Ophthalmic Manifestations of HIV in the Highly Active Anti-Retroviral Therapy Era

Abstract

HIV-related eye disease can be classified as retinal HIV microangiopathy, opportunistic infections, neuro-ophthalmic manifestations and unusual malignancies. There is a 52-100% lifetime accumulative risk of HIV patients developing eye problems. Seventy-seven per cent of patients with ocular manifestations of HIV had CD4 counts < 200 cells/μL. Cytomegalovirus (CMV) is the most prevalent opportunistic infection, however, Africa has a low incidence of this, and more commonly squamous cell carcinoma, compared to the western hemisphere. Due to highly active antiretroviral therapy (HAART), the anti-CMV therapy may be discontinued if the CD4+ T cell count is > 100 cells/μL for a minimum of three months. Despite HAART, patients with a CD4 count < 50 cells/μL have a similar risk of developing CMV retinitis as compared to the pre-HAART era. Opportunistic infections include CMV, herpetic retinopathy (progressive outer retinal necrosis - PORN), less commonly toxoplasmosis, pneumocystis and cryptococcus. Malignancies associated with HIV include Kaposi's sarcoma and conjunctival squamous cell carcinoma. Cranial nerve palsies, optic disc swelling and atrophy are characteristic neuro-ophthalmic features. They usually occur secondary to meningitis/encephalitis (from cryptococcus and tuberculosis). With the advent of HAART, new complications have developed in CMV retinitis: immune recovery uveitis (IRU) and cystoid macula oedema (CMO). Immune recovery uveitis occurs in 71% of patients if HAART is started before the induction of the anti-CMV treatment. However, this is reduced to 31% if HAART is started after the induction treatment. Molluscum contagiosum and Kaposi's sarcoma can spontaneously resolve on HAART. Highly active anti-retroviral therapy has reduced the frequencies of opportunistic infections and improved the remission duration in HIV patients.

Aggressive conjunctival Kaposi sarcoma as the initial manifestation of acquired immunodeficiency syndrome

“…In addition to the indolent cotton-wool spots seen on fundus exam in HIV-positive patients, ophthalmologists often provide assistance in diagnosing HIV infections by recognizing HIV-related illnesses such as KS, herpes zoster ophthalmicus, fungal infections, Tuberculosis, syphilis, Toxoplasmosis, cytomegalovirus (CMV), pneumocystis, and progressive outer retinal necrosis. 17 , 18 While certain conditions such as CMV are associated with more advanced stages of HIV/AIDS, some of these illnesses can occur in earlier stages, allowing for very early detection of HIV infection by ophthalmologists.…”

Ocular manifestations in patients attending antiretroviral therapy centre at a tertiary care hospital in Himachal Pradesh, India

“…Ocular adnexal involvement occurs in up to 25 per cent of the patients. Common adnexal lesions are HZO, molluscum contagiosum, conjunctival microvasculopathy and Kaposi's sarcoma 9 . In our study, five (3.3%) patients had stye, two (1.3%) had molluscum contagiosum while two (1.3%) had HZO.…”

Demographic and clinical features of pediatric uveitis at a tertiary referral center in Iran

“…Seventy-seven percent of patients with ocular manifestations of HIV infection have been noticed to have CD4 counts <200 cells/μL. [ 2 ] In an interesting Thailand study, intraocular HIV-1 RNA was detected in 32% of HIV-positive patients with uveitis. Intraocular HIV-1 RNA loads were associated with high-HIV-1 RNA plasma loads ( P < 0.001) and not being on highly active antiretroviral therapy ( P = 0.005).…”