CMV Retinitis Treatment & Management

Updated: Oct 20, 2016
  • Author: Michael Altaweel, MD, FRCSC; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

Medical Care

An internist or infectious disease specialist coordinates medical care. Ophthalmic assessment is required on a regular basis, with frequency dependent on existence of CMV retinitis and on CD4 count. The immunosuppressed individual requires evaluation for other opportunistic infections and surveillance for side effects of prescribed medications.

Highly active antiretroviral therapy (HAART)  [73]

This treatment regimen has altered the long-term management of CMV retinitis. [74, 75] Because the antiviral medications used to treat CMV are virustatic, patients needed to continue their use for the rest of their lives. The advent of HAART, with consequent recovery of immune function (2 consecutive CD4+ T-cell counts of ≥ 100 cells/μL at least 6 mo apart) allows individuals to discontinue their CMV therapy if the retinitis has resolved adequately with antiviral treatment. [9] As long as the CD4 count remains elevated, little risk exists of disease recurrence. [76]

Intravenous or oral therapy can be discontinued, or a scheduled implant replacement can be delayed indefinitely. [77, 78]

Careful monitoring of both immune status and ophthalmic findings are necessary to prevent retinal damage from an asymptomatic recurrence.

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Surgical Care

Individuals with CMV retinitis commonly require surgical intervention, whether for repair of a retinal detachment or for intravitreal instillation of ganciclovir by injection or implantation.

Retinal detachment due to CMV retinitis

This condition occurs in 5-29% of eyes in various case series. High incidence of bilaterality exists. [79]

Repair is most successful with vitrectomy, endolaser, scleral buckle, and silicone oil endotamponade. [80]

A total reattachment rate of 76% exists; macular attachment occurs in 90%. Mean postoperative visual acuity is 6/18.

Prophylactic laser for the other eye with CMV did not prevent retinal detachment. [81, 82]

Intravitreal ganciclovir implant  [83, 84]

Dosing is 1 µg/h sustained release with life span of 8 months. [85]  

Study of immediate versus deferred therapy:

  • Deferred - 15 days to progression
  • Immediate - 226 days to progression, only 5 of 14 progressed
  • Retinal detachment rate 11% (13-26% in IV treatment group)
  • Within 6 months, 50% develop CMV retinitis in fellow eye.

Advantages include the following:

  • Less systemic toxicity
  • Better effect versus CMV in implanted eye
  • Can use AZT concomitantly
  • No indwelling catheter
  • Implant is useful if intolerant of systemic ganciclovir or if progression continues despite intravenous treatment. [86]

Disadvantages include the following:

  • Sixty-seven percent developed CMV in the fellow eye versus 0-15% rate in intravenous treatment group.
  • No systemic effect for CMV organ disease
  • Risk of retinal detachment and vitreous hemorrhage: [87] Retinal detachment may occur despite the implant rather than as a consequence of surgery. The risk of detachment is reduced if immune recovery occurs in the period after the ganciclovir implant. [58]

Intravitreal ganciclovir injection  [88]

Details are as follows:

  • Delayed progression of disease
  • Topical anesthesia
  • Short half-life - Injection is required twice per week.
  • Increased risk of endophthalmitis, retinal detachment, and vitreous hemorrhage
  • Can be successful as sole treatment for CMV retinitis associated with immunosuppression without AIDS; in a case series of 13 eyes with active lesions, 5.54 ± 3.36 intravitreal ganciclovir injections were required, allowing resolution in 1.81 ± 1.25 months, with one late recurrence [89]

Intravitreal foscarnet   [65] or cidofovir  [66] injection

High-dose injection (2.4 mg) of foscarnet once to twice per week as an alternative to ganciclovir in patients who are intolerant

Cidofovir is given every 5-6 weeks. Potential side effects include iritis (18% with prophylactic oral probenecid) and/or visually significant hypotony (1%)

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Consultations

See the list below:

  • Infectious disease specialist
  • Evaluation of general medical condition - Assessment for other end-organ sequelae of CMV infection (pneumonitis, gastroenteritis); evaluation for other opportunistic infections

  • Evaluation for criteria sufficient to meet the diagnosis of AIDS

  • Assessment of confirmatory lab tests

  • Institution of systemic therapy (for CMV retinitis and for AIDS)

  • General internist, hematologist, and/or oncologist referral if CMV retinitis is associated with immunosuppression for non–HIV-related reasons

  • Transplantation specialist for transplant-related CMV retinitis

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