Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Cytomegalovirus Retinitis

Cytomegalovirus retinitis (CMVR) is the most common ocular opportunistic infection in people with HIV and the leading cause of blindness in this group [S5]. It also occurs with transplantation, haematological malignancy and iatrogenic immunosuppression [S5]. In low- and middle-income countries it remains common in people presenting late with HIV, and almost a third have vision loss [S2].

Key points - Diagnosis is clinical: a susceptible, immunocompromised patient with characteristic fundus findings; intraocular fluid PCR is used when confirmation is needed [S10]. - Oral valganciclovir is the preferred first-line treatment, with intravitreal ganciclovir when CMVR threatens the posterior pole (2025 international consensus) [S10]. - Antiretroviral therapy (ART) matters: recurrence was 10% in ART-treated vs 33% in untreated HIV patients [S9]. - Routine retinal screening of late-presenting HIV patients should be considered; CD4 count was below 50 cells/µL in 73.4% of cases where reported [S2]. - Immune recovery uveitis must be distinguished from CMVR relapse [S10].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Lesion approaching the posterior pole. Indication for intravitreal ganciclovir [S10].
• CD4 count below 50 cells/µL. Present in 73.4% of CMVR cases where reported [S2].
• Retinal detachment. Occurred in a pooled 11% of treated patients [S9]; ultra-widefield photography helps detect early retinal breaks [S11].
• New inflammation after starting ART. Immune reconstitution inflammatory syndrome developed in 37.7% of patients with prior CMVR [S1]; immune recovery uveitis must be separated from relapse [S10].
• Neutropenia on ganciclovir. The most reported adverse effect, up to 50% [S9].

Recognise it

• Who. People with advanced HIV/AIDS [S9]; also non-HIV patients ranging from limited immune dysfunction (advanced age, diabetes) to haematological and rheumatological disease, and local ocular immunosuppression [S4].
• Burden. Pooled prevalence in Asia was 14.0% of HIV-positive adults examined, with no clear decline between 1993-2002 and 2009-2013 [S2]. In Africa, CMVR was found in 0% to 2.6% of examined HIV-infected individuals, and CMV seroprevalence exceeded 90% in most populations [S3].
• Signs. CMVR may be asymptomatic at first; relatively mild vitreous inflammation helps distinguish it from other diseases in HIV [S8]. It usually starts in the peripheral retina and advances toward the posterior pole, with central necrosis and intraretinal haemorrhage giving the "pizza pie" appearance [S8].

Confirm it

• Clinical examination and colour fundus photography are the primary methods for diagnosis and follow-up; ultra-widefield photography detects peripheral and satellite lesions [S11].
• OCT shows inner retinal necrosis and complications such as cystoid macular oedema and epiretinal membrane; autofluorescence outlines the advancing edge and healed lesions [S11]. OCT angiography and ICGA have limited roles [S11].
• Intraocular fluid PCR when confirmation is necessary [S10].
• Screening in resource-limited regions: fundus photography, CD4 count and telemedicine can be used [S8]; telemedicine and AI-aided interpretation may reduce screening resource needs [S10].

Manage it

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Tier A (primary care / no specialist)

• Ensure people with HIV are on ART; ART-treated patients had fewer recurrences [S9]. IRIS risk is highest when ART starts with CD4 below 50 cells per microL, and might be reduced by starting ART before immunodeficiency becomes advanced [S1].
• Refer late-presenting HIV patients for retinal screening, especially with low CD4 count [S2] (timing in the table below).

Tier B (general eye clinic)

1. Screen high-risk patients with dilated fundoscopy or fundus photography [S2] [S10].
2. Start antiviral treatment early; it significantly reduces the risk of vision loss [S8]. Oral valganciclovir is preferred first-line [S10]. Doses are not covered by these abstracts: follow national HIV guidelines and local formularies.
3. Monitor blood counts for neutropenia [S9].
4. Coordinate with the HIV programme so ART is started or optimised; HIV programmes must be able to manage late presenters [S2].

Tier C (specialist centre)

1. Intravitreal ganciclovir when the posterior pole is threatened [S10]. In pooled data, inflammation resolution tended to be higher with intravitreal than intravenous antivirals (88% vs 75%, not significant) [S9].
2. Outcomes to expect. Across 59 studies (4,501 patients): inflammation resolution 90%, visual acuity improvement 18%, recurrence 19%, retinal detachment 11% [S9].
3. Stopping maintenance. Can be considered after 6 months of inactive CMVR with immune reconstitution [S10].
4. Immune recovery uveitis. No definite diagnostic criteria or standardised treatment exist; timing of antiviral and ART initiation is a complex decision [S7].
5. Second-line options. Novel antivirals and immunotherapies, such as CMV-specific adoptive T-cell therapy and CMV immunoglobulin, are emerging [S8] [S10].
6. Non-HIV patients. Treatment strategy still lacks consensus [S4].

Refer when

Pitfalls

• Assuming CMVR has disappeared in the ART era in low- and middle-income settings [S2].
• Missing asymptomatic early disease without screening [S8].
• Mistaking immune recovery uveitis for relapse, or relapse for immune recovery uveitis [S10].
• Overlooking CMVR in HIV-negative immunosuppressed patients, including those with local ocular immunosuppression [S4].

Evidence notes

• There are no established treatment guidelines from trial evidence; the antiviral meta-analysis pooled varied, mostly non-comparative regimens [S9].
• Widespread ART has reduced CMVR [S5] [S6], but LMIC data show persistently high prevalence in late presenters [S2]; the two pictures differ by setting.
• Not covered by these sources: drug doses, intravitreal injection schedules, foscarnet and cidofovir specifics, congenital CMV, and paediatric disease.

Related articles

• Ocular Toxoplasmosis
• Vitreoretinal lymphoma

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.