Managing CMV Retinitis

• The choice of initial therapy for CMV retinitis should be individualized, based on tolerance of systemic medications; prior exposure to anti-CMV drugs; and on the location of lesions (AIII).
• Given the evident benefits of systemic therapy in preventing contralateral eye involvement, reducing CMV visceral disease, and improving survival, treatment should include systemic therapy whenever feasible.

Initial Therapy Followed by Chronic Maintenance Therapy—For Immediate Sight-Threatening Lesions (within 1,500 microns of the fovea)

Preferred Therapy

• Ganciclovir 5 mg/kg IV every 12 hours for 14–21 days, then 5 mg/kg IV daily (AI), or
• Ganciclovir 5 mg/kg IV every 12 hours for 14–21 days, then valganciclovir 900 mg PO daily (AI), or
• Valganciclovir 900 mg PO every 12 hours for 14-21 days, then 900 mg daily (AI);

  with or without

• Intravitreal injections of ganciclovir (2 mg/injection) or foscarnet (2.4 mg/injection) repeat weekly until lesion inactivity is achieved. This is to provide higher intraocular levels of drug and faster control of the infection until steady-state intraocular ganciclovir concentrations are achieved (AIII);

Note: IV ganciclovir can be switched to oral valganciclovir if the patient is clinically improving and there are no concerns about gastrointestinal absorption.

Alternative Therapy

• Intravitreal injections as listed above (AIII); plus one of the following systemic therapies: 
  • Foscarnet 60 mg/kg IV every 8 hours or 90 mg/kg IV every 12 hours for 14–21 days, then 90–120 mg/kg IV every 24 hours (BI), or
  • Cidofovir 5 mg/kg/week IV for 2 weeks, then 5 mg/kg every other week; each dose should include 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) (CI). Cidofovir is contraindicated in patients with a serum creatinine >1.5 mg/dL, a calculated creatinine clearance ≤5 mL/min or a urine protein ≥100 mg/dL (equivalent to ≥2+ proteinuria). Given the nephrotoxic potential of cidofovir, cautious use of cidofovir with tenofovir is advised.
    • Note: This regimen should be avoided in patients with sulfa allergy because of cross hypersensitivity with probenecid.

• Valganciclovir 900 mg PO every 12 hours for 14–21 days, then 900 mg once daily (AI) for the first 3–6 months until antiretroviral therapy-induced immune recovery (AII). 

• Minimizing lesion size by treating all CMV retinitis lesions until there is immune recovery may reduce the incidence of immune reconstitution uveitis (BII).
• Immune reconstitution uveitis might develop in the setting of immune reconstitution.

• Periocular or intravitreal corticosteroid or a short course of systemic steroid (BIII).