Evidence and Consensus-Based Imaging Guidelines in Cytomegalovirus Retinitis: Multimodal Imaging in Uveitis (MUV) Task Force – Report 15

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PURPOSE: To develop imaging- and consensus-based guidelines for the application of multimodal imaging in cytomegalovirus retinitis (CMVR). DESIGN: Consensus agreement guided by a systematic literature review and expert committee deliberation using the nominal group technique (NGT). PARTICIPANTS: International uveitis specialists and retina experts participating in the Multimodal Imaging in Uveitis (MUV) task force. METHODS: Experts independently reviewed published literature and representative cases of active and inactive CMVR using color fundus photography (CFP), OCT, fundus autofluorescence, fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA), and OCT angiography. Through structured NGT sessions, the committee developed consensus-based descriptors of active and inactive CMVR, key imaging biomarkers of disease activity, and characteristic complications. The proposed guidelines were subsequently voted on by the full MUV task force. MAIN OUTCOME MEASURES: Identification of reproducible multimodal imaging features of CMVR; definition of modality-specific biomarkers of disease activity and healing; consensus on the preferred imaging modalities for diagnosis, monitoring, and detection of complications. RESULTS: The experts agreed that CFP remains the most essential baseline and follow-up imaging modality for documenting the pattern, extent, and borders of the lesion, as well as the response to treatment. Ultra-widefield CFP was particularly valued for its ability to detect peripheral/satellite lesions and complications such as early retinal breaks. OCT is helpful in identifying inner retinal necrosis, characterizing retinal layer involvement, and development of complications such as cystoid macular edema (CME) and epiretinal membrane. Fundus autofluorescence assists in delineating the advancing edge of active retinitis and identifies healed lesions by their sharply demarcated hypoautofluorescent appearance. Fundus fluorescein angiography may help in identifying arteriolar occlusion, CME, and optic nerve head leakage. OCT angiography and ICGA have limited roles in diagnosing CMVR or assessing disease activity. CONCLUSIONS: Clinical examination/CFP remains the primary method for evaluating CMVR, in addition to other clinical tools such as diagnostic laboratory testing. OCT and FFA serve as complementary tools for detecting ocular complications, especially in immune-recovery uveitis. These consensus-based guidelines provide a framework for optimal imaging selection in CMVR and support future refinements of standardized diagnostic criteria. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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