Literature Review and Institutional Imaging Analysis of Ritonavir Retinal Toxicity

Purpose: To evaluate the potential retinal toxicity associated with ritonavir, a protease inhibitor widely used to treat HIV. Methods: This study comprised a literature review of PubMed and EMBASE for all published cases of ritonavir-associated retinal toxicity as well as a retrospective chart review of patients treated with ritonavir who underwent bilateral retinal macular and ultra-widefield imaging at an urban tertiary care medical center. Retinal images were evaluated for morphologies consistent with previously reported cases of ritonavir toxicity. Results: The literature review identified 16 cases of retinal toxicity potentially linked to ritonavir, 7 (44%) of which reported liver dysfunction. A chart review of 483 patients taking ritonavir with bilateral retinal imaging demonstrated no cases of ritonavir toxicity, consistent with the literature. Conclusions: Fewer than half of the published cases of ritonavir retinal toxicity had liver dysfunction, suggesting a possible dissociation between the liver and retinal toxicities. Based on the absence of retinal toxicity in our institution’s cohort, this study proposes that ritonavir retinal toxicity is far less common than previously considered, there may be a genetic predisposition to ritonavir toxicity, and previous reports may be cases of misdiagnosed hereditary maculopathies.