Anterior segment findings in AIDS patients with cytomegalovirus retinitis

Presumed fuchs heterochromic iridocyclitis and Posner-Schlossman syndrome: comparison of cytomegalovirus-positive and negative eyes

PURPOSE

To compare the characteristics of cytomegalovirus (CMV)-positive and negative eyes with presumed Posner-Schlossman syndrome (PSS) and Fuchs heterochromic iridocyclitis (FHI).

DESIGN

Retrospective interventional case series.

METHODS

One hundred and three eyes of 102 patients with presumed PSS or FHI, seen at the Singapore National Eye Centre, underwent aqueous analysis for CMV by polymerase chain reaction (PCR). Their records were reviewed for clinical features and human immunodeficiency virus (HIV) status of the CMV-positive patients. The main outcome measures were age, gender, maximum intraocular pressure, endothelial cell count, endothelial changes, PCR results, and presence of uveitic cataract and/or glaucoma.

RESULTS

Sixty-seven eyes with presumed PSS were tapped, of which 35 (52.2%) were CMV-positive. There were 36 eyes of 35 patients with presumed FHI, of which 15 (41.7%) were CMV-positive. All the CMV-positive patients were HIV negative. Nodular endothelial lesions were seen in 18 eyes (36.0%) with CMV infection, and reticulate deposits were seen in all the presumed FHI eyes. CMV-positive and CMV-negative PSS eyes were clinically similar. Older age at diagnosis, male gender, and nodular endothelial lesions were significantly associated with CMV infection in presumed FHI eyes (age: odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0 to 1.2; P = .01; male gender: OR, 9.4; 95% CI, 1.0 to 88.6; P = .049; nodular endothelial lesions: OR, 13.9; 95% CI, 1.5 to 132.7; P = .02).

CONCLUSIONS

There are no clinically detectable differences between CMV-positive and negative presumed PSS eyes. CMV-positive presumed FHI patients are more likely to be male, older at diagnosis or have nodular endothelial lesions.

Anterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome

Ocular complications are known to occur as a result of human immunodeficiency virus (HIV) disease. They can be severe leading to ocular morbidity and visual handicap. Cytomegalovirus (CMV) retinitis is the commonest ocular opportunistic infection seen in acquired immune deficiency syndrome (AIDS). Though posterior segment lesions can be more vision-threatening, there are varied anterior segment manifestations which can also lead to ocular morbidity and more so can affect the quality of life of a HIV-positive person. Effective antiretroviral therapy and improved prophylaxis and treatment of opportunistic infections have led to an increase in the survival of an individual afflicted with AIDS. This in turn has led to an increase in the prevalence of anterior segment and adnexal disorders. Common lesions include relatively benign conditions such as blepharitis and dry eye, to infections such as herpes zoster ophthalmicus and molluscum contagiosum and malignancies such as squamous cell carcinoma and Kaposi′s sarcoma. With the advent of highly active antiretroviral therapy, a new phenomenon known as immune recovery uveitis which presents with increased inflammation, has been noted to be on the rise. Several drugs used in the management of AIDS such as nevirapine or indinavir can themselves lead to severe inflammation in the anterior segment and adnexa of the eye. This article is a comprehensive update of the important anterior segment and adnexal manifestations in HIV-positive patients with special reference to their prevalence in the Indian population.

Cytomegalovirus as a Cause of Anterior Uveitis in Immunocompetent Patients

PURPOSE

To describe 7 cases of unilateral, chronic and/or recurrent anterior uveitis caused by cytomegalovirus (CMV) in immunocompetent patients; to identify specific ophthalmologic characteristics; and to evaluate the clinical effect of valganciclovir treatment.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Immunocompetent patients (n = 7) with a history of chronic and/or recurrent unilateral anterior uveitis and a positive analysis for either CMV-DNA and/or antibodies against CMV in their aqueous humor (Goldmann-Witmer coefficient > 3).

METHODS

Full ophthalmologic examination, anterior chamber fluid analysis, serologic examination, and systemic evaluation. Treatment modalities included topical steroids, topical and/or systemic antiglaucoma medications, glaucoma surgery, and systemic valganciclovir.

MAIN OUTCOME MEASURES

Visual acuity, inflammation, and intraocular pressure (IOP).

RESULTS

Chronic unilateral anterior uveitis was seen in 6 patients, whereas recurrent uveitis was observed in 1. Additional findings consisted of slight iris atrophy and secondary glaucoma (n = 3), secondary glaucoma without iris abnormalities (n = 3), and a slightly elevated IOP without iris abnormalities (n = 1). Examinations of the aqueous humor by polymerase chain reaction demonstrated CMV-DNA in 6 patients and were negative for other herpes viruses in all. Goldmann-Witmer coefficients were strongly positive in 4 out of 5 patients. Other laboratory investigations were within normal limits. No other causes for uveitis were identified. Because of the insufficient effect of topical steroids and antiglaucoma medications, 5 patients were treated with additional oral valganciclovir with good clinical response in terms of uveitis activity and IOP. Discontinuation of valganciclovir in 1 patient resulted in a prompt recurrence of uveitis activity.

CONCLUSIONS

Cytomegalovirus may cause a chronic and/or recurrent anterior uveitis in otherwise healthy patients. Iris atrophy and glaucoma may accompany it, but an inflammatory reaction in the anterior chamber may be the only sign. Aqueous humor analysis is of the utmost importance in differentiating between CMV and other herpes viruses and in making a definite diagnosis in chronic anterior uveitis. Valganciclovir may be very effective in treating CMV anterior uveitis, but its exact role can only be determined in larger studies with a longer follow-up.

Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease

The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.

Human immunodeficiency virus–positive patient with bilateral corneal endothelial deposits

BACKGROUND

Ocular disorders associated with the human immunodeficiency virus are numerous as are ocular side effects from medications used to treat all of the manifestations of the virus. This report presents a unique case of bilateral, peripheral, and corneal endothelial deposits that may be a result of either the human immunodeficiency virus or the medication rifabutin. Rifabutin was the only medication prescribed that is known to cause endothelial deposits. Rifabutin is part of a multidrug therapy to prevent or treat Mycobacterium avium complex, a common pulmonary disease of immunocompromised individuals.

CASE REPORT

A 69-year-old man with a 20-year history of being human immunodeficiency virus-positive presented with bilateral, asymptomatic, peripheral, and corneal endothelial deposits of unknown etiology. Literature research suggested that the deposits did not appear like cytomegalovirus retinitis-related deposits but rather a variant of rifabutin-associated deposits.

CONCLUSIONS

These rifabutin-associated deposits differed from known rifabutin-associated deposits previously reported in the literature. These deposits have increased in pigmentation and density 5 years after the patient discontinued the drug. This case may represent another variation of rifabutin-associated endothelial deposits. Knowledge of human immunodeficiency virus and all the associated ocular findings (owing to both the condition and its treatment) is important, because the length of time patients are living with human immunodeficiency virus is increasing.

Human immunodeficiency virus-positive patients with posterior intracorneal precipitates

PURPOSE

To describe an unusual and possibly new keratopathy in human immunodeficiency virus (HIV)-positive patients.

DESIGN

Retrospective observational case series.

PARTICIPANTS

: Six HIV-positive patients at four centers.

METHODS

A complete medical history was obtained and a thorough ophthalmic examination was performed on each of the patients.

RESULTS

Each patient had bilaterally symmetrical keratopathy consisting of variably pigmented round and reticular posterior intracorneal precipitates at the level of Descemet's membrane. The precipitates were diffuse, but larger and more prominent near the limbus and finer toward the central cornea. None of the eyes were inflamed, and all had normal vision. No patient had uveitis on presentation or any history of cytomegalovirus retinitis.

CONCLUSION

These patients have a unique posterior keratopathy, which requires further investigation.