Ocular Immunology and Inflammation

ISSN: 0927-3948 (Print) 1744-5078 (Online) Journal homepage: https://www.tandfonline.com/loi/ioii20

Contralateral Eye Involvement and Retinal

Detachment in Patients with Cytomegalovirus
Retinitis Treated with Intravitreous Ganciclovir

Somsanguan Ausayakhun, Louise J. Lu, Sakarin Ausayakuhn, Onnisa

Nanegrungsunk, Atitaya Apivatthakakul, Dao Luewattananont, Chaiayaphot
Photcharapongsakul, Yingna Liu, Gary N. Holland, Todd P. Margolis, David
Heiden & Jeremy D. Keenan

To cite this article: Somsanguan Ausayakhun, Louise J. Lu, Sakarin Ausayakuhn, Onnisa
Nanegrungsunk, Atitaya Apivatthakakul, Dao Luewattananont, Chaiayaphot Photcharapongsakul,
Yingna Liu, Gary N. Holland, Todd P. Margolis, David Heiden & Jeremy D. Keenan (2020):
Contralateral Eye Involvement and Retinal Detachment in Patients with Cytomegalovirus
Retinitis Treated with Intravitreous Ganciclovir, Ocular Immunology and Inflammation, DOI:
10.1080/09273948.2020.1728344

To link to this article: https://doi.org/10.1080/09273948.2020.1728344

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OCULAR IMMUNOLOGY AND INFLAMMATION
https://doi.org/10.1080/09273948.2020.1728344

ORIGINAL ARTICLE

Contralateral Eye Involvement and Retinal Detachment in Patients with

Cytomegalovirus Retinitis Treated with Intravitreous Ganciclovir
Somsanguan Ausayakhun, MD, MHSca, Louise J. Lu, BAb,c, Sakarin Ausayakuhn, MDa, Onnisa Nanegrungsunk, MDa,
Atitaya Apivatthakakul, MDa, Dao Luewattananont, MDa, Chaiayaphot Photcharapongsakul, MDa, Yingna Liu, MDb,d,
Gary N. Holland, MDe, Todd P. Margolis, MD, PhDf, David Heiden, MDg, and Jeremy D. Keenan, MD, MPH b,d
a
Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; bFrancis I. Proctor Foundation, University of
California, San Francisco, California, USA; cYale University School of Medicine, New Haven, Connecticut, USA; dDepartment of Ophthalmology,
University of California, San Francisco, California, USA; eDepartment of Ophthalmology, Ocular Inflammatory Disease Center, UCLA Stein Eye
Institute, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; fDepartment of Ophthalmology and Visual Sciences, Washington
University School of Medicine, St. Louis, Missouri, USA; gDepartment of Ophthalmology and Pacific Vision Foundation, California Pacific Medical
Center, San Francisco, California, USA

ABSTRACT ARTICLE HISTORY

Purpose: To determine the incidence of contralateral eye involvement and retinal detachment in HIV- Received 25 October 2019
infected patients with cytomegalovirus retinitis treated with repeated intravitreous ganciclovir. Revised 22 January 2020
Methods: In a prospective cohort study in Northern Thailand, HIV-infected patients with cytomegalo- Accepted 7 February 2020
virus retinitis were treated with antiretroviral therapy and intravitreous ganciclovir injections and KEYWORDS
followed for 3 months for contralateral cytomegalovirus retinitis and retinal detachment. Contralateral eye
Results: Of 49 participants with unilateral cytomegalovirus retinitis at enrollment, 7 developed contral- involvement;
ateral eye involvement (4.8/100 person-months, 95% CI 1.9–9.8). Of 105 eyes without a retinal detach- cytomegalovirus retinitis;
ment at enrollment, 6 developed a retinal detachment (2.0/100 eye-months, 95% CI 0.7–4.3). Baseline ganciclovir; HIV; retinal
clinical factors were not associated with the development of either outcome. detachment; Thailand
Conclusion: Eyes treated with intravitreous ganciclovir experienced retinal detachment at a rate similar
to other populations treated with systemic antivirals. The risk of contralateral eye involvement was
relatively high during the first 3 months after initial diagnosis despite the institution of antiretroviral
therapy.

Cytomegalovirus (CMV) retinitis is a vision-threatening ret-
inal infection most commonly seen in severely immunocom-
promised persons living with human immunodeficiency
virus/acquired immunodeficiency syndrome (HIV/AIDS).1–4
Patients typically experience this opportunistic infection at
CD4+ T lymphocyte levels of 50 cells/μL or lower, although
active retinitis can persist during the early stages of immune
reconstitution following antiretroviral therapy.5–8 CMV reti-
nitis can lead to blindness, most commonly from retinal
detachment or an expanding area of retinal necrosis.
The global incidence of CMV retinitis has declined mea-
surably in the past two decades of the HIV/AIDS epidemic, in
large part due to the widespread use of highly active antire-
troviral treatment (HAART).9–11 However, CMV retinitis
remains a prevalent opportunistic infection and cause of
vision loss among persons living with HIV in resource-
limited settings.12–15 A recent systematic review and meta-
analysis of studies reporting the prevalence of CMV retinitis
in low- and middle-income countries found that the highest
prevalence of CMV retinitis by region was in Asia, with
a pooled prevalence of 14.0% (11.8–16.2%).15
Systemic antiviral therapy with valganciclovir is the
standard of care for CMV retinitis in high-income
countries. However, given the high cost of oral valganci-
clovir, clinicians in most middle- and low-income coun-
tries institute local therapy with repeated intravitreous
ganciclovir injections until immune reconstitution.16–19
Local therapy is anecdotally thought to be effective, but
the evidence base is poor and existing studies have con-
flicting results. The Longitudinal Studies on the Ocular
Complications of AIDS (LSOCA) found that intraocular
antiviral therapy was associated with higher rates
of second eye involvement, retinitis progression, and
visual field loss compared with systemic antiviral
therapy.20 However, intraocular therapies were not typi-
cally used as primary therapy in LSOCA, so these results
could have been confounded by indication. In contrast to
these findings, a more recent retrospective study from
Thailand in which intravitreous injections were the pri-
mary therapy has observed much better outcomes.21
However, the retrospective nature of this study may also
have generated bias. We designed the present prospective
cohort study in order to provide better evidence regarding
the safety and efficacy of repeated ganciclovir injections
for CMV retinitis in a setting typical for where the vast
majority of affected patients are managed.

CONTACT Jeremy D. Keenan jeremy.keenan@ucsf.edu 533 Parnassus Ave, San Francisco, CA 94143
Supplemental data for this article can be accessed here.
© 2020 Taylor & Francis Group, LLC
2 S. AUSAYAKHUN ET AL.
Methods
Ethical approval for this study was obtained from the
Committee on Human Research at the University of
California, San Francisco, and the Chiang Mai University
Faculty of Medicine Research Ethics Committee. The research
adhered to the tenets of the Declaration of Helsinki.
Study Design & Eligibility
This was a prospective interventional cohort study that was
conducted at the Ocular Infectious Diseases Clinic at Chiang
Mai University’s Maharaj Nakorn Hospital, a tertiary referral
hospital in Northern Thailand. Patients were referred by HIV
providers and ophthalmologists from Maharaj Nakorn Hospital,
neighboring district hospitals, and private offices. Enrollment in
the study was offered to all persons living with HIV who were
newly diagnosed with CMV retinitis at the clinic and had not
previously received any form of treatment for CMV retinitis.
Intervention
Participants received repeated injections with intravitreous gan-
ciclovir, 2 mg/0.1 mL, according to a previously reported
protocol.16 Eyes with active retinitis received weekly ganciclovir
injections until retinitis quiescence, as determined by the treat-
ing ophthalmologist based primarily on fading of the border
opacity on indirect ophthalmoscopy. Following quiescence, eyes
received an injection every 2 weeks for 1 month then every
3 weeks for 1.5 months. Eyes with recurrent retinitis were
restarted on weekly injections. All patients who were not already
receiving HAART prior to enrollment were started on an anti-
retroviral regimen consisting of daily tenofovir disoproxil fuma-
rate 300 mg, emtricitabine 600 mg qd, and efavirenz 600 mg qd.
No patients received systemic anti-CMV therapy.
Exposures
Elements from the history, dilated fundus examination, and
laboratory evaluations at the baseline visit (i.e., the initial diag-
nosis of CMV retinitis) were treated as exposure variables, with
responses assessed prospectively on a standardized form at the
time of examination. The extent of retinitis was classified
according to a commonly used system in which zone 1 is the
area within 3000μm of the fovea or 1500μm of the optic disc
margin, zone 2 is the area from the margin of zone 1 to the
vortex vein ampullae, and zone 3 is the area from the margin of
zone 2 to the ora serrata.22 Vitreous haze was determined via
clinical examination, based on the National Eye Institute (NEI)
system with a grade of 1+ or greater indicating the presence of
vitreous haze.23 CD4+ T-lymphocyte counts were performed at
the Maharaj Nakorn Hospital laboratory.
Outcomes
Two main outcomes were pre-specified: contralateral CMV
retinitis in participants with initially unilateral disease
(i.e. second eye involvement) and new onset of retinal detach-
ment. These clinical outcomes were determined through
standardized dilated fundus examinations performed by an
ophthalmologist during regularly scheduled injection visits
and then at 3, 6, and 12 months following diagnosis.
Loss to Follow-Up
A study coordinator telephoned participants who missed study
visits. Loss to follow-up was expected given high mortality rates
in this population, and therefore primary outcomes were
assessed at the 3-month visit.24 We attempted to ascertain the
vital status of participants lost to follow-up, but in practice this
proved difficult.
Statistical Considerations
The unit of analysis for the development of contralateral CMV
retinitis was the participant, and the unit of analysis for retinal
detachment was the eye. The analysis population was the subgroup
of participants or eyes without the respective outcome at baseline
and was therefore different for each analysis. Survival methods
were used for each analysis, with incidence rates summarized in
Kaplan–Meier curves and risk factors assessed in complete-case,
Cox proportional hazards models that accounted for non-
independence of eyes from the same participant. Firth’s penalized
likelihood methods were used for cases in which model conver-
gence could not be achieved due to separation. Sensitivity analyses
were conducted that modeled duration of antiretroviral therapy in
different ways (i.e., as a continuous variable, or dichotomized at
different thresholds); these were consistent with the primary ana-
lysis and are not reported. Sample size decisions were based on the
retinal detachment outcome; a sample size of 90 participants
would allow estimation of incidence with a confidence interval
of ±7% assuming a 10% incidence of retinal detachment.
Results
Study Population
A total of 111 eyes with CMV retinitis from 76 persons living
with HIV were enrolled between May 2013 and March 2016,
including 103 eyes with CMV retinitis at enrollment and 8
eyes that developed CMV retinitis in the contralateral eye
after enrollment. The median age of participants at the time
of CMV retinitis diagnosis was 35 years (IQR = 30 to 41) and
36 (47%) were female; 67 (88%) were already on antiretroviral
therapy at the time of the initial diagnosis and 43 (57%) had
a CD4 count of 50 cells/µL or greater. Baseline ocular char-
acteristics are shown in Table 2. The median time in follow-
up was 10 months (range 0 to 13), with 58 (76%) participants
making the 3-month visit, 47 (62%) making the 6-month visit,
and 39 (51%) making the 12-month visit. Participants and
eyes lost to follow-up were not significantly different from
those not lost to follow-up (Supplementary Tables 1 and 2).
Contralateral Eye Involvement
A total of 49 participants had unilateral CMV retinitis at enroll-
ment, of whom 7 developed contralateral eye involvement over
the following 3 months (incidence 4.8 per 100 person-months,
 OCULAR IMMUNOLOGY AND INFLAMMATION 3

95% CI 1.9 to 9.8; Figure 1A). None of the person-level or eye-
level baseline characteristics were predictive of subsequent con-
tralateral eye involvement at 3 months aside from most anterior
retinitis involvement (zone 3 involvement associated with
less second eye involvement; hazard ratio [HR] 0.09, 95%CI
0.0006 to 0.84, P = .03; Table 1). One additional patient devel-
oped contralateral eye involvement over the remainder of the
study period (12-month incidence 2.2 per 100 person-months,
95% CI 0.9 to 4.3; median onset 6.5 weeks, IQR 4.8 to 8.3 weeks;
Figure 1B). Of the 8 contralateral eyes with subsequent CMV
retinitis, 6 (75%) had posterior pole (i.e., zone 1) disease, 4 (50%)
had more than 25% of the retinal surface area involved, 5
(67.5%) had visual acuity worse than 20/60, and 3 (37.5%) had
visual acuity worse than 20/400 at the time of diagnosis. None of
the person-level or eye-level baseline characteristics were pre-
dictive of subsequent contralateral eye involvement over
12 months (Supplementary Table 3).
Retinal Detachment
Of the 111 eyes diagnosed with CMV retinitis during the
study period, 105 did not have a retinal detachment at the
time of initial diagnosis. Of these, 6 eyes from 6 people
developed a retinal detachment over the first 3 months (eye-
level incidence: 2.0 per 100 eye-months, 95% CI 0.7 to 4.3;
person-level incidence: 2.9 per 100 person-months, 95% CI
1.0 to 6.2). The baseline characteristic with the greatest mag-
nitude of association with subsequent retinal detachment was
large retinitis lesion size (HR 2.99, 95%CI 0.55 to 16.4;
P = .19), although none of the baseline characteristics
achieved statistical significance due to the relatively low num-
ber of events (Table 2). Another 7 eyes developed a retinal
detachment during the remainder of the study period, for
a total of 13 eyes from 10 participants (12-month eye-level
incidence 1.9 per 100 eye-months, 95% CI 1.0 to 3.2; person-
level incidence 2.1 per 100 person-months, 95% CI 0.1 to 3.8;
median time 4.6 months after retinitis diagnosis, IQR 2.8 to
6.2 months; Figure 1B). Of the 7 eyes with retinal detachment
after the 3-month visit, all had finished intravitreous ganci-
clovir therapy and had quiescent retinitis (median time of last
injection 20 weeks prior to retinal detachment, IQR 19 to 33,
range 8 to 50). None of the person-level or eye-level baseline
characteristics were predictive of subsequent retinal detach-
ment over 12 months (Supplementary Table 3).

A B
30% 30%
Second eye involvement (% people)

Retinal detachment (% eyes)

20% 20%

10% 10%

0% 0%
0 3 6 9 12 0 3 6 9 12
Months Months

Figure 1. Kaplan–Meier curves depicting the development of (A) contralateral eye involvement among 49 participants with initially unilateral cytomegalovirus
retinitis and (B) retinal detachment in 105 eyes that initially were not detached. Dashed lines indicate 95% confidence intervals; hatch marks indicate censoring due
to loss to follow-up.

Table 1. Risk factors for the development of second eye involvement at 3 months.
Second eye No second eye Univariablea Multivariablea,b
Baseline characteristics N = 7 subjects N = 42 subjects HR (95% CI) HR (95% CI) P-value
Patient-level
Age, y 32 ± 7 34 ± 10 0.98 (0.89 to 1.05) 1.00 (0.90 to 1.08) .98
Female 3 (43%) 17 (40%) 1.09 (0.24 to 4.47) 0.91 (0.14 to 5.75) .92
CD4 < 50 cells/µL 4 (57%) 18 (43%) 1.52 (0.37 to 6.82) 2.22 (0.46 to 12.0) .32
On antiretrovirals ≤ 3 mos 5 (71%) 26 (62%) 1.18 (0.28 to 6.54) 1.33 (0.26 to 8.72) .73
Eye-level
Active retinitis 7 (100%) 37 (88%) 1.55 (0.19 to 201.7) 0.80 (0.04 to 119.7) .90
Zone 1 involvement 5 (71%) 20 (48%) 2.11 (0.51 to 11.8) 1.54 (0.31 to 9.09) .59
Zone 3 involvement 0 (0%) 16 (38%) 0.12 (0.001 to 1.01) 0.09 (0.0006 to 0.84) .03
>25% of retina involved 3 (43%) 10 (24%) 2.07 (0.46 to 8.51) 2.56 (0.42 to 18.6) .31
CI = confidence interval; HAART = highly active antiretroviral therapy; HR = hazard ratio from Cox proportional hazards model.
a
Assessed with Firth’s penalized maximum likelihood bias reduction method for Cox regression to account for separation.
b
Includes all covariates in the table.
4 S. AUSAYAKHUN ET AL.

Table 2. Risk factors for the development of retinal detachment at 3 months.

a,b
RD No RD Univariable Multivariable
Baseline characteristics (N = 6 eyes) (N = 105 eyes) HR (95% CI) HR (95% CI) P-value
Patient-level
Age, y 37 ± 8 36 ± 9 1.01 (0.95 to 1.09) 1.04 (0.94 to 1.12) .42
Female 4 (67%) 52 (50%) 1.88 (0.35 to 10.2) 1.32 (0.24 to 8.41) .75
CD4 < 50 cells/µL 3 (50%) 41 (39%) 1.67 (0.33 to 8.37) 1.21 (0.21 to 6.66) .82
On antiretrovirals > 3 mos 4 (67%) 58 (55%) 1.13 (0.22 to 5.92) 0.86 (0.18 to 5.23) .85
Eye-level
Active retinitis 6 (100%) 89 (85%) 1.23 (0.15 to 160.4)b 2.16 (0.12 to 338.5) .63
Zone 1 involvement 4 (67%) 48 (46%) 2.41 (0.47 to 12.2) 1.80 (0.33 to 12.4) .50
Zone 3 involvement 2 (33%) 31 (30%) 1.36 (0.25 to 7.39) 1.11 (0.18 to 5.45) .90
>25% of retina involved 3 (50%) 25 (24%) 3.26 (0.62 to 17.0) 2.99 (0.55 to 16.4) .19
CI = confidence interval; HR = hazard ratio from Cox proportional hazards model; RD = retinal detachment.
a
Includes all covariates in the table.
b
Assessed with Firth’s penalized maximum likelihood bias reduction method for Cox regression (without subject-level clustering) to account for separation.

Discussion in line with studies conducted in the pre-HAART era.25–27

This prospective interventional cohort study followed
a population of persons living with HIV in northern
Thailand for the first 12 months after they were diagnosed
with CMV retinitis. All participants were treated with antire-
troviral therapy and repeated intravitreous ganciclovir injec-
tions. The main findings of this study are two-fold. First,
patients with unilateral CMV retinitis treated with local ther-
apy had a substantial risk of developing contralateral eye
involvement—about 5% per month over the first 3 months
after diagnosis. The risk of contralateral eye involvement
subsequently decreased, presumably as patients became
immune reconstituted. Second, approximately 2% of eyes
with CMV retinitis developed a retinal detachment each
month during the first year after diagnosis. Unlike the out-
come of contralateral eye involvement, the incidence of retinal
detachment was fairly stable over the first year, indicating
a continued risk even after injections have been discontinued.
Incidence rates are dependent on the duration of follow-up
when risk varies over time, and thus comparison of incidence
rates from different studies must be done with caution when
the length of follow-up differs between studies. In this study,
we reported incidence rates separately for follow-up times of
3 months and 12 months, both because loss to follow-up may
have resulted in biased 12-month estimates and also because
of the potential for differential risk over time. The results
regarding contralateral eye involvement from our study (i.e.,
an incidence of approximately 58 per 100 person-years at
3 months and 26 per 100 person-years at 12 months) are
consistent with a retrospective study of patients treated with
HAART and intravitreous ganciclovir in southern Thailand in
which the incidence of contralateral eye involvement was
17 per 100 person-years over a mean of 1.6 years of follow-
up, with the vast majority occurring before 6 months.21 In
contrast, the long-term rate of contralateral eye involvement
among persons treated with intravitreous ganciclovir in the
LSOCA cohort was estimated to be much higher (approxi-
mately 55 per 100 person-years at a mean of 5 years of follow-
up). However, the LSOCA estimate was based on 24 patients
(i.e., approximately 15% of the cohort at risk) who may have
received local therapy because of more advanced or resistant
disease and thus not be representative of the typical patient
with CMV retinitis.20 Of note, the LSOCA estimates are more
The lower rate of contralateral eye involvement in the present
cohort study is likely due to the high coverage of HAART
since the bulk of contralateral cases occurred during the first
3 months after diagnosis, when patients presumably had not
yet experienced immune reconstitution.
The incidence of contralateral eye involvement in this popu-
lation was not trivial, suggesting a potential disadvantage of
intravitreous ganciclovir compared to systemic anti-CMV ther-
apy. Although the frequent office visits required for intravitreal
injections theoretically should have improved surveillance for
contralateral eyes, and thus could have resulted in earlier detec-
tion of retinitis, the clinical characteristics of the contralateral
eyes in this study were similar or perhaps even worse than the
first eyes, suggesting that contralateral eye involvement is of
clinical importance. Previous observational studies of CMV
retinitis have found that systemic antiviral therapy is associated
with a significantly lower risk of developing retinitis in the
contralateral eye, providing one rationale for the use of systemic
therapy in place of intravitreous drug injections.25,26,28 For
example, patients in LSOCA who received systemic anti-CMV
therapy had an 80% reduction in contralateral eye disease com-
pared to those who received intraocular treatment only (i.e.,
ganciclovir implant or intravitreous injections).24 However, sys-
temic antiviral therapy is cost-prohibitive in most low- and
middle-income countries, where the vast majority of patients
with CMV retinitis reside. Thus, patients in developing countries
would seem to be at increased risk for contralateral eye involve-
ment compared to patients treated in more industrialized set-
tings. While cost is a formidable obstacle in such settings,
systemic therapy with oral valganciclovir is nonetheless
a desirable alternative if available, especially in the first few
months when immune reconstitution has not yet been achieved
and the risk of contralateral eye involvement is highest.
The incidence of retinal detachment in this Thai population
with newly diagnosed CMV retinitis (i.e., approximately 25 per
100 person-years) was lower than several studies from the pre-
HAART era, and more on par with other populations treated in
the era of antiretroviral therapy. For example, the rate of retinal
detachment was 50 per 100 person-years in a large retrospective
cohort study of patients seen between 1983 and 1992 in which
patients were not treated with HAART, and 61 per 100 person-
years in a prospective trial of a similar patient population

conducted from 1990 to 91 in the pre-HAART era.3,27,29,30 In
contrast, the rate of retinal detachment among patients with newly
diagnosed CMV retinitis in the LSOCA cohort, in which 79% of
the participants received antiretroviral therapy at enrollment, was
19 per 100 person-years.31
Incident retinal detachment has been reported to be asso-
ciated with larger lesion size, lower CD4+ T-lymphocyte
counts, and activity of retinitis in previous studies.3,27,29,31,32
The present study also found a higher risk of retinal detach-
ment in eyes with larger lesion sizes and active retinitis at
baseline. However, these associations did not reach statistical
significance, likely due to limited statistical power as well as
time-varying confounding. The risk of retinal detachment
among locally treated patients in this study was similar to
that of systemically treated patients from other studies who
did not receive intravitreous injections, so it is possible that
therapeutic injections with intravitreous ganciclovir may not
substantially increase retinal detachment risk in eyes with
CMV retinitis.22,30 The continued incidence of retinal detach-
ment after 3 months—in participants with quiescent retinitis
who were no longer receiving injections—provides some evi-
dence that the risk of retinal detachment is more likely
a result of the retinitis itself and not directly attributable to
the intravitreous injections. However, the lack of a control
group in this study precludes any causative inference.
This study has several limitations. Loss to follow-up was
relatively high, especially for the 12-month follow-up visit. It
is likely that some participants were lost to follow-up because
of advanced HIV or death, though it proved difficult to
ascertain information about systemic HIV, systemic CMV,
or death based on obtainable clinic records since patients
received HIV care at a variety of institutions. If loss to follow-
up was associated with poor outcomes, then the estimates of
contralateral eye involvement and retinal detachment from
this study could be underestimated. In order to avoid the
biases of time-varying confounding and differential loss to
follow-up, only the clinical features at the time of presenta-
tion were analyzed as possible risk factors of subsequent
contralateral eye involvement and retinal detachment. We
acknowledge that potential risk factors would have changed
after presentation (e.g., CD4 counts would have generally
increased while on antiretroviral therapy; patients would
have received variable numbers of intravitreous injections,
etc.), the complexities of which are not captured in this
analysis. The limited sample size and low number of out-
comes resulted in wide confidence intervals that make it
difficult to draw firm conclusions about the differential risk
of contralateral eye involvement over time or the absence of
predictive baseline risk factors. CMV and HIV viral loads
were not measured due to lack of funds. Other limitations
of observational studies apply, including the possibility of
unmeasured confounders, differential loss to follow-up, and
uncertain generalizability to populations outside Northern
Thailand.
Overall, this study showed that the incidence rate of retinal
detachment among patients receiving HAART and intravitr-
eous ganciclovir injections was similar to other studied popu-
lations in high-income countries in the HAART era,
suggesting that repeated intravitreous antiviral injections for
OCULAR IMMUNOLOGY AND INFLAMMATION 5
CMV retinitis appear to be a safe treatment. The risk of
retinal detachment was fairly consistent throughout the 12-
month follow-up period, suggesting that patients should be
educated about the symptoms of retinal detachment and
should continue to receive dilated fundus examinations long
after the retinitis has become quiescent. Involvement of the
contralateral eye was relatively common in the first 3 months
after diagnosis, highlighting the need for more affordable
systemic anti-CMV therapies to narrow treatment disparities
and effectively treat the global burden of CMV retinitis.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
Funding
This work was supported by the Doris Duke Charitable Foundation
through an International Clinical Research Fellowship.
ORCID
Jeremy D. Keenan http://orcid.org/0000-0002-7118-1457
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