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HIV and the eye: CMV retinitis and more

  • Eye and systemic disease

HIV affects the eye mostly when CD4 counts are low. CMV retinitis can blind silently, so patients with very low CD4 need dilated exams.

Updated

See it in 3D: Retina · Eyelids

What it is

Eye disease in HIV depends on the degree of immunosuppression. The commonest finding is a microvasculopathy with cotton-wool spots and small haemorrhages, usually harmless. The most dangerous is cytomegalovirus (CMV) retinitis, a necrotising retinitis when the CD4 count falls very low, which destroys the retina and can detach it. Antiretroviral therapy has made it much rarer, but it still occurs in patients diagnosed late.

Eye findings

  • HIV microvasculopathy: cotton-wool spots, small haemorrhages; no symptoms.
  • CMV retinitis: white necrotic retina with haemorrhages, spreading along the vessels; usually with CD4 under 50 cells/µL.
  • Herpes zoster ophthalmicus in a young adult can be the first sign of HIV.
  • Ocular syphilis, toxoplasmosis and acute retinal necrosis are more frequent and atypical.
  • Kaposi sarcoma can affect the lids and conjunctiva.

Screening and follow-up

  • CMV retinitis may cause only floaters or a patchy field loss; many patients have no symptoms.
  • When antiretroviral therapy restores immunity, inflammation can flare in eyes with previous CMV (immune recovery uveitis).
  • Every patient with ocular syphilis or unexplained uveitis should be tested for HIV, and vice versa.

Next step / Initial management

  • CD4 under about 50: dilated retinal exam by ophthalmology at diagnosis and periodically, even without symptoms.
  • Suspected CMV retinitis: same-day ophthalmology; systemic anti-CMV treatment (ganciclovir or valganciclovir) with or without intravitreal therapy, and start or optimise antiretroviral therapy.
  • Herpes zoster ophthalmicus in a young person: offer an HIV test.
  • Follow the national HIV guideline for opportunistic infection screening and prophylaxis.

Test yourself

Think of the answer, then tap the question to see it.

At what CD4 level does CMV retinitis usually occur?

Below about 50 cells per microlitre.

What is the commonest ocular finding in HIV?

HIV microvasculopathy: cotton-wool spots and small haemorrhages without symptoms.

What is immune recovery uveitis?

Inflammation that flares in eyes with previous CMV retinitis when antiretroviral therapy restores immunity.

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Connections

See it in 3D2

The structures of Durgical's 3D anatomy where it is found.

In Pharmacology1

← All of ophthalmology

Educational content; not a clinical guideline and no substitute for assessment by a health professional. For sudden visual loss, severe eye pain, a chemical burn or an eye injury, go to an emergency department at once.

Sources: Ocular Manifestations of HIV (StatPearls Publishing (NCBI Bookshelf), 2025); Retinitis (StatPearls Publishing (NCBI Bookshelf), 2024); Guía de práctica clínica: infección por VIH/SIDA en adolescentes y adultos (Ministerio de Salud y Protección Social de Colombia, 2014).

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