|Managing CMV Retinitis
Initial Therapy Followed by Chronic Maintenance Therapy—For Immediate Sight Threatening Lesions (within 1500 microns of the fovea)
- The choice of initial therapy for CMV retinitis should be individualized, based on location and severity of the lesion(s), the level of immunosuppression, and other factors (e.g., concomitant medications, ability to adhere to treatment) (AIII).
- Given the evident benefits of systemic therapy in preventing contralateral eye involvement, reduce CMV visceral disease and improve survival,whenever feasible, treatment should include systemic therapy.
- The ganciclovir ocular implant, which is effective for treatment of CMV retinitis, is no longer available.
- Intravitreal injections of ganciclovir (2 mg/injection) or foscarnet (2.4 mg/injection) for 1–4 doses over a period of 7–10 days to provide higher intraocular levels of drug and faster control of the infection until steady state intraocular ganciclovir concentrations are achieved (AIII); plus
- Valganciclovir 900 mg PO BID for 14–21 days, then 900 mg once daily (AI)
For Peripheral Lesions:
- Intravitreal injections as listed above (AIII); plus one of the following systemic therapy:
- Ganciclovir 5 mg/kg IV q12h for 14–21 days, then 5 mg/kg IV daily (AI), or
- Ganciclovir 5 mg/kg IV q12h for 14–21 days, then valganciclovir 900 mg PO daily (AI), or
- Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21 days, then 90–120 mg/kg IV q24h (AI), or
- Cidofovir 5 mg/kg/week IV for 2 weeks, then 5 mg/kg every other week with saline hydration before and after therapy and probenecid 2 g PO 3 hours before the dose followed by 1 g PO 2 hours after the dose, and 1 g PO 8 hours after the dose (total of 4 g) (BI).
Note: This regimen should be avoided in patients with sulfa allergy because of cross hypersensitivity with probenecid.
- Administer one of the systemic antiviral therapy listed above for the first 3–6 months until ART induced immune recovery (AII).
Treatment of IRU:
- Minimizing lesion size by treating all CMV retinitis lesions until there is immune recovery may reduce the incidence of IRU (BII).
- IRU might develop in the setting of immune reconstitution.
Stopping Chronic Maintenance Therapy for CMV Retinitis:
- Periocular corticosteroid or a short course of systemic steroid (BIII).
Reinstituting Chronic Maintenance for CMV Retinitis:
- CMV treatment for at least 3–6 months, and lesions are inactive, and with CD4 count >100 cells/mm3 for 3 to 6 months in response to ART (AII).
- Therapy should be discontinued only after consultation with an ophthalmologist, taking into account magnitude and duration of CD4 count increase, anatomic location of the lesions, vision in the contralateral eye, and the feasibility of regular ophthalmologic monitoring.
- Routine (i.e., every 3 months) ophthalmologic follow-up is recommended after stopping chronic maintenance therapy for early detection of relapse or IRU, and then periodically after sustained immune reconstitution (AIII).
- CD4 count <100 cells/mm3 (AIII).