of CMV retinitis activity. Such assays could provide rapid and reliable tools to assist in management of patients with CMV retinitis in whom the view of the retina is obscured.