Impact of Antiviral Therapy in Cytomegalovirus-Positive Anterior Uveitis

Purpose To evaluate the risk of recurrence of anterior uveitis (AU) with positive polymerase chain reaction results for cytomegalovirus (CMV)-AU before and after initiation of antiviral therapy and compare the efficacy and safety of 2 treatment strategies: (1) initial oral valganciclovir followed by topical 0.15% ganciclovir and (2) continuous topical 2% ganciclovir. Design Retrospective cohort study from a tertiary ophthalmic center and a uveitis-specialized private clinic. Participants Patients with CMV-AU who received antiviral therapy from May 2015 to March 2024. Methods Clinical records were analyzed retrospectively across the study period. Patients were treated with (1) a 6-week course of oral valganciclovir, followed by 0.15% ganciclovir ointment (oral to 0.15% group), or (2) continuous treatment with 2% topical ganciclovir (2% topical group). Recurrence rates were compared for the year before and after treatment initiation, expressed per person-years (PYs). Recurrence-free survival was analyzed using Kaplan–Meier analysis. A severe corneal endothelial cell (EC) loss was defined as ≥5% yearly loss from the baseline. Main Outcome Measures Recurrence rate (PYs) and a severe EC loss. Results A total of 136 patients were included, with a median follow-up of 27 months (346.8 PYs). The recurrence rate significantly decreased from 2.87 PYs before treatment to 1.16 PYs after treatment (59.6% reduction; P < 0.0001). Post-treatment recurrence occurred in 98 patients (72.0%) after treatment. The median recurrence-free survival was 5.0 months (95% confidence interval [CI], 3.4–6.6), with a 1-year recurrence-free survival rate of 31.0%. Recurrence rates were reduced by 54.3% in the oral to 0.15% group (n = 113) and by 78.8% in the 2% topical group (n = 23). No recurrences occurred during the initial 6-week oral valganciclovir phase. Severe EC loss was more frequent in the 2% topical group (70.0%) compared with the oral to 0.15% group (34.4%; P = 0.003). Multivariate logistic regression identified that 2% topical treatment, compared with the oral to 0.15% regimen, was associated with severe EC loss (Exp (B) = 3.68; P = 0.032), after adjusting for age, sex, total follow-up period, and total recurrence number. Conclusions Cytomegalovirus AU exhibited a very high recurrence rate, which was significantly reduced by antiviral therapy. Oral valganciclovir preserved corneal EC better than 2% ganciclovir but featured increased recurrence after step-down to the 0.15% ganciclovir. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.