Spectrum of responses to intravitreal ganciclovir in the management of non AIDS related HCMV retinitis

Objective: To report and evaluate intravitreal ganciclovir injections in non-AIDS patients with human cytomegalovirus (HCMV) retinitis. Design: Retrospective chart review. Participants: Two SLE patients and one patient post chemotherapy for a non Hodgkin's lymphoma presented with myelosuppression and persistent cytomegalovirus retinitis despite systemic ganciclovir therapy. Methods: Patients were treated with 100 μL of intravitreal ganciclovir (4 mg/dL), initially given weekly. Systemic anti-CMV medication was stopped, and following quiescence, intravitreal injections were tapered and ultimately stopped based on therapeutic response. Patients were followed periodically for signs of recurrence. Results: Intravitreal ganciclovir was well tolerated and led to remission of the retinitis in 2 patients. One patient had persistent smouldering disease and reached quiescence using an intravitreal ganciclovir implant. Fluorescence-activated cell sorting analysis in one patient showed the presence of low CD4 and CD8 while treated with systemic ganciclovir, which improved with intravitreal treatment. In another, the low ratio was maintained against cytomegalovirus-specific antigens. Conclusions: Intravitreal ganciclovir injections should be considered as a treatment option in selected iatrogenically immunocompromised patients with HCMV retinitis. Responses may vary and will require an adjusted approach to treatment.