A 32-year-old man with newly diagnosed HIV (CD4 count 38 cells/μL) presents with floaters and blurred vision in the right eye. Fundoscopy reveals the pattern marked **A** in the diagram—a confluent, dense hemorrhagic retinal necrosis advancing along the vascular arcades with a granular leading edge. The anterior chamber is quiet with minimal inflammation. Which of the following is the most appropriate INITIAL management for this patient?
A. Intravitreal foscarnet injection alone without systemic therapy pending immune reconstitution
B. Intravenous ganciclovir 5 mg/kg twice daily for 14–21 days followed by oral valganciclovir maintenance
C. Topical corticosteroids and NSAIDs with deferral of antiretroviral therapy to avoid immune recovery uveitis
D. Oral acyclovir 800 mg five times daily with close monitoring for immune recovery uveitis
Explanation
Why Intravenous ganciclovir 5 mg/kg twice daily for 14–21 days followed by oral valganciclovir maintenance is right
The pattern marked A—confluent, dense hemorrhagic necrosis advancing along vessels—is the hallmark "brushfire" or "pizza-pie" appearance of fulminant CMV retinitis, the most common opportunistic ocular infection in advanced AIDS (CD4 <50 cells/μL). The minimal anterior chamber inflammation and full-thickness necrotizing retinitis distinguish this from acute retinal necrosis (ARN). Per AAO BCSC and ACTG guidelines, induction therapy with intravenous ganciclovir 5 mg/kg BID for 14–21 days is the gold standard, followed by lifelong oral valganciclovir 900 mg daily maintenance until immune reconstitution (CD4 >100 for >3–6 months on ART). Concurrent initiation of HAART is essential to restore CD4 count and prevent progression.
Why each distractor is wrong
Oral acyclovir 800 mg five times daily with close monitoring for immune recovery uveitis: Acyclovir is ineffective against CMV; it is the drug of choice for HSV and VZV (which cause ARN in immunocompetent patients). CMV retinitis requires ganciclovir, valganciclovir, foscarnet, or cidofovir. Acyclovir would allow unchecked CMV replication and retinal detachment.
Intravitreal foscarnet injection alone without systemic therapy pending immune reconstitution: While intravitreal foscarnet is used for sight-threatening or zone 1 disease, it is never used as monotherapy without systemic induction. Intravitreal injections are adjunctive to intravenous or oral systemic therapy. Monotherapy risks resistance and rapid progression.
Topical corticosteroids and NSAIDs with deferral of antiretroviral therapy to avoid immune recovery uveitis: Deferring ART is contraindicated and dangerous—it allows CMV to progress unchecked and leads to retinal detachment in ~30% of untreated cases. While immune recovery uveitis (IRU) is a known complication of ART initiation, the benefit of immune reconstitution far outweighs the risk of IRU, which is manageable with topical or periocular corticosteroids. Topical agents alone do not penetrate the retina and are inadequate for CMV retinitis.
