Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 7 Sept 2026Clinical review pending
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New visual symptoms with advanced immunosuppression
Floaters, missing vision or reduced acuity in a person with advanced HIV can represent destructive retinitis even when the eye is white and painless. A negative plasma CMV PCR does not make the retina safe.
Action: Arrange same-day discussion and assessment through emergency ophthalmology and the HIV team. Record acuity in each eye, symptom onset, immune status and current medicines; do not await repeat blood virology before referral.
Synopsis
Recognise vision-threatening infection in people with HIV, distinguish retinal disease from reassuring blood results, and coordinate urgent ocular and systemic treatment.
CMV becomes a particular concern with severe cellular immunodeficiency, often a CD4 count below 50 cells/µL.
Peripheral infection may spare central acuity and cause few early symptoms.
An experienced dilated retinal examination usually establishes the diagnosis; blood PCR cannot replace it.
Key red flags
New floaters or visual field loss with a markedly reduced CD4 count.
Investigation priorities
01
Dilated retinal examination and photographyFirst step
Identify lesion distribution and record a baseline for treatment response.
Management branches
Suspected infectionGet the retina assessed urgently
New visual symptoms occur with advanced HIV or other strong concern for infectious retinitis.
Contact the eye emergency service and HIV clinician with the onset, laterality, acuities and immune history.
Arrange same-day assessment and safe travel; deteriorating vision may make independent driving unsafe.
Key medicines
Valcyte 450 mg valganciclovir tablets for adult CMV retinitisFor adults with creatinine clearance at least 60 mL/min, the UK SmPC specifies 900 mg orally twice daily for 21 days for induction, then 900 mg once daily for maintenance. Take with food when possible. Reduce according to the SmPC renal table; tablets are not recommended below 10 mL/min and should not be used for haemodialysis patients.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 7 Sept 2026; clinical approval remains outstanding.