Ocular disorders associated with a new severe acquired cellular immunodeficiency syndrome

Frosted Branch Angiitis; Case Series and Literature Review

PURPOSE

Frosted branch angiitis (FBA) is a rare form of retinal vasculitis. Four case series and an extensive literature review of 236 cases were conducted to clarify the characteristics of this rare condition.

METHODS

Case series and literature review.

RESULTS

An analysis of the reported cases revealed that a majority (54.6%) developed FBA in the presence of an underlying disease, with recurrence and complications requiring surgical intervention being rare. The frequency of bilateral occurrence (55.0%) and prevalence in female patients (45.0%) were noted to be lower than previously reported.

CONCLUSION

In general, idiopathic FBAs are more likely to be bilateral and diagnosed at a younger age than secondary FBAs. In idiopathic FBA, fundus involvement is more generalized, exudates tend to be more translucent, and extensive retinal hemorrhage tends to be less frequent. However, there were no differential characteristic fundus features that clearly distinguished idiopathic FBA from secondary FBA.

Cytomegalovirus retinitis in hospitalized people living with HIV in the late antiretroviral therapy era in São Paulo, Brazil

BACKGROUND

There is scarce information on AIDS-related cytomegalovirus (CMV) retinitis in middle-income countries. The objectives of this study were to identify the prevalence of active CMV retinitis in severely immunosuppressed people living with HIV (PLWHIV) and to describe its main features.

METHODS

This retrospective cohort study was carried out at a tertiary center in São Paulo, Brazil. We included hospitalized adults PLWHIV with CD4 count ≤100 cells/μL, ≥ one quantitation of CMV DNA in plasma, and indirect ophthalmoscopy evaluation.

RESULTS

Thirty-eight (21.6%) of 176 participants had at least an ophthalmoscopy diagnosis and only 3 (1.7%) individuals presented active CMV retinitis. All these participants were male, and retinitis was asymptomatic in 2 cases. Two participants had extraocular end-organ CMV disease and detectable CMV DNA in plasma.

CONCLUSIONS

These results show a low prevalence of active CMV retinitis in the evaluated population. However, 2 of 3 participants had asymptomatic active CMV retinitis and a fifth of participants had at least one ophthalmoscopy diagnosis, suggesting the need for routine ophthalmologic evaluation in hospitalized severely immunosuppressed PLWHIV. The profile of participants with active CMV retinitis was similar to that described in the pre-ART era and quantitation of CMV DNA in plasma was variable.

Macular Changes Observed on Optical Coherence Tomography Angiography in Patients Infected With Human Immunodeficiency Virus Without Infectious Retinopathy

Purpose

As the human immunodeficiency virus (HIV) pandemic is far from over, whether there are subclinical macular changes in HIV-positive patients is something that should not be overlooked. We aimed to apply optical coherence tomography angiography (OCTA) to assess the macular structure and microvasculature changes in patients with HIV without infectious retinopathy.

Methods

HIV-positive and -negative participants were included and classified into three groups: HIV-negative, HIV-positive, and HIV-positive with microvasculopathy. OCTA parameters regarding macular structure and microvasculature were analyzed.

Results

Compared with the HIV-negative group, the superficial retinal vessel density (VD) in the parafovea sectors and the whole Early Treatment of Diabetic Retinopathy Study (ETDRS) grid and the choroidal vascularity index (CVI) in the whole ETDRS grid were significantly decreased in the HIV-positive and HIV-positive with microvasculopathy groups (p < 0.05). No differences were found in OCTA parameters between the HIV-positive and HIV-positive with microvasculopathy groups. Retinal, retinal nerve fiber layer-ganglion cell layer-inner plexiform layer (RNFL-GCL-IPL), RNFL, GCL-IPL, and INL thickness showed a negative association with the duration of HIV diagnosis or antiretroviral therapy (ART) (all p < 0.05). All OCTA microvasculature parameters showed no association with HIV-related clinical variables (all p > 0.05).

Conclusions

Subclinical macular changes existed in HIV-infected patients without clinical infectious retinopathy. Substructures from inner retinal layers might be associated with HIV infection or ART duration.

Analysis of Macular Microvasculature in Human Immunodeficiency Virus Infection

PURPOSE

To evaluate the retinal and choroidal microvascular blood flow in patients with human immunodeficiency virus (HIV) infection using optical coherence tomography angiography (OCTA).

METHODS

Macular OCTA parameters including vessel density (VD) of parafoveal superficial capillary plexus (SCP-VD) and deep capillary plexus (DCP-VD), foveal vessel density (FD), foveal avascular zone area, and flow area of choriocapillaris were analyzed in 42 HIV-positive patients, and compared with 42 healthy controls.

RESULTS

The mean SCP-VD, DCP-VD and FD were significantly lower in HIV-positive group compared with controls (p < .001, p = .014, p = .026; respectively). Reduced SCP-VD was associated with higher HIV RNA plasma level (r = -0.400, p = .021) and lower CD4 + T cell count (r = 0.314, p = .046) in HIV-positive patients.

CONCLUSIONS

Macular microvascular blood flow is affected by HIV infection. OCTA can detect microvascular flow abnormalities in retinal capillary plexus in HIV-positive patients.

Ocular manifestations of HIV and AIDS patients on antiretroviral therapy in a tertiary hospital in South Africa

Background: Human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) causes impairment to the immune system, which then leads to immunocompromised conditions, and allows for opportunistic infection to invade many organs of the human body. Ocular involvement is very common; the various ocular complications may be asymptomatic and they may be the initial manifestations of the underlying diseases.Aim: This study aimed to determine the prevalence and the type of ocular manifestations that occur in HIV and AIDS patients.Setting: The study was conducted on ART (antiretroviral treatment) clinic patients in the Department of Ophthalmology at the Steve Biko Academic Hospital, Pretoria.Methods: This descriptive, cross-sectional study was conducted on HIV and AIDS patients referred from the ART clinic for complete ophthalmological evaluation, irrespective of the immune system status and presence or absence of symptoms. All the participants underwent an ophthalmologic evaluation, which included case history and ocular examinations of both anterior and posterior segments.Results: Out of the 177 participants, 72.3% had visual acuity of between 6/3 to 6/18, 10% had poor vision, 7% had lost one eye to ocular complications and 5% were blind. The most common anterior segment manifestations were uveitis and dry eye, whilst HIV-related retinopathy and papilledema were the most prevalent conditions in the posterior segment. Only three participants had third cranial nerve palsy.Conclusion: The prevalence of ocular manifestations was significantly higher with lower CD4+ cell counts, which could be regarded as predictors for the occurrence of ocular morbidity in HIV and AIDS patients.

A Mouse Model That Mimics AIDS-Related Cytomegalovirus Retinitis: Insights into Pathogenesis

With the appearance of the worldwide AIDS pandemic four decades ago came a number of debilitating opportunistic infections in patients immunosuppressed by the pathogenic human retrovirus HIV. Among these was a severe sight-threatening retinal disease caused by human cytomegalovirus (HCMV) that remains today a significant cause of vision loss and blindness in untreated AIDS patients without access or sufficient response to combination antiretroviral therapy. Early investigations of AIDS-related HCMV retinitis quickly characterized its hallmark clinical features and unique histopathologic presentation but did not begin to identify the precise virologic and immunologic events that allow the onset and development of this retinal disease during HIV-induced immunosuppression. Toward this end, several mouse models of experimental cytomegalovirus retinitis have been developed to provide new insights into the pathophysiology of HCMV retinitis during AIDS. Herein, we provide a summary and comparison of these mouse models of AIDS-related HCMV retinitis with particular emphasis on one mouse model developed in our laboratory in which mice with a murine acquired immunodeficiency syndrome (MAIDS) of murine retrovirus origin develops a reproducible and well characterized retinitis following intraocular infection with murine cytomegalovirus (MCMV). The MAIDS model of MCMV retinitis has advanced the discovery of many clinically relevant virologic and immunologic mechanisms of virus-induced retinal tissue destruction that are discussed and summarized in this review. These findings may extend to the pathogenesis of AIDS-related HCMV retinitis and other AIDS-related opportunistic virus infections.

Evidence for the involvement of interleukin-1α during development of experimental cytomegalovirus retinitis in immunosuppressed mice

Interleukin-1α (IL-1α) is an alarmin involved in the recruitment of macrophages and neutrophils during tissue inflammation. IL-1α can undergo cleavage by proteases, such as calpain-1, that enhances IL-1α binding to its receptor, although proteolytic cleavage is not necessary for biological activity. Macrophages and neutrophils are involved in the retinal inflammation associated with development of AIDS-related human cytomegalovirus (HCMV) retinitis. We therefore performed studies to test the hypothesis that IL-1α gene expression is stimulated intraocularly during retinitis development using two mouse models of murine cytomegalovirus (MCMV) retinitis that differ in method of immunosuppression, one by retrovirus-induced immunosuppression (MAIDS) and the other by corticosteroid-induced immunosuppression. MCMV-infected eyes of groups of retinitis-susceptible mice with MAIDS of 10 weeks duration (MAIDS-10 mice) and retinitis-susceptible corticosteroid-treated mice showed significant stimulation of IL-1α mRNA. Western blot analysis confirmed IL-1α protein production within the MCMV-infected eyes of MAIDS-10 mice. Whereas significant intraocular calpain-1 mRNA and protein production were also observed within MCMV-infected eyes of MAIDS-10 mice, the MCMV-infected eyes of retinitis-susceptible corticosteroid-treated mice showed a pattern of mRNA synthesis equivalent to that found within the MCMV-infected eyes of healthy mice that fail to develop retinitis. Our findings suggest a role for the alarmin IL-1α in the pathogenesis of MCMV retinitis in immunosuppressed mice. These findings may extend to the pathogenesis of HCMV retinitis in patients with AIDS or other forms of immunosuppression.

Human immunodeficiency virus and intraocular inflammation in the era of highly active anti retroviral therapy - An update

Intraocular inflammation in patients with human immunodeficiency virus (HIV) infection is commonly due to infectious uveitis. Ocular lesions due to opportunistic infections (OI) are the most common and have been described extensively in the pre highly active antiretroviral therapy (HAART) era. Many eye lesions were classified as acquired immunodeficiency syndrome (AIDS) defining illnesses. HAART-associated improvement in immunity of the individual has changed the pattern of incidence of these hitherto reported known lesions leading to a marked reduction in the occurrence of ocular OI. Newer ocular lesions and newer ocular manifestations of known agents have been noted. Immune recovery uveitis (IRU), the new menace, which occurs as part of immune recovery inflammatory syndrome (IRIS) in the eye, can present with significant ocular inflammation and can pose a diagnostic and therapeutic challenge. Balancing the treatment of inflammation with the risk of reactivation of OI is a task by itself. Ocular involvement in the HAART era can be due to the adverse effects of some systemic drugs used in the management of HIV/AIDS. Drug-associated retinal toxicity and other ocular side effects are being increasingly reported. In this review, we discuss the ocular manifestations in HIV patients and its varied presentations following the introduction of HAART, drug-associated lesions, and the current treatment guidelines.

Immunological and Viral Markers of Hiv Infection and Retinal Microangiopathy

The relationship between retinal microangiopathy and some features of human immunodeficiency virus (HIV) infection such as HIV antigenemia, antibodies to the viral proteins, T lymphocyte subsets, were studied in 71 patients with acquired immunodeficiency syndrome (AIDS). The absence of antibodies to the HIV p24 protein was significantly related to retinal microangiopathy (p = 0.0051) and more closely to retinal cotton-wool spots (p = 0.0007); the combination of positive antigenemia with the absence of antibodies to p24, which is typical of the later phases of HIV infection, was found in a larger percentage of patients with cotton-wool spots (p = 0.0013) than in subjects with every sign of microangiopathy (p = 0.0546). T-helper (CD4+) cells count below 200 cells/mm3 was also detected in a higher percentage of patients with HIV-related retinal microangiopathy (p = 0.009). These findings suggest that retinal microangiopathy and especially retinal cotton-wool spots are related to the progression of immunodeficiency.

Endophthalmitis: Then and Now

PURPOSE

To report historically evolving strategies (then and now) in prevention and management of endophthalmitis.

DESIGN

A perspective on relevant topics in the prophylaxis and management of endophthalmitis.

METHODS

This is an author-selected review of studies leading to changes in strategies for endophthalmitis management over the last 100 years.

RESULTS

The current perspective discusses the trends and strategies over the past century. Historically, 3 endophthalmitis time-periods have existed and include the pre-antimicrobial era, the predominantly systemic antimicrobial era, and the current intravitreal antimicrobial era. The management of endophthalmitis from different etiologies, including endogenous, postinjection, post-cataract surgery, and other anterior segment-related (eg, post-penetrating keratoplasty), bleb-associated, glaucoma drainage device-associated, and open globe injury-associated, are discussed. Specific etiologies may predict most common microbial causes and may guide differing management strategies. Pars plana vitrectomy offers theoretical advantages but is generally reserved for patients with more advanced disease.

CONCLUSIONS

Despite advances over the past 100 years, endophthalmitis is an important sight-threatening complication. Timely management with the appropriate use of antimicrobial agents may optimize visual outcomes.

Chronic Retinal Necrosis Severely Complicated by Neovascular Glaucoma: A Case Report

BACKGROUND

Chronic retinal necrosis (CRN) is a rare chronic granular necrotizing retinitis that was first described in 2013. CRN is characterized by intraocular inflammation accompanied by occlusive vasculitis, granular retinitis, and slowly progressing necrosis around the retina in a host with partial immune dysfunction. Cytomegalovirus (CMV) is reported to be a causative agent. There are several ocular complications such as retinal detachment and neovascular glaucoma; however, there has been no description of a clinical manifestation of neovascular glaucoma in CRN. We herein present a case of severe neovascular glaucoma in association with CRN.

CASE PRESENTATION

An 80-year-old man was referred to our hospital with poor control of inflammation and intraocular pressure (IOP). The IOP in his left eye was 29 mm Hg. Anterior chamber cells (2+) and keratic precipitates were observed. In the peripheral retina, vitreous opacities and granular necrotizing retinitis were noticed. Fluorescein angiography revealed extensive retinal nonperfusion area from the macula lesion to the periphery. PCR analysis of aqueous humor showed the presence of CMV. A diagnosis of CRN was made soon afterwards. Antiviral drug and systemic corticosteroid were administered. The treatment temporally resolved the symptom; however, panretinal photocoagulation and intravitreal injection of bevacizumab were performed to treat iris neovascularization. During the follow-up, trabeculectomy was performed because of poor IOP control. At the final visit, severe uncontrolled neovascular glaucoma caused hyphema, and his left eye lost light perception.

CONCLUSION

The prognosis of CRN is poor because of severe neovascular glaucoma and careful observation and active treatments are necessary.

Murine cytomegalovirus infection of mouse macrophages stimulates early expression of suppressor of cytokine signaling (SOCS)1 and SOCS3

Human cytomegalovirus (HCMV) is a species-specific β-herpesvirus that infects for life up to 80% of the world’s population and causes severe morbidity in at-risk immunocompromised populations. Suppressors of cytokine signaling (SOCS)1 and SOCS3 are host proteins that act as inducible negative feedback regulators of cytokine signaling and have been implicated in several ocular diseases and viral infections. We recently found in our mouse model of experimental cytomegalovirus retinitis that subretinally-injected murine cytomegalovirus (MCMV) stimulates ocular SOCS1 and SOCS3 during retrovirus-induced immune suppression of murine AIDS (MAIDS), and that infiltrating macrophages are prominent cellular sources of retinal SOCS1 and SOCS3 expression. Herein we investigate possible virologic mechanisms whereby MCMV infection may stimulate SOCS1 and/or SOCS3 expression in cell culture. We report that infection of IC-21 mouse macrophages with MCMV propagated through the salivary glands of BALB/c mice, but not from tissue culture in C57BL/6 fibroblasts, transiently stimulates SOCS1 and SOCS3 mRNA transcripts, but not SOCS5 mRNA. Viral tegument proteins are insufficient for this stimulation, as replication-deficient UV-inactivated MCMV fails to stimulate SOCS1 or SOCS3 in IC-21 macrophages. By contrast, infection of murine embryonic fibroblasts (MEFs) with either productive MCMV or UV-inactivated MCMV significantly stimulates SOCS1 and SOCS3 mRNA expression early after infection. Treatment of MCMV-infected IC-21 mouse macrophages with the antiviral drug ganciclovir significantly decreases MCMV-stimulated SOCS3 expression at 3 days post-infection. These data suggest cell type-specific, different roles for viral immediate early or early gene expression and/or viral tegument proteins in the early stimulation of SOCS1 and SOCS3 during MCMV infection. Furthermore, putative biphasic stimulation of SOCS3 during late MCMV infection of IC-21 mouse macrophages may occur by divergent virologic mechanisms.

Loss of amplitude of accommodation in pre-presbyopic HIV and AIDS patients under treatment with antiretrovirals

Background: The prevalence of HIV and AIDS is causing an enormous public health burden. Its manifestations spare no organ. Ocular complications are mainly attributed to various opportunistic infections which are directly or indirectly caused by immune deficiency.Purpose and aim: The purpose of this study was to determine the effect of HIV and AIDS on subjective amplitude of accommodation of patients under treatment with antiretrovirals and then to compare their results to those of control subjects.Methods: The study took place over a period of 10 months. A quantitative study was carried out on 58 subjects (29 ± 5.5 years) with HIV and AIDS and 35 (28.67 ± 4.6 years) controls of similar age. Amplitude of accommodation was measured using the subjective Royal Air Force push-up method. The influence of CD4+ cell count was also recorded.Results: People with HIV and AIDS had lower mean amplitude of accommodation (5.69 ± 0.88 D) compared to controls (8.53 ± 1.2 D). The decrease in amplitude of accommodation did not show any correlation with the CD4+ cell count. Lower amplitude of accommodation exists in people living with HIV and AIDS when compared with age-related healthy people.Conclusion: The results suggest that patients with HIV and AIDS on antiretroviral drugs (ARVs) have reduced amplitude of accommodation and might experience presbyopia earlier in life than participants without HIV and AIDS. The reduced amplitude of accommodation could be the initial presentation of HIV infection before the systemic manifestation. The possible causes could be the direct neuronal infection by HIV-1, ARVs use, pathological changes of the lens and ciliary muscle or the sensory component of the visual system. It is unknown whether the reduced amplitude of accommodation occurred prior to antiretroviral therapy or represents an ongoing injury to the eye and visual system by the HIV.

Retinal Microvasculopathy Is Common in HIV/AIDS Patients: A Cross-Sectional Study at the Cape Coast Teaching Hospital, Ghana

Purpose. The purpose of this study was to evaluate the ocular disorders in HIV positive patients attending the Cape Coast Teaching Hospital, Ghana. Methods. A cross-sectional study using systematic random sampling was conducted on 295 HIV positive patients. Data collection consisted of semistructured questionnaires, laboratory investigation, medical profile, and ophthalmic examination. Statistical association tests including χ², independent t-test, and ANOVA were done. A p value ≤ 0.05 was considered statistically significant. Results. Of the 295 participants, 205 (69.5%) were on antiretroviral therapy while 90 (30.3%) were not on therapy. Majority of the participants (162, 54.9%) were in clinical stage two, followed by stages three (68, 23.1%), one (62, 21%), and four (3, 1%), respectively. The overall prevalence of ocular disorders was 5.8%. The most common HIV related ocular disorder was HIV retinal microvasculopathy (58.8%), followed by herpes zoster ophthalmicus and Toxoplasma retinochoroiditis, both representing 11.8% of ocular disorders seen. Cytomegalovirus retinitis, Bell's palsy, and optic neuritis were the least common (5.9%). CMV retinitis recorded the highest viral load of 1,474,676 copies/mL and mean CD4 count of 136 cells/mm³. The mean CD4 count for participants with HIV related ocular disorders was significantly lower compared to participants without disorders (t = 2.5, p = 0.012). Participants with ocular disorders also recorded significantly higher mean viral loads than those who did not have ocular disorders (t = 2.8, p = 0.006). Conclusion. Lower CD4 counts and high viral load copies were associated with the manifestation of HIV related ocular disorders.

Ocular Manifestations of Acquired Immunodeficiency Syndrome

Purpose

To investigate the patterns and risk factors of the ocular manifestations of acquired immunodeficiency syndrome (AIDS) and their correlation with CD4+ count in the era of highly active antiretroviral therapy (HAART).

Methods

This retrospective study examined 127 AIDS patients who presented to Soonchunhyang University Hospital. Data were collected from patient interviews, clinical examinations, and laboratory investigations. Ophthalmologic examinations included the best-corrected visual acuity, intraocular pressure, anterior segment and adnexal examination, and dilated fundus examination.

Results

Of the 127 patients with AIDS, 118 were on HAART and 9 were not. The mean CD4+ count was 266.7 ± 209.1 cells/µL. There were ocular manifestations in 61 patients (48.0%). The incidence of anterior segment manifestations was higher than posterior segment manifestations at 28.3% and 19.7%, respectively. The mean CD4+ count was significantly (p < 0.05) lower in the patients with posterior versus anterior segment ocular manifestations. The most common ocular manifestation was retinal microvasculopathy (15.0%), followed by keratoconjunctivitis sicca (14.2%), conjunctival microvasculopathy (9.4%), cytomegalovirus retinitis (3.1%), herpes zoster ophthalmicus (2.4%), and blepharitis (1.6%). Retinal microvasculopathy and cytomegalovirus retinitis were common in patients with CD4+ counts <200 cells/µL, while keratoconjunctivitis sicca and conjunctival microvasculopathy were common in patients with CD4+ counts of 200 to 499 cells/µL. There was a significant (p < 0.05) association between ocular manifestation and CD4+ count or age.

Conclusions

The introduction of HAART has changed the landscape of ocular presentations in patients with AIDS. In this study, anterior segment and external ocular manifestations occurred more frequently than posterior segment manifestations. Also, the mean CD4+ count was significantly lower in patients with posterior segment ocular manifestations versus anterior segment ocular manifestations. We found that CD4+ count and age >35 years were independent risk factors for developing ocular manifestations.

[Ophthalmological alterations at the initial diagnosis of HIV infection]

Acquired immunodeficiency syndrome (AIDS) caused by the human immunodeficiency virus (HIV), is one of the most important infectious causes of death in the twentieth and twenty-first centuries. Ocular manifestations can appear in particular when the CD4 cell count is low. This article presents a case report of a 38-year-old homosexual man in whom HIV microangiopathy retinopathy syndrome (MAPS) was found during the assessment of the initial HIV diagnosis. Typical findings in MAPS are conjunctival and retinal vessel abnormalities, cotton wool spots as well as intraretinal hemorrhages. Loss of vision is a rare complication but MAPS shows an impairment of the immune status and is also associated with a higher mortality.

Ocular Manifestations in Patients with HIV Infection/AIDS who were Referred from the ART Centre, Hassan, Karnataka, India

BACKGROUND

Ocular involvement in HIV infection/AIDS is very common and it includes various clinical presentations which may be asymptomatic or atypical or they may be the initial manifestations of the underlying disease. The severity of these lesions increases as the immune competency decreases, leading to visual impairment or blindness.

OBJECTIVE

The purpose of this study was to determine the prevalence and the types of HIV associated ocular conditions and their effect on the vision in patients with HIV/AIDS.

METHODS

This cross sectional study was based on the patients with HIV infection/AIDS, who were referred to the Ophthalmic OPD, District hospital, Hassan. These patients were referred from the District ART Centre for a complete ophthalmic evaluation, irrespective of their immune status and the presence or absence of symptoms. All the patients underwent a complete ophthalmic examination, which included both anterior and posterior segment evaluation and colour vision assessment.

RESULTS

Out of the 553 patients, 66% belonged to the age group of 21-40 years. 87% of the patients had a BCVA of >6/18, whereas 4.7% had very poor vision. 37.6% of the patients had ocular manifestations. Anterior segment, posterior segment and neuro-ophthalmic manifestations were seen in 7%, 9.94% and 5.79% of the patients respectively. The most common anterior segment manifestation was recurrent lid infections, while HIV microangiopathy was the most common posterior segment manifestation. The other unusual findings included an abnormal colour vision in 6.3% of the patients and bilateral lid retraction in 8.5% of the patients.

CONCLUSION

Since ocular manifestations are very common and as they can occur at any time during the course of HIV infection, an awareness on various patterns of the ocular disease and the screening of all the patients with HIV infection/AIDS is a must.

Cytomegalovirus retinitis associated with Good's syndrome

PURPOSE

To report a case of cytomegalovirus (CMV) retinitis associated with Good's syndrome.

METHODS

A 57-year-old man presented to our ophthalmology clinic with complaints of visual loss in the left eye for 2 weeks. His medical anamnesis revealed myasthenia gravis, thymoma resection, multiple chest infections, and Campylobacter septicemia. Left eye examination revealed mild anterior uveitis, moderate vitritis, and superotemporal active retinitis.

RESULTS

Polymerase chain reaction of both aqueous humor and vitreous tap were positive for CMV DNA, which suggested CMV retinitis. The patient was treated with systemic treatment of acyclovir and ganciclovir combined with weekly intravitreal injections of ganciclovir and foscarnet. Retinitis resolved within 3 weeks and visual acuity improved.

CONCLUSIONS

CMV retinitis can be associated with Good's syndrome.

Optimal management of cytomegalovirus retinitis in patients with AIDS

Cytomegalovirus (CMV) retinitis is the most common cause of vision loss in patients with acquired immunodeficiency syndrome (AIDS). CMV retinitis afflicted 25% to 42% of AIDS patients in the pre-highly active antiretroviral therapy (HAART) era, with most vision loss due to macula-involving retinitis or retinal detachment. The introduction of HAART significantly decreased the incidence and severity of CMV retinitis. Optimal treatment of CMV retinitis requires a thorough evaluation of the patient's immune status and an accurate classification of the retinal lesions. When retinitis is diagnosed, HAART therapy should be started or improved, and anti-CMV therapy with oral valganciclovir, intravenous ganciclovir, foscarnet, or cidofovir should be administered. Selected patients, especially those with zone 1 retinitis, may receive intravitreal drug injections or surgical implantation of a sustained-release ganciclovir reservoir. Effective anti-CMV therapy coupled with HAART significantly decreases the incidence of vision loss and improves patient survival. Immune recovery uveitis and retinal detachments are important causes of moderate to severe loss of vision. Compared with the early years of the AIDS epidemic, the treatment emphasis in the post- HAART era has changed from short-term control of retinitis to long-term preservation of vision. Developing countries face shortages of health care professionals and inadequate supplies of anti-CMV and anti-HIV medications. Intravitreal ganciclovir injections may be the most cost effective strategy to treat CMV retinitis in these areas.

The role of infectious agents in the etiology of ocular adnexal neoplasia

Given the fact that infectious agents contribute to around 18% of human cancers worldwide, it would seem prudent to explore their role in neoplasms of the ocular adnexa: primary malignancies of the conjunctiva, lacrimal glands, eyelids, and orbit. By elucidating the mechanisms by which infectious agents contribute to oncogenesis, the management, treatment, and prevention of these neoplasms may one day parallel what is already in place for cancers such as cervical cancer, hepatocellular carcinoma, gastric mucosa-associated lymphoid tissue lymphoma and gastric adenocarcinoma. Antibiotic treatment and vaccines against infectious agents may herald a future with a curtailed role for traditional therapies of surgery, radiation, and chemotherapy. Unlike other malignancies for which large epidemiological studies are available, analyzing ocular adnexal neoplasms is challenging as they are relatively rare. Additionally, putative infectious agents seemingly display an immense geographic variation that has led to much debate regarding the relative importance of one organism versus another. This review discusses the pathogenetic role of several microorganisms in different ocular adnexal malignancies, including human papilloma virus in conjunctival papilloma and squamous cell carcinoma, human immunodeficiency virus in conjunctival squamous carcinoma, Kaposi sarcoma-associated herpes virus or human herpes simplex virus-8 (KSHV/HHV-8) in conjunctival Kaposi sarcoma, Helicobacter pylori (H. pylori,), Chlamydia, and hepatitis C virus in ocular adnexal mucosa-associated lymphoid tissue lymphomas. Unlike cervical cancer where a single infectious agent, human papilloma virus, is found in greater than 99% of lesions, multiple organisms may play a role in the etiology of certain ocular adnexal neoplasms by acting through similar mechanisms of oncogenesis, including chronic antigenic stimulation and the action of infectious oncogenes. However, similar to other human malignancies, ultimately the role of infectious agents in ocular adnexal neoplasms is most likely as a cofactor to genetic and environmental risk factors.

AIDS and ophthalmology: the first quarter century

PURPOSE

To describe changes in the acquired immunodeficiency syndrome (AIDS) epidemic that are important to ophthalmologists, to provide an overview of issues relevant to current evaluation and treatment of human immunodeficiency virus (HIV)-related eye disease, and to identify problems related to the eye and vision that require continued study.

DESIGN

Literature review and commentary.

METHODS

Selected articles from the medical literature and the author's clinical and research experiences over 25 years were reviewed critically.

RESULTS

The AIDS epidemic has had a profound impact on ophthalmology since the ophthalmic manifestations of AIDS were first described in 1982. The introduction of highly active antiretroviral therapy (HAART) has markedly reduced the incidence of cytomegalovirus (CMV) retinitis, but has not eliminated new cases altogether. Treatment strategies for CMV retinitis have evolved over the past decade. Current issues of importance include choice of initial anti-CMV drugs; time at which anti-CMV drug treatment is discontinued in patients who achieve immune recovery; strategies for monitoring patients at risk for disease reactivation; and management of complications (retinal detachment, immune recovery uveitis). Attention also is being directed to the problem of visual disturbances (reduced contrast sensitivity, altered color vision, visual field abnormalities) that can occur in HIV-infected individuals without infectious retinopathies.

CONCLUSIONS

Ocular disorders associated with HIV disease remain important problems in the United States, despite HAART, and increasingly are important worldwide. The approach to management of CMV retinitis has evolved from short-term treatment of a preterminal infection to the long-term management of what has become a chronic disease. Many challenges remain to be addressed.

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.

Ocular pathology in acquired immunodeficiency syndrome

Gross and microscopic ocular findings were prospectively studied in 38 human immunodeficiency virus (HIV)-seropositive subjects undergoing postmortem examination. Pathologic lesions were detected in 27 patients (71%), with 67% of the abnormal findings detected only microscopically.

Non-cancerous ophthalmic clues to non-ocular cancer

This survey reviews selected medical disorders in which the ophthalmologist has a unique opportunity of anticipating the existence of asymptomatic, life-threatening disease simply by recognizing that certain benign conditions involving the eye or adnexa represent clues to occult non-ocular cancer and other neoplasias. Having knowledge that these clues are associated with specific types of neoplasia, the ophthalmologist can then initiate a goal-directed oncologic investigation designed to identify the underlying neoplasm with the hope of providing potentially life-saving therapy. The survey is organized to feature each clue separately. The clinical characteristics of the clue are described and illustrated with color photographs when possible. A discussion reviews associated malignancies and other important medical features. The survey begins with clues expressed anteriorly in the lids, progressively reviewing those clues located more posteriorly, concluding with clues involving the retinal pigment epithelium and choroid.

[Eye involvement in AIDS-related Kaposi sarcoma]

BACKGROUND

The study evaluates the incidence of ocular compromise in the Kaposi's sarcoma associated with AIDS.

METHODS

We revised the clinical histories of HIV seropositives patients seen in the ophthalmology department from January, 1994 to December, 1998. All patients were examined by direct visually and dilated fundus examination with the use of either a direct or an indirect ophthalmoscope.

RESULTS

In 6,552 patients, ocular Kaposi's sarcoma was diagnosed in 17 (0.25%), predominantly in male sex (88.23%). The lesions predominated in eyelids, and the inferior has been the most affected. In only one female, the ocular compromise was the first neoplastic manifestation.

CONCLUSIONS

The ocular compromise in the Kaposi's sarcoma is an alternative to be considered in AIDS patients with previous or simultaneous cutaneous or visceral involvement. Due to the few clinical signs of these lesions, a thorough ocular study is recommended in these patients.

Treatment of cytomegalovirus retinitis with an intraocular sustained-release ganciclovir implant

The objective of this prospective study was to evaluate the efficacy and complications of the use of an intraocular sustained-release ganciclovir implant for the treatment of active cytomegalovirus (CMV) retinitis in AIDS patients. Thirty-nine eyes of 26 patients were submitted to ocular surgery. All patients underwent complete ocular examination before and after surgery. The surgical procedure was always done under local anesthesia using the same technique. The mean time for the surgical procedure was 20 min (range, 15 to 30 min). The average follow-up period was 3.7 months. Of all patient, only 4 presented recurrence of retinitis after 8, 8, 9 and 2 months, respectively. Three of them received a successful second implant. All 39 eyes of the 26 patients presented healing of retinitis as shown by clinical improvement evaluated by indirect binocular ophthalmoscopy and retinography. Retinitis healed within a period of 4 to 6 weeks in all patients, with clinical regression signs from the third week on. Six (15.4%) eyes developed retinal detachment. None of the patients developed CMV retinitis in the contralateral eye. The intraocular implant proved to be effective in controlling the progression of retinitis for a period of up to 8 months even in patients for whom systemic therapy with either ganciclovir or foscarnet or both had failed. The intraocular sustained-release ganciclovir implant proved to be a safe new procedure for the treatment of CMV retinitis, avoiding the systemic side effects caused by the intravenous medications and improving the quality of life of the patients.

Ocular findings in HIV-1 positive and HIV-1 negative participants in a rural population-based cohort in Uganda

PURPOSE

To report the ocular findings in HIV-1 seropositive individuals and HIV-negative controls in a population-based cohort in rural Uganda.

METHODS

Participants were examined by an ophthalmologist, who was unaware of their HIV-status.

RESULTS

238 participants were examined, 43 were HIV-1 prevalent cases (infected prior to 1990); 62 were HIV-1 incident cases and 133 were HIV-negative controls. Eleven of the HIV-positive participants had AIDS, and a further 8 had a CD4 count of less than 200 cells/mm3. Bilateral low vision was recorded in 9 participants and cataracts were the main cause of bilateral low vision. The mean intra-ocular pressure (IOP) was 12.6 mm Hg, and no association was found between IOP and CD4 lymphocyte count. Although significantly more HIV positives had some sign of intraocular inflammation compared to the negatives (p = 0.02) there was no significant linear trend in the HIV positives with decreasing CD4 count. Overall, 11 (26%) prevalent, 6 (10%) incident cases and 8 (6%) HIV-negatives controls had some evidence of intraocular inflammation, however, only one person had reduced visual acuity attributable to these lesions. Punctate epithelial erosions and keratic precipitates in the anterior chamber were seen significantly more frequently in HIV-positives compared to the HIV-negative controls. Cotton wool spots were not seen.

CONCLUSIONS

A substantial proportion of HIV-infected persons had ocular findings which may have been attributable to their infection, however in only one case did this result in reduced visual acuity. Although the ocular complications of AIDS seem to comprise a large extra element in the work load of tertiary care hospitals dealing with eye problems, on a population basis such cases are infrequent.

Cytomegalovirus retinitis in patients with acquired immune deficiency syndrome

Cytomegalovirus (CMV) retinitis is the most common intra-ocular infection in patients with acquired immune deficiency syndrome (AIDS), and a leading cause of AIDS-related morbidity. Untreated CMV retinitis in AIDS patients is a progressive and potentially blinding disorder. The diagnosis of CMV retinitis is a clinical one and it is important for physicians to be familiar with the clinical features of the disease. Ophthalmic screening of AIDS sufferers should be undertaken at regular intervals, and this is dictated, in part, by the patient's CD4+ T-lymphocyte (CD4) counts. CMV retinitis may be treated with systemic ganciclovir, foscarnet or cidofovir, or with local (intravitreal) therpy. CMV-related retinal detachment is treated surgically. In some patients with quiescent CMV retinitis receiving highly active anti-retroviral therapy, anti-CMV maintenance therapy may be discontinued in favour of close ophthalmologic observation and CD4 count monitoring.

Restoration of cytomegalovirus-specific CD4+ T-lymphocyte responses after ganciclovir and highly active antiretroviral therapy in individuals infected with HIV-1

Recent studies of subjects infected with human immunodeficiency virus (HIV-1) have produced conflicting results about the extent of reconstitution possible in the CD4+ lymphocyte repertoire after highly active antiretroviral therapy (HAART). The effect of HAART on the incidence of opportunistic infections will probably depend on reconstitution of antigen-specific CD4+ lymphocyte responses to important pathogens, including cytomegalovirus (CMV), the leading cause of blindness in AIDS. Several studies have demonstrated an important role for CD4+ lymphocytes in controlling CMV replication in vitro and in clinical studies. It is now possible to quantitate antigen-specific CD4+ lymphocyte responses by flow cytometry. Using this method, we studied CMV-specific CD4+ lymphocyte responses in individuals infected with HIV-1 with and without a history of active CMV-associated end organ disease (EOD), and in those with quiescent CMV EOD after ganciclovir therapy and HAART. The presence of active CMV-associated EOD strongly correlated with loss of CMV-specific lymphocyte responses (P = 0.0004). In contrast, patients with no history of CMV-associated EOD and most patients with quiescent EOD after HAART demonstrated strong CMV-specific CD4+ lymphocyte responses. These data indicate that the loss of CMV-specific CD4+ lymphocyte responses in individuals infected with HIV-1 who have active CMV EOD may be restored after ganciclovir therapy and HAART, which provides evidence for functional immune reconstitution to an important pathogen.

Ocular disease in children with vertically acquired human immunodeficiency virus infection

BACKGROUND

Clinical reports suggest that ocular disease in infants and children vertically infected with human immunodeficiency virus (HIV) is different from that in adults. Pediatric patients with acquired immunodeficiency syndrome (AIDS) and HIV infection are being treated more aggressively and are living longer, but current literature on the incidence of AIDS-related ocular disease in vertically acquired HIV infection is limited.

METHODS

Thirty-three children with culture-positive, vertically acquired HIV infections were prospectively followed with ophthalmic examinations between September 1991 and August 1996 at the University of Massachusetts. Patients were categorized as having symptomatic or asymptomatic HIV disease according to the U.S. Centers for Disease Control and Prevention guidelines. Absolute CD4 counts and other measures of immune function were obtained.

RESULTS

The average length of follow-up was 30 months, and the average number of ophthalmic examinations per patient was 4.8. Ten patients developed ophthalmic findings. Nine of 18 (50%) patients with symptomatic AIDS disease developed ophthalmic findings. One of 15 asymptomatic HIV-infected patients developed ocular findings. Two patients with absolute CD4 counts less than 10 developed cytomegalovirus retinitis.

CONCLUSIONS

These results suggest that AIDS-related ophthalmic disease is less common in vertically infected children than in adult AIDS patients. It also supports intensified clinical surveillance for cytomegalovirus retinitis in children with end-stage disease and very low CD4 counts.

Ocular opportunistic infection incidences among patients who are HIV positive compared to patients who are HIV negative

OBJECTIVE

The purpose of the study was to examine the incidence of ocular opportunistic infections among patients who are human immunodeficiency virus (HIV) positive compared to patients who are HIV negative.

DESIGN

The study design was a retrospective cohort study.

PARTICIPANTS

All patients were recruited from 1984 until 1995 at the San Francisco General Hospital.

INTERVENTION

Incidences for numerous diagnoses were compared among the exposure group (HIV positive) and nonexposed control group (HIV negative).

MAIN OUTCOME MEASURES

The diagnoses studied were cytomegalovirus (CMV) retinitis, herpes zoster ophthalmicus, Pneumocystis carinii choroidopathy, herpes simplex keratitis, Toxoplasma retinitis, fungal retinitis, ocular syphilis, and ocular lymphoma.

RESULTS

Among the HIV-positive pool, there were 1800 patient visits with a total of 5200 person-years of follow-up. Among the HIV-negative control pool, there were 48,200 patient visits with a total of 30,100 person-years of follow-up. Incidence rates were calculated using the product-limit method, and risk ratios were calculated using the Cox proportional hazards model. Incidence rate differences were calculated using the incidence density method. Among the outcomes studied, only CMV retinitis, herpes zoster ophthalmicus, and, to a lesser extent, Toxoplasma retinitis showed both an elevated risk ratio and rate difference among patients who were HIV positive compared to patients who were HIV negative. Of the other outcomes studied, either the risk ratio, rate difference, or both were similar among patients who were HIV positive compared to patients who were HIV negative.

CONCLUSIONS

Not all ocular infections seen in patients who are HIV positive should be considered opportunistic, because many occur with similar incidence among patients who are HIV negative. The biologic reasons for this will require further study.

Increasing survival in AIDS patients with cytomegalovirus retinitis treated with combination antiretroviral therapy including HIV protease inhibitors

OBJECTIVE

To assess the effect of combination antiretroviral therapy including HIV protease inhibitors on the survival of patients with cytomegalovirus retinitis (CMVR).

DESIGN AND PARTICIPANTS

A longitudinal study of patients with CMVR diagnosed between October 1992 and May 1996 and followed to May 1997.

SETTING

UK National Health Service specialist HIV medicine department.

OUTCOME MEASURE

Time to death from first diagnosis of CMVR. Data were censored on 31 May 1997.

RESULTS

Data were available on 147 patients with CMVR. Median survival of CMVR patients before December 1995 was 256 days [95% confidence interval (CI), 197-315]. Following the introduction of protease inhibitors in December 1995 this rose to 555 days (95% CI, 351-759). By 31 May 1996 median survival for the entire group of patients alive with CMVR had risen to 720 days (95% CI, 551-889). The mean survival after CMVR diagnosis was 224 days (n=89; 95% CI, 186-261; 1-year survival, 16%) in those who took no further antiretroviral therapy, 353 days in those who took nucleoside reverse transcriptase inhibitors but no protease inhibitors (n=34; 95% CI, 289-418; 1 -year survival, 50%), and 914 days in those who took a protease inhibitor (n=24; 95% CI, 768-1059; 1-year survival, 83%; P < 0.0001). Multivariate analysis showed that the strongest independent predictor of improved survival was having ever received a protease inhibitor after CMVR (relative risk of death, 0.063; 95% CI, 0.027-0.149; P < 0.0001).

CONCLUSIONS

The use of HIV protease inhibitors in combination antiretroviral therapy has been associated with a marked increase in the survival of patients with CMVR.

Treatment of cytomegalovirus retinitis with intraocular implants

Cytomegalovirus (CMV) retinitis affects 20% to 40% of patients with AIDS and is the leading cause of vision loss associated with AIDS. Three treatment options currently exist (ie, IV administration of antiviral medications, intravitreal injections of ganciclovir, surgical implantation of devices that provide sustained release of ganciclovir). As patients with AIDS live longer, perioperative nurses may care for more patients with CMV retinitis who undergo implantation of these devices.

Biodegradable polymeric device for sustained intravitreal release of ganciclovir in rabbits

PURPOSE

A scleral plug made of biodegradable polymer implanted at the pars plana was evaluated to determine its ability to control the intravitreal release of ganciclovir.

METHODS

Scleral plugs containing 25% ganciclovir were prepared with poly(lactic-glycolic acid) (molecular weight, 121 kDa). The release of ganciclovir was evaluated in vitro by spectrophotometry. In vivo intravitreal ganciclovir concentrations were measured by high performance liquid chromatography following plug implantation in pigmented rabbits. The biocompatibility of the device was determined by indirect ophthalmoscopy, electroretinography, and light and electron microscopy.

RESULTS

The in vitro study showed that the plug released ganciclovir throughout a 10-week period. The in vivo study demonstrated that the plugs maintained the drug concentration in the vitreous in a therapeutic range adequate to treat cytomegalovirus (CMV) retinitis for 12 weeks. No significant retinal toxicity was observed.

CONCLUSIONS

This study demonstrated that this drug delivery system can potentially be useful to treat CMV retinitis.