Not your usual capillary non-perfusion!

A 40-year-old Asian Indian male on chemotherapy for B-cell acute lymphoid leukemia (hemoglobin: 10.5 g/dL, total leucocyte count: 4500/mm3, platelet count: 1.36 lac/mm3) developed bilateral cytomegalovirus (CMV) retinitis (CMV-DNA positive from the blood sample, 5.75 × 103 IU/mL). Treatment with oral valganciclovir resulted in the resolution of retinitis lesions, and repeat blood CMV-DNA levels were negative. Maintenance dose oral valganciclovir (900 mg/dL) was continued. Fundoscopy on routine follow-up revealed retinal hemorrhages with occluded vessels in the left eye (double arrow) [Fig. 1] (A). Fluorescein angiography showed capillary non-perfusion (CNP) areas in the temporal and inferior periphery (asterisk) (B). Laser photocoagulation was done to CNP areas (arrowheads) (C). A week later, he developed new retinitis lesions in areas corresponding to the laser scars (arrows) (D).Figure 1: Fundus photograph (Optos California ultra-widefield imaging 200 DTx icg, Scotland, United Kingdom) of left eye showing retinal hemorrhages with occluded vessels (double arrow) (a). Fluorescein Angiography shows capillary non-perfusion (CNP) areas in the temporal and inferior periphery (asterisk) (b) for which laser photo-coagulation was done (arrow-heads) (c). A week later, he developed new retinitis lesions in areas corresponding to the laser scars (arrows) (d).What is your next step? Treat with oral corticosteroids Repeat fundus fluorescein angiography Give full therapeutic dose of valganciclovir 900 mg BD. Consider alternative diagnosis and workup the patient for autoimmune diseases. Findings Fundus examination shows granular CMV retinitis lesions (arrows) (D). Diagnosis Recurrence of cytomegalovirus retinitis following laser photocoagulation. The lesions resolved upon treatment with valganciclovir. Correct answer C) Give full therapeutic dose of valganciclovir 900 mg BD. Discussion Occlusive retinal vasculitis has been reported in patients with cytomegalovirus (CMV) retinitis and may represent active disease even in the absence of retinitis. Wang et al.[1] reported panretinal occlusive vasculitis in four eyes of three non-HIV patients. The patients were managed with oral antivirals, intravitreal anti-VEGF, and panretinal photocoagulation. Fabozzi et al.[2] reported another case of CMV occlusive retinal vasculitis in the absence of retinitis in a Southeast-Asian male. The patient responded to the treatment with oral antivirals and laser photocoagulation. In a large series of 39 patients with CMV necrotizing retinopathy, Long et al.[3] reported occlusive vasculitis and neovascular glaucoma in 5.1% of the patients. CMV infection may present with occlusive vasculitis. Therefore, it becomes important to carefully monitor and follow-up the patients with CMV retinitis, even after retinitis lesions have resolved. Timely management in form of laser photocoagulation and antiviral therapy can prevent neovascular complications. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.