When hematology meets ophthalmology: Cytomegalovirus retinitis in pediatric stem cell recipients

Abstract

Cytomegalovirus (CMV) retinitis is a significant yet infrequent complication in pediatric hematopoietic stem cell transplant recipients, occurring in approximately 4% of cases. Its presentation typically coincides with immune reconstitution, between 6 weeks to 6 months post-transplant, emphasizing the need for timely detection. Symptoms often develop insidiously, underscoring the role of fundus examinations during episodes of CMV viremia. However, the low incidence challenges the necessity of routine screenings, as they may strain clinical resources without clear benefits to patient outcomes. Management includes systemic and intravitreal antivirals, such as ganciclovir and foscarnet, and adoptive T-cell therapy for refractory cases. Tailored follow-up strategies are crucial, with considerations for lesion activity and CMV viremia status to determine the duration of therapy. Baseline and post-transplant screenings remain a topic of debate, with evolving guidelines needed to balance patient safety and clinical feasibility. Future research is needed to address optimal screening intervals and investigate the role of pre-existing CMV serostatus in transplant eligibility and outcomes.

Keywords: Cytomegalovirus retinitis; Pediatric stem cell transplant; Hematopoietic stem cell transplantation; Cytomegalovirus viremia; Ocular complications; Antiviral therapy; Immune reconstitution; T-cell therapy; Screening protocols

Core Tip: Cytomegalovirus retinitis in pediatric hematopoietic stem cell transplant recipients is a complex and potentially devastating complication, but with early detection and appropriate management, outcomes can be significantly improved. Screening protocols continue to evolve, with the emphasis on identifying high-risk patients during periods of immune reconstitution. Management of cytomegalovirus retinitis in pediatric patients post-hematopoietic stem cell transplant requires a comprehensive approach that balances effective viral suppression with the mitigation of drug-related toxicities. Antiviral therapies, whether systemic, intravitreal, or implantable, remain central to treatment. Adjunctive immunotherapies, particularly adoptive T-cell therapy, offer promising outcomes in refractory cases. Emerging modalities, including high-dose intravitreal regimens and novel antivirals, hold potential for future advancements. Individualized treatment plans, guided by patient-specific risk factors and disease severity, are crucial to optimize outcomes and preserve vision in this vulnerable population.