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Clinical Summary

Patients may complain of the gradual and usually painless onset of the following visual sensations: floaters, scintillating scotomas (quivering blind spots), decreased peripheral visual field, and metamorphopsia (wavy distortion of vision). Cytomegalovirus (CMV) infiltrates appear as focal, small (but may be larger, confluent) white lesions in the retina that look like cotton wool spots. CMV is a necrotizing virus that is spread hematogenously, so that damage is concentrated in the retina adjacent to the major vessels and the optic disk. Often hemorrhage is involved with significant retinal necrosis (dirty white with a granular appearance), giving the “pizza pie” or “cheese and ketchup” appearance. Optic nerve involvement and retinal detachments can be present.

The differential includes other infections such as toxoplasmosis, other herpesviruses, syphilis, and occasionally other opportunistic infections.

Management and Disposition

Reversal, if possible, of immunosuppression; antiviral agents have been used effectively to treat this condition.


  1. HIV retinopathy consists of scattered retinal hemorrhages and scattered, multiple cotton wool spots that resolve over time, whereas CMV lesions will typically progress.

  2. Although exposure to the CMV virus is widespread, the virus rarely produces a clinically recognized disease in nonimmunosuppressed individuals.


CMV Retinitis. “Pizza pie” or “cheese and ketchup” appearance is demonstrated by hemorrhages and the dirty, white, granular-appearing retinal necrosis adjacent to major vessels. (Photo contributor: Richard E. Wyszynski, MD.)


CMV Retinitis. Hemorrhages and dirty white retinal necrosis are seen extending from the optic disk to the peripheral fundus. (Photo contributor: Jeffrey Goshe, MD.)

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