✍️ Double stranded DNA virus
✍️ Progressive hemorrhagic necrotizing retinitis
✍️ involving all retinal layers
✍️ 12% of AIDS patients; usually when CD4 count < 50 cells/mm3
✍️ 40% bilateral at presentation
✍️ Rare syndrome of neonatal cytomegalic inclusion disease
✅Cytomegalovirus clinical picture
✍️ Symptoms
☝️ often asymptomatic
☝️ floaters
☝️ scotoma
☝️ drop of vision or field defect with complications
✍️signs
☝️ well-circumscribed necrotizing retinitis (2 appearances)
☝️ mild AC and vitreous reaction
☝️ Brushfire appearance
• indolent, granular, yellow-white advancing edge
• peripheral atrophic “burned out” region
☝️ Pizza-pie appearance
• thick yellow-white necrosis
• hemorrhage
• vascular sheathing
✅Cytomegalovirus Zones
✍️ Zone 1
☝️1 disc diameter surrounding the disc
☝️ 2 disc diameter around the fovea
☝️ immediately sight threatening
✍️ Zone 2
☝️anterior to zone 1 and posterior to vortex vein ampullae
✍️ Zone 3
☝️ peripheral to zone 2
✅Cytomegalovirus Pathology
✍️ infected retinal cells are markedly enlarged, then necrotic, finally atrophic
✍️ large owl’s eye intranuclear inclusions
✅Cytomegalovirus of DD
✍️ HIV retinopathy
✍️ toxoplasmosis
✍️ syphilis
✍️ tuberculosis
✍️ pneumocystis
✍️ cryptococcosis
✍️ choroidal bacterial seeding
✍️ acute retinal necrosis syndrome (ARN)
✍️ progressive outer retinal necrosis (PORN).
✅Cytomegalovirus investigation
✍️HIV testing
✍️ CD4 counting
✍️ PCR for CMV DNA
✅Cytomegalovirus Treatment
✍️ antiviral therapy (induction during first
2 weeks)
✍️ intravitreal injections for sight threatening lesions
✍️ Ganciclovir (Cytovene)
☝️ virostatic
☝️ TOXICITY
• myelosupression
• neutropenia
• thrombocytopenia
☝️ INDUCTION
5–7.5 mg/kg IV bid for 2–4 weeks ( central line IV)
☝️ MAINTENANCE
5–10mg/kgIV qd
☝️ INTRAVITREAL INJECTION
2 mg/0.1 mL 2–3 times a week for 2–3 weeks
✍️ Foscarnet
☝️ virostatic
☝️ TOXICITY
• renal
• seizures
• anemia
☝️ INDUCTION
90 mg/kg IV bid or 60 mg/kg IV( central line IV)
tid for 2 weeks
☝️ MAINTENANCE
90–120 mg/kg IV qd
☝️ INTRAVITREAL INJECTION
2.4 mg/0.1 mL 2–3 times a week for 2-3 weeks, then 1–2 times a week
✍️ Cidofovir (Vistide)
☝️ longer half-life
☝️ TOXICITY
• renal
• anterior uveitis (50%)
• hypotony
☝️ INDUCTION
3–5 mg/kg IVonce a week for 2 weeks
☝️ MAINTENANCE
3–5 mg/kg IV once every 2 weeks ( peripheral line IV)
☝️ INTRAVITREAL INJECTION
165–330 μg once a week for 3 weeks, then every 2 weeks
☝️ Associated with lowering of IOP (about 2 mmHg)
☝️ 20– 50% develop iritis (about 5 days after last infusion)
☝️ Probenecid and hydration with each dose to reduce renal toxicity and decrease iritis
☝️ B-scan ultrasound in patients with severe hypotony revealed CB atrophy
✍️ Ganciclovir implant (Vitrasert)
☝️ lasts approximately 8 months
☝️ increased risk of RD with implantation
✍️ Oral valganciclovir
☝️ prodrug
☝️ 60% bioavailability
☝️ fatty foods increase bioavailability
☝️ reaches peak concentration after 2 hours
☝️ INDUCTION: 900 mg BID for 21 days
☝️ MAINTENANCE: 900 mg QD
✍️ Surgery
☝️ vitrectomy with long-acting tamponade for RRD repair (occurs in 5–29% of patients)