Treatment of CMV Retinitis

Initial Treatment Selection Based on Lesion Location

The Centers for Disease Control and Prevention recommends ganciclovir intraocular implant plus oral valganciclovir as the preferred initial therapy for sight-threatening CMV retinitis, while oral valganciclovir alone is adequate for small peripheral lesions 1, 2, 3
Ganciclovir intraocular implant plus oral valganciclovir 900 mg twice daily is superior to systemic therapy alone for preventing relapse in patients with sight-threatening lesions 1, 2, 4
Some ophthalmologists recommend an initial intravitreous ganciclovir injection at diagnosis to deliver high local drug concentration immediately until the implant can be surgically placed 1, 2
Oral valganciclovir 900 mg twice daily is the preferred initial therapy for small peripheral lesions due to ease of administration and avoidance of surgical/catheter complications 1, 2, 4

The Centers for Disease Control and Prevention recommends IV ganciclovir 5 mg/kg twice daily for induction, followed by maintenance dosing, as an alternative systemic treatment option for CMV retinitis 4
IV foscarnet is recommended for patients with ganciclovir intolerance or resistance 4, 5
IV cidofovir is recommended as a third-line option, though it carries substantial nephrotoxicity risk 4, 6

Treatment should continue until sufficient immune recovery occurs, defined as a CD4+ count >100 cells/µL sustained for 3-6 months 4, 5, 7
Antiretroviral therapy should be initiated or optimized concurrently with CMV treatment in HIV-infected patients 1, 5, 6

Ophthalmologic monitoring should include dilated indirect ophthalmoscopy at diagnosis, after completion of induction therapy, at 1 month, then monthly while on treatment 5
Monthly standardized fundus photographs provide optimal documentation for detecting early relapse 5
Laboratory monitoring should include complete blood counts and platelet counts twice weekly during induction, then weekly during maintenance 5
Serum electrolytes and renal function should be monitored twice weekly during induction, then weekly, especially for patients receiving foscarnet and cidofovir 5

Ganciclovir/valganciclovir toxicities include severe neutropenia, anemia, thrombocytopenia, nausea, diarrhea, and renal dysfunction 5, 6
Foscarnet toxicities include nephrotoxicity, electrolyte abnormalities, and neurologic dysfunction 4, 5, 6
Cidofovir toxicities include dose-related nephrotoxicity, ocular hypotony, and are contraindicated in patients with renal dysfunction or proteinuria 3, 5, 6