totoxic lesion from coaxial light has been estimated to
be as short as 7.5 minutes, depending on intensity of
illumination, clarity of ocular media, pupil size, and
focus of the beam.
3
In contrast to coaxial light, oblique
indirect illumination contributes minimally to retinal
irradiance.
1
We consider the following factors as playing a perti-
nent role in producing the phototoxic lesion in our
patient. Coaxial light was used to illuminate the surgical
field during the entire procedure. The retrobulbar block,
which immobilized the eye, increased the probability
that a focused hot spot would remain on a specific area
of the retina for an extended period of time. The block
also dilated the pupil, and the dilation was not reversed.
Because the ocular media were clear and a corneal cover
was not used, maximum coaxial light was allowed
through the dilated pupil. Supplemental nasal oxygen
was administered, which may potentiate phototoxic
retinal damage.
4
In patients with a phototoxic lesion that spares the
fovea, the long-term prognosis for retention of central
visual acuity is good
5
; however, photic lesions that
involve the fovea can lead to notable vision loss. To
diminish the likelihood of phototoxic injury, the fol-
lowing precautions should be considered. Oblique indi-
rect illumination should be used when coaxial light is
not necessary. When coaxial light is required, the
intensity of the light should be kept as low as is
practical, and the microscope should be repositioned
intermittently to minimize prolonged illumination of
any one area of the retina. If possible, pupillary dilation
should be reversed. When visualization posterior to the
cornea is not required, opaque material should be placed
over the cornea. During surgery, after administration of
local anesthesia in patients younger than 40 years,
oxygen by nasal canula should be omitted unless medi-
cally necessary.
4
By reporting this case, we wish to bring
to the attention of ophthalmic surgeons the risk of
photic maculopathy associated with pterygium surgery.
REFERENCES
1. Michels M, Sternberg P Jr. Operating microscope-induced
retinal phototoxicity: pathophysiology, clinical manifestations
and prevention. Surv Ophthalmol 1990;34:237–252.
2. Byrnes GA, Antoszyk AN, Mazur DO, Kao T-C, Miller SA.
Photic maculopathy after extracapsular cataract surgery: a
prospective study. Ophthalmology 1992;99:731–738.
3. Irvine AR, Wood I, Morris BW. Retinal damage from the
illumination of the operating microscope: an experimental
study in pseudophakic monkeys. Arch Ophthalmol 1984;102:
1358 –1365.
4. Jaffe GJ, Irvine AR, Wood IS, Severinghaus JW, Pino GR,
Haugen C. Retinal phototoxicity from the operating micro-
scope: the role of inspired oxygen. Ophthalmology 1988;95:
1130 –1141.
5. Postel EA, Pulido JS, Byrnes GA, et al. Long-term follow-up
of iatrogenic phototoxicity. Arch Ophthalmol 1998;116:753–
757.
Cytomegalovirus Retinitis in
HIV-Infected Patients With
and Without Highly Active
Antiretroviral Therapy
Serge Doan, MD, Isabelle Cochereau, MD,
Nurhayat Guvenisik, MD,
Marie-Christine Diraison, MD,
Haı ¨ssam Mousalatti, MD, and
Thanh Hoang-Xuan, MD
PURPOSE: To assess the impact of highly active antiretro-
viral therapy on the epidemiology of cytomegalovirus
retinitis in patients infected with the human immunode-
ficiency virus (HIV).
METHODS: In a study performed in a single center for
infectious diseases, we compared the data collected in
1995 (without highly active antiretroviral therapy) with
1997 data (with highly active antiretroviral therapy).
RESULTS: In a comparison of 1997 with 1995 data, the
mean CD4
cell count of patients with cytomegalovirus
(CMV) retinitis was higher (169 150 CD4/l vs 15
47 CD4/l) (P .05), and the relapses of CMV retinitis
were less frequent (17% vs 36%) (P .02). Newly
diagnosed CMV retinitis decreased from 6.1% (59 of
952 patients) in 1995 to 1.2% (nine of 726 patients) in
1997 (P < .0001). In 1997, patients with newly diag-
nosed or relapsing CMV retinitis had a lower mean
CD4
(37 42) cell count than patients with no
relapsing CMV retinitis (197 160) (P .01).
CONCLUSION: The incidence and recurrences of CMV
retinitis decreased from 1995 to 1997, probably as a
result of restored immunity while the patients were
undergoing highly active antiretroviral therapy; how-
ever, the increasing frequency of HIV resistance to
highly active antiretroviral therapy justifies close ocular
follow-up. (Am J Ophthalmol 1999;128:250 –251.
© 1999 by Elsevier Science Inc. All rights reserved.)
P
ROGNOSIS OF HUMAN IMMUNODEFICIENCY VIRUS (HIV)
infection has been dramatically improved with the
advent of highly active antiretroviral therapy, which con-
sists of a combination of nucleoside analogs and HIV
protease inhibitors. Highly active antiretroviral therapy
reduces the incidence of opportunistic infections and
prolongs survival by improving immune status, as reflected
Accepted for publication March 11, 1999.
From the Service d’Ophtalmologie, Ho ˆpital Bichat, Claude-Bernard
46, rue Henri Huchard, 75018 Paris, France. This study was supported in
part by a grant from Ensemble contre le Sida-Sidaction-Fondation pour la
Recherche Me ´dicale, Paris, France (I.C.).
Inquiries to Isabelle Cochereau, MD, Service d’Ophtalmologie, Ho ˆpi-
tal Bichat, Claude-Bernard-46, rue Henri Huchard, 75018 Paris, France;
fax: 33 1 40 25 88 46; e-mail: oph.sec@bch.ap-hop-paris.fr
AMERICAN JOURNAL OF OPHTHALMOLOGY 250 AUGUST 1999