CMV Retinitis: Recognition and Treatment in Immunocompromised Patients
Last updated: November 2026
Cytomegalovirus (CMV) retinitis is a necrotising retinitis of the severely immunocompromised. It became rare in HIV after effective antiretroviral therapy, but it is still seen with late HIV diagnosis and increasingly after organ and bone marrow transplantation and chemotherapy.
Who is at risk?
- HIV with a CD4 count below 50 cells/µL (the classic group).
- Transplant recipients, patients on chemotherapy or heavy immunosuppression, and some critically ill patients.
- Screen high-risk patients, as early retinitis is often asymptomatic.
Clinical patterns
| Pattern | Appearance |
|---|---|
| Fulminant ("pizza pie" or "cottage cheese and ketchup") | Dense white necrosis with haemorrhage along the vascular arcades |
| Indolent (granular) | Granular white lesion with few haemorrhages, often peripheral |
| Frosted branch angiitis | Severe perivascular sheathing |
Characteristically little vitreous inflammation (because of immunosuppression), slow "brushfire" advance at the border, and risk of retinal detachment through the thin atrophic retina.
Differential diagnosis
- Acute retinal necrosis (HSV or VZV): rapid, peripheral, marked vitritis, occurs in the immunocompetent too.
- Progressive outer retinal necrosis (VZV) in AIDS.
- Toxoplasmosis, syphilis, fungal and HIV microvasculopathy (cotton wool spots).
Treatment
| Phase | Usual regimen (adults, normal kidney function) |
|---|---|
| Induction (2–3 weeks) | Oral valganciclovir 900 mg twice daily, or IV ganciclovir 5 mg/kg twice daily; intravitreal ganciclovir (2 mg) or foscarnet injections for sight-threatening zone 1 lesions |
| Maintenance | Valganciclovir 900 mg once daily until immune recovery (in HIV, CD4 above 100 for 3–6 months on antiretroviral therapy) |
| Resistant disease | Foscarnet or cidofovir with specialist input |
Doses are adjusted for kidney function, and valganciclovir and ganciclovir cause bone marrow suppression: monitor blood counts with the physician.
Immune recovery uveitis
After antiretroviral therapy restores immunity, some patients develop vitritis, macular oedema and epiretinal membrane in eyes with previous CMV retinitis. Treat with steroids (often periocular or intravitreal).
Where residents slip
- Expecting a red, inflamed eye: vitritis is minimal.
- Forgetting to screen asymptomatic patients with CD4 below 50.
- Not adjusting the dose for kidney function.
Test yourself: flip cards
Related: Uveitis Made Easy: SUN Terms, Patterns and Work-up, Ocular Toxoplasmosis: Diagnosis, When to Treat and Regimens, Uveitis Work-up: A Targeted Approach for Residents.
Key sources
- Jabs DA. Cytomegalovirus retinitis and the acquired immunodeficiency syndrome: bench to bedside. Am J Ophthalmol. 2011;151:198-216
- Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. CMV disease section (current version)
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