How should I manage a patient with CMV retinitis who is immunocompromised?

Management of cytomegalovirus (CMV) retinitis in immunocompromised patients requires prompt initiation of antiviral therapy to prevent vision loss and systemic dissemination. The first-line treatment typically involves systemic antiviral agents such as intravenous ganciclovir or oral valganciclovir, which have demonstrated efficacy in controlling CMV replication and retinal inflammation NICE CKS. In cases where systemic therapy is contraindicated or insufficient, intravitreal injections of ganciclovir or foscarnet can be used to deliver high local drug concentrations directly to the retina Zhang et al. 2024.

Alongside antiviral treatment, it is critical to optimize the patient’s immune status where possible, such as initiating or adjusting antiretroviral therapy in HIV-positive patients to restore immune function and reduce CMV reactivation risk NICE CKS. Regular ophthalmologic monitoring is essential to assess treatment response and detect complications like retinal detachment early Zhang et al. 2024. Adjunctive corticosteroids are generally avoided due to the risk of exacerbating viral replication unless there is significant immune recovery uveitis.

In summary, management integrates systemic antiviral therapy as the cornerstone, supplemented by intravitreal antivirals if needed, immune restoration strategies, and close ophthalmic follow-up to preserve vision and control infection NICE CKS; Zhang et al. 2024.