Utility of Screening Examination for Cytomegalovirus Retinitis Among Patients With Cytomegalovirus Viremia

Abstract

Purpose: To determine the utility of cytomegalovirus retinitis (CMVR) screening among patients with cytomegalovirus (CMV) bloodstream infection (viremia) in the context of multiple and recently implemented statewide policies in heightening congenital screening.

Design: Retrospective diagnostic testing evaluation.

Subjects: All patients with CMV viremia and ophthalmologic examination during the study period between 2010 and 2023 were included.

Methods: Patients with CMV viremia were identified via International Classification of Diseases, 10^th Revision code. Information regarding their demographics and clinical course was collected from respective electronic health records.

Main outcome measures: Immunocompromising conditions, CMV testing modality, CMV plasma titer, ophthalmic findings, CD4 count, CMVR diagnosis (presumed or confirmed based on direct ocular tissue confirmation), and visual acuity.

Results: A total of 234 patients with CMV viremia who underwent a screening dilated fundus examination during inpatient hospitalization between 2010 and 2019 were identified. A total of 18 patients (7.7%) with CMV viremia were found to have CMVR. Among 49 pediatric patients, 2 (4.1%) had CMVR; zero neonates with congenital infection had CMVR. Five patients with CMVR had confirmed ocular CMV infection by aqueous humor testing; the remaining 13 patients did not and were classified as presumed CMVR cases. Among all CMVR cases, 14 (78%) were symptomatic, whereas 2 (11%) were asymptomatic and 2 (11%) were unable to report symptoms. Factors associated with increased risk of CMVR diagnosis included HIV/AIDS infection (unadjusted odds ratio [OR], 4.83, 95% CI, 1.76-12.35) and presence of ocular symptoms (unadjusted OR, 14.3, 95% CI, 3.6-64.4). After adjusting for race, HIV/AIDS infection status, and presence of ocular symptoms, HIV/AIDS infection (adjusted OR, 4.12, 95% CI, 1.33-14.22) and ocular symptoms (adjusted OR, 14.88, 95% CI, 3.82-99.2) remained significantly associated with increased risk of CMVR.

Conclusions: Patients with CMV viremia and HIV/AIDS infection or visual symptoms are at significantly elevated risk of CMVR and should undergo ophthalmic examination. Meanwhile, the utility of dilated fundus examination in neonates with congenital CMV infection but no clinically observable sequelae of infection is debatable, given the rarity of CMVR while undergoing concurrent systemic treatment in this population. Although larger, prospective studies would be informative, retinal screening in neonates with congenital CMV infection without other clinical signs of infection does not appear supported by these and other recent data.