[Prophylaxis of Recurrent Cytomegalovirus Uveitis with Topical Ganciclovir]

Cytomegalovirus (CMV) can cause recurrent or chronic hypertensive anterior uveitis in immunocompetent patients. Antiviral treatment options include topical ganciclovir or systemic valganciclovir. However, recurrences are common after stopping treatment. We evaluated the efficacy of long-term topical ganciclovir therapy as prophylaxis for recurrent activity.

Retrospective analysis of all CMV uveitis patients seen between 2011 and 2018 at Zurich University Hospital. Inclusion criteria were suspected viral anterior uveitis and a positive CMV polymerase chain reaction of the anterior chamber (AC) tap. After diagnosis, topical therapy with ganciclovir gel 5 × daily was started and tapered according to clinical activity. Topical steroids and glaucoma medication were used according to clinical assessment. An active episode was defined as increase in AC inflammatory activity and/or a uveitis-related rise in intraocular pressure (IOP) greater than 25 mmHg. Episodes were analysed before and after initiation of ganciclovir therapy.

Six patients, median age 51 (range 24 - 62) years old, were included. All patients had hypertensive unilateral anterior uveitis and presented with small to medium sized endothelial precipitates and with 0.5+ to 2+ AC cells. Median IOP in the affected eye at initial presentation was 43 mmHg (range 36 - 60). Median time from first episode to diagnosis was 19.5 (range 5 - 193) months. Median number of episodes before ganciclovir treatment was 4 (2 - 20), corresponding to a mean of 3.04 episodes per year. Median follow-up time after initiation of ganciclovir medication was 26 (range 4 to 62) months. Median number of episodes under treatment was 1 (range 0 - 6), corresponding to a mean of 0.19 episodes per year (p = 0.04, 2-sided paired t-test). The median (range) for the individually chosen long-term prophylactic dose was ganciclovir gel 2 (0 - 4) times daily, and topical steroids 1 (0 - 2) times daily. Lower doses lead to recurrences in 3 patients (50%). Glaucoma and cataract surgery were performed in 2 patients (33%).

Although a rare entity in Central Europe, the important feature of CMV uveitis is its hypertensive and recurrent nature. In our cases, topical ganciclovir was found to be an effective treatment. Inflammatory activity was well controlled by using an individually assessed prophylactic dose. Larger studies assessing long-term prophylaxis are desirable.