CMV retinitis

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Background

  • Most frequent and serious ocular opportunistic infection
  • Leading cause of blindness in AIDS patients
  • Typically occurs with CD4 less than 50
Fundus photograph of CMV retinitis

Clinical Features

  • Variable, but may include:
    • Change in visual acuity
    • Visual field cuts (Scotomas, loss of central vision)
    • Floaters, flashing lights
    • Photophobia
    • Eye redness/pain

Differential Diagnosis

Acute onset flashers and floaters

HIV associated conditions

Evaluation

  • CD4 typically < 50 cells/mm³
  • Fundoscopy:
    • Fluffy white perivascular lesions
    • Dirty white granular retinal necrosis
    • Adjacent hemorrhage - "Pizza pie" appearance

Management

Antivirals

Severe Vision Threatening

  • Ganciclovir intraocular implant for 8 months AND
    • Valganciclovir 900mg PO q12hrs x 14 days FOLLOWED BY 900mg PO q24hrs x 7 days

Peripheral lesions

  • Valganciclovir 900mg PO q12hrs x 21 days FOLLOWED BY 900mg PO q24hrs x 7 days

Complications

  • Retinal detachment
  • Complete Vision loss
  • CMV Immune Recovery Uveitis (IRU)
    • Patients with retinitis who develop blurry vision after starting HART need ophtho eval to assess for CMV progression, relapse, or IRU
    • Possible cause - T-cell mediated immune reconstitution to latent CMV intraocular antigens
    • Symptoms - Floaters, photophobia, blurred vision
    • Occurs median 20 weeks after starting HAART
    • Urgent ophtho eval

Disposition

  • Despite treatment, 10% lose vision

See Also

References

  1. Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.
  • Rothmans RE, Marco CA, Yang S. Human immunodeficiency virus infection and acquired immunodeficiency syndrome, in Tintinalli JE, Stapczynski JS, Ma OJ, et al (eds): Tintinalli’s Emergency Medicine, ed 7. New York, The McGraw-Hill Companies Inc., 2011.