Cytomegalovirus (CMV) Retinitis
"Pizza pie" Retinopathy
You are looking at a mixture of cotton wool spots, infiltrates, and hemorrhages. This combination spells death for the retina. The virus gets into the vascular endothelium, closes off blood vessels, and spreads through tissue like wildfire. The entire retina can be destroyed within weeks.
This is a moderately advanced stage. The earliest sign may be a cotton wool spot. This presents a diagnostic problem, because cotton wool spots are also a non-infectious sign of microvascular occlusion in early HIV disease. Still, any severely immunocompromised patient who develops a cotton wool spot must be presumed to have early CMV retinitis and watched carefully.
CMV retinitis may also start in the retinal periphery with infiltrates and vitreous floaters.
CMV retinitis is most often seen in immunocompromised patients (HIV, organ transplant) and in neonates whose mothers are infected. In adults, it is associated with very low suppressor T-cell counts. It may be the presenting sign of systemic or central nervous system CMV infection. Treatment with systemic ganciclovir or foscarnet can arrest this process. These medications can also be delivered through a reservoir sewn onto the sclera.