Retinitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Ilan Dock, B.S.;Charmaine Patel, M.D. [2];Ahmed Zaghw, M.D. [3];Ammu Susheela, M.D. [4]

Overview

There is no single medical therapy to treat all types of retinitis. Due to the many underlying causes of retinitis, treatment is administered directly according to the underlying cause. These treatments will vary from vitamin therapy and preventative strategies to a long list of potential antimicrobial therapies.

Medical Therapy

Retinitis Pigmentosa

• There is no known cure for retinitis pigmentosa.
• Current therapies involve lessened exposure to light as well as an increased uptake of Vitamin A - 15,000 IU/day.

Cytomegalovirus Retinitis

• Preferred regimen (1): Ganciclovir intraocular implant PLUS Valganciclovir 900 mg PO bid for 14-21 days THEN Valganciclovir 900mg PO qq for maintenance therapy - for immediate sight-threatening lesions
• Preferred regimen (2): Valganciclovir 900 mg PO bid for 14-21 days THEN Valganciclovir 900 mg PO qq for maintenance therapy - for peripheral lesions
• Alternative regimen (1): Foscarnet 60 mg/kg IV q8h OR Foscarnet 90 mg/kg IV q12h for 14-21 days THEN Foscarnet 90-120 mg/kg IV q24h *Alternative regimen (2): Cidofovir 5 mg/kg IV for 2 weeks THEN Cidofovir 5 mg/kg IV every other week - each dose should be admnistered with IV saline hydration and probenecid
• Alternative regimen (3): Ganciclovir 5 mg/kg IV q12h for 14-21 days THEN Valganciclovir 900 mg PO bid
• Alternative regimen (4): Fomivirsen intravitreal injection - for relapses
• Note: keep a maintenance dose of Valganciclovir 900 mg PO qd until CD4 >100/mm³

Ocular tuberculosis

Adult patients

• Intensive phase

• Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) PO qd for 2 months AND Rifampin 10 mg/kg (max: 600 mg) PO qd for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) PO qd for 2 months AND Ethambutol 15-20 mg/kg (max: 1 g) PO qd for 2 months

• Continuation phase

• Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) PO qd for 4 months AND Rifampin 10 mg/kg (max: 600 mg) PO qd for 4 months

Pediatric patients

• Intensive phase

• Preferred regimen: Isoniazid 10-15 mg/kg (max: 300 mg) PO qd for 2 months AND Rifampin 10-20 mg/kg (max: 600 mg) PO qd for 2 months AND Pyrazinamide 15-30 mg/kg (max: 2 g) PO qd for 2 months AND Ethambutol

Continuation phase

• Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) PO qd for 4 months AND Rifampin 10–20 mg/kg (max: 600 mg) PO qd for 4 months
• Note (1): Ethambutol may be administered at a dose of 15-20 mg/kg (max: 1 g) PO qd for 2 months but is generally avoided because of potential ocular toxicity.
• Note (2): A short course of systemic corticosteroids may be necessary initially if there is sight-threatening inflammation.

Fungal

• Commonly prescribed antifungal agents are Amphotericin B (AmB-d), Flucytosine, or Fluconazol
• Other antifungal agents may include the drugs within the azole class.
• Treatment must be closely monitored due to the significant occurrence of toxicity in patients.

Ocular Syphilis

• Pathogen-directed antimicrobial therapy

• Preferred regimen (1): Penicillin 4 MU IV q4h for 10-14 days AND Benzathine penicillin 2.4 MU IM once weekly for 3 weeks

• Note (1): Corticosteroids (Prednisone 60-80 mg PO qd) are co-administered to decrease intra-ocular inflammation and prevent rebound inflammation from Jarisch Herxheimer reaction.
• Note (2): All patients with presumed ocular syphilis should be tested for HIV, and all should have a lumbar puncture before starting therapy to exclude concurrent neurosyphilis.

Ocular Toxoplasmosis

Adults

• 1. Pathogen-directed antimicrobial therapy

• Preferred regimen: Pyrimethamine 200 mg PO qd on day 1 then 50-75 mg PO qd for 2 weeks beyond resolution of symptoms AND Sulfadiazine 1-1.5 g PO qid for 2 weeks beyond resolution of symptoms AND Leucovorin (Folinic acid) 5-20 mg PO 3 times/week for 3 weeks beyond resolution of symptoms

Pediatric

• Preferred regimen: Pyrimethamine 2 mg/kg PO first day then 1 mg/kg each day AND Sulfadiazine 50 mg/kg PO bid AND folinic acid (Leucovorin 7.5 mg/day PO ) for 4 to 6 weeks followed by reevaluation of the patient's condition

• Alternative regimen: The fixed combination of Trimethoprim with Sulfamethoxazole has been used as an alternative.
• Note: If the patient has a hypersensitivity reaction to sulfa drugs, Pyrimethamine AND Clindamycin can be used instead.