Response of human immunodeficiency virus-associated uveitis to zidovudine

A Review of Human Ocular RNA Virus Infections Excluding Coronavirus, Human T-Cell Lymphotropic Virus, and Arboviruses

We provide an updated review of pre-selected RNA viruses causing ocular inflammation in humans. RNA viruses such as coronaviruses and arboviruses are reviewed elsewhere. A Google Scholar search was conducted to identify recent publications on ocular inflammation caused by the RNA viruses specified here. Human RNA viruses target a wide range of ocular tissues from the anterior to the posterior. Influenza, measles and mumps cause anterior segment manifestations including conjunctivitis and keratitis, while retinitis and optic neuritis may be seen posteriorly. Newcastle disease and RSV cause conjunctivitis, whereas HIV causes characteristic anterior uveitis. Cataracts, microphthalmos, and iris abnormalities are common in congenital Rubella, while Rubella virus is associated with Fuchs uveitis syndrome. Newer technologies make it possible to detect more than one pathogen if present simultaneously. RNA viruses may produce significant ocular morbidity, and care should be taken to investigate ocular symptoms during disease outbreaks.

A distinct cytokines profile in tear film of dry eye disease (DED) patients with HIV infection

PURPOSE

To investigate the tear cytokine profile in HIV patients with dry eye disease (DED) and study the association between the severity of ocular inflammatory complications and tear cytokines levels. We postulate that HIV-mediated inflammation may be the underlying pathogenic mechanism for HIV-associated DED.

METHODS

The current prospective case-control study compared tear film cytokine profiles in DED patients with HIV infection (n=34) and age/gender-matched DED patients without HIV infection [controls (n=32)]. Participants were recruited from tertiary referral eye care centre and communicable disease clinics, Singapore. Ocular surface health was documented using tear film, Schirmer's test, corneal staining, and conjunctival injection measurements. Tear samples were collected using Schirmer's strips and analysed for the levels of 41 cytokines using Luminex bead assay. Logistic regression models were performed to determine correlation and significance.

RESULTS

Among the 41 cytokines analysed, statistically significant differences were observed in the mean values of epithelial growth factor (EGF), growth related oncogene (GRO) and interferon gamma-induced protein 10 (IP-10). EGF and IP-10 levels were higher and GRO levels were lower in the tears of DED patients with HIV infection compared to DED patients without HIV infection. No significant association was found between varying levels of ocular surface parameters and cytokine concentrations in HIV patients with DED (p>0.05).

CONCLUSIONS

EGF and IP-10 were significantly elevated and GRO levels were lower in the tear profile of HIV patients with DED compared to immunocompetent patients with DED. This study suggests a novel cytokine driven paradigm for ocular inflammatory complications of HIV infection. Additional studies in large organised cohorts can validate the results.

Clinical manifestations of human immunodeficiency virus-induced uveitis

PURPOSE

To describe the clinical manifestations of patients with human immunodeficiency virus (HIV)-induced uveitis in Thailand.

DESIGN

Prospective cohort study of 6 patients with HIV-induced uveitis.

PARTICIPANTS

Six patients (8 eyes) with HIV-induced uveitis who had an extremely high intraocular: plasma HIV-1 RNA ratio.

METHODS

The clinical manifestations and laboratory findings are reported of 6 consecutive patients with HIV-induced uveitis who had an extremely high intraocular-to-plasma HIV-1 RNA ratio and were diagnosed between July 2009 and May 2011.

MAIN OUTCOME MEASURES

Clinical manifestations and laboratory findings.

RESULTS

Human immunodeficiency virus-induced uveitis was diagnosed in 4 men and 2 women with an average age of 41 years at presentation. None of the patients were receiving highly active anti-retroviral therapy (HAART) or had clinical or laboratory evidence, or both, of opportunistic infections. The mean plasma load was 218 688 copies/ml (median, 137 500 copies/ml; range, 24 900-540 000 copies/ml), and the mean intraocular HIV load was 20 937 755 copies/ml (median, 7 499 000 copies/ml; range, 2 460 000-89 800 000 copies/ml). The average CD4 cell count was 192 cells/μl (median, 248 cells/μl; range, 5-342 cells/μl). All the patients had decreased vision, and none had conjunctival hyperemia. The anatomic location of uveitis was anterior in all patients, and associated vitreitis was present in 4 patients; none exhibited retinal lesions or scars. Anterior segment inflammation and keratic precipitates were observed in all patients, and none responded to topical corticosteroid therapy. After the administration of HAART, the intraocular inflammation disappeared entirely within several weeks in all of the patients and the intraocular and plasma HIV loads decreased.

CONCLUSIONS

Human immunodeficiency virus-induced uveitis should be suspected in HAART-naïve, HIV-positive patients or in those in whom this treatment fails and who have anterior uveitis without any retinal lesions and exhibit no response to topical corticosteroids. The concurrent determination of HIV load in the intraocular fluids and plasma may clarify the cause of HIV-associated uveitis.

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.

Bilateral panuveitis in HIV-1-infected patients with CD8 lymphocytosis

AIMS

To report the presence of HIV-1-infected patients with bilateral panuveitis, CD8 lymphocytosis, and an absence of parotid involvement.

METHODS

Case series of four HIV-1-infected patients naive to antiretroviral treatment.

RESULTS

Four patients with symptomatic panuveitis are presented. Ocular, systemic, and investigation findings are reported. Recognised causes of panuveitis were excluded. All patients showed a clinical response to steroids and antiretroviral therapy.

CONCLUSIONS

Symptomatic panuveitis may occur in HIV-1-infected individuals with CD8 lymphocytosis in the absence of a recognised cause. These patients have clinical features that resemble diffuse infiltrative lymphocytosis syndrome and may represent a subgroup of this syndrome.

Postmortem histological survey of the ocular lesions in a British population of AIDS patients

AIMS

To study ocular pathology and systemic correlations in a series of 73 postmortem eyes from British patients who died from AIDS before the introduction of a HAART regimen.

METHODS

The eyes were studied with conventional histology, special histochemical stainings, and immunohistochemistry.

RESULTS

72.6% of the cases showed chronic uveal inflammation, caused by opportunistic agents in 37.7% of them (cytomegalovirus (CMV) in 30.1%, C neoformans in 5.6%, and Gram positive bacteria in 1.8%). Cytoid bodies were noted in 10/73 eyes, three linked to CMV retinitis. Six retinal haemorrhages, four of which were secondary to CMV, were found. 14 specimens (19. 1%) showed foci of calcification, and a further 11 (15%) calcium oxalate deposits. In no cases were the calcific deposits suspected clinically. Six eyes (8.2%) did not show any abnormality.

CONCLUSIONS

CMV retinitis is the most common (28.7%, 21/73) ocular infection in this series and may occur either during or in the absence of systemic dissemination. Conversely, ocular cryptococcosis appears to be an epiphenomenon of systemic and CNS disease. No other opportunistic ocular infections were present in this series. Interesting findings were the presence of intraocular precipitates of calcium oxalate and calcium phosphate or carbonate in a significant number of cases (15% and 19%, respectively), and the high prevalence of idiopathic uveal inflammation (43.8%).

Human immunodeficiency virus type 1 can infect human retinal pigment epithelial cells in culture and alter the ability of the cells to phagocytose rod outer segment membranes

Human immunodeficiency virus type 1 (HIV-1) has been found in the vitreous of persons with AIDS. Here we investigated the susceptibility of human retinal pigment epithelial (RPE) cells to HIV-1 infection in culture and the effects of HIV-1 on the phagocytic function of the RPE. We found that 10 of 11 populations of RPE cells isolated from different fetal or adult eyes were susceptible to low-level replication of HIV-1/NL4-3 as determined by the detection of viral DNA and spliced viral RNA encoding envelope. HIV-1 infection was not inhibited by recombinant soluble CD4, suggesting that CD4 is not required for virus entry into RPE cells. RPE cells fused with target cells constitutively expressing HIV-1 envelope glycoproteins, indicating that HIV-1 enters cells by receptor-mediated fusion. Exposure to HIV-1 or recombinant gp120 caused a two- to four-fold increase in the binding and uptake of isolated rod outer segments by RPE cells. These findings introduce a new cell target of HIV-1 replication in the eye and indicate that RPE cells function aberrantly when exposed to HIV-1 or its envelope glycoprotein.

Symptomatic anterior uveitis in HIV-positive patients

Symptomatic anterior uveitis is rare in HIV-positive patients. The uveitis associated with cytomegalovirus retinitis (CMVR), the commonest ocular manifestation in AIDS patients, is rarely symptomatic and patients do not typically present with a red painful eye in conjunction with blurred vision. In this article we report 12 cases of symptomatic anterior uveitis in HIV-positive patients and discuss the aetiology. The case notes of all HIV-positive patients presenting to the eye department with symptoms of uveitis over a 4-year period were studied retrospectively. The notes were analysed for age, sex, race, risk factors of HIV, features of the uveitis, concurrent disease and CD4 counts. Only 12 patients were identified to have symptomatic uveitis out of a total 172 patients. There were 9 males and 3 females with an average age of 35 years. None of these patients were taking either rifabutin, protease inhibitors or cidofovir. Seven out of the 12 patients had granulomatous uveitis. Of these 7 patients, 4 had CD4 counts over 200 and no other concurrent illness whilst 3 patients, with CD4 counts between 130-200, were subsequently found to have an underlying aetiology namely lymphoma, tuberculosis and candida. The remaining 5 patients, all with CD4 counts below 40, had a history of systemic illness with herpes zoster preceding the onset of the uveitis. HIV-positive patients with symptoms of uveitis do not have active CMVR and the ophthalmologist must search for other causes such as tuberculosis or lymphoma in those with granulomatous uveitis or herpes zoster in those with non-granulomatous uveitis. The CD4 count may be helpful.

Changing patterns of HIV related ocular disease

Cytomegalovirus (CMV) retinitis is the commonest ocular complication of AIDS and the prevention of recurrence has been dependent on lifelong maintenance treatment. Recently there has been a dramatic downturn in the number of new cases of CMV retinitis, which has been attributed to the introduction of highly active antiretroviral therapy (HAART) and subsequent improved survival. Whereas paucity of inflammation has been considered to be the hallmark of the ophthalmic manifestations of AIDS, with immune recovery, a new pattern of ophthalmic AIDS has emerged. This is characterised by a heightened inflammatory response and more frequent complications associated with this response--for example, vitritis, cystoid macular oedema. In spite of this, regression of CMV retinitis has been reported, as well as absence of reactivation or progression after withdrawal of anti-CMV maintenance treatment. How long this situation will continue is not known and we remain cautious about the future of CMV retinitis and other opportunistic ocular infections.

Iritis associated with intravenous cidofovir

OBJECTIVE

To report two patients with AIDS and cytomegalovirus retinitis who developed iritis after receiving intravenous cidofovir. Both experienced recurrent symptoms upon rechallenge.

CASE SUMMARIES

Two HIV-positive patients with cytomegalovirus retinitis infections previously controlled with intravenous ganciclovir or foscarnet were treated with intravenous cidofovir. Symptoms of iritis developed after the second or third dose of cidofovir. One patient experienced symptoms unilaterally, while the other patient had bilateral symptoms. In both patients, the iritis resolved with topical ophthalmic therapy, but recurred following subsequent infusions of cidofovir. Therapy with cidofovir was discontinued, and no further recurrences of iritis were noted. One patient had post-inflammatory fixed dilated pupils.

CONCLUSIONS

Iritis can uncommonly occur in patients receiving intravenous cidofovir and oral probenecid. With prompt drug discontinuation and administration of topical corticosteroids and/or mydriatic agents, symptoms are usually reversible.

Virus infections of the eye

In reviewing the clinical features, diagnostic evaluations and therapies of the most common ocular viral infections we attempt to whet your appetite for attacking the numerous challenges in diagnosis and treatment of viral eye disease. The herpes viruses, HSV, VZV and CMV are the cause of significant ocular morbidity. HSV most commonly affects the cornea producing keratitis that can be recurrent and may lead to corneal clouding and neovascularisation. Manifestations can be purely infectious or immunological and treatment options must be tailored to the underlying pathophysiology. Herpes zoster ophthalmicus, caused by VZV infection of the first branch of the trigeminal nerve, produces a characteristic rash and can progress to keratitis and uveitis. HSV and VZV can cause retinitis in both immunocompetent and immunocompromised individuals. There has been a significant increase in the incidence of CMV retinitis since the beginning of the AIDS epidemic. We review the numerous new treatments, diagnostic tests and treatment strategies which have been developed in response to this potentially blinding retinal infection. Adenovirus produces an epidemic conjunctivitis and epidemic keratoconjunctivitis which are severe and extremely contagious conjunctival infections. HIV, molluscum contagiosum, EBV and rubeola also cause ocular diseases which are described.Copyright 1998 John Wiley & Sons, Ltd.

Uveitis associated with human immunodeficiency virus infection

PURPOSE

To report uveitis associated with human immunodeficiency virus (HIV) infection and to suggest guidelines for treatment.

METHODS

Six HIV-seropositive patients (10 eyes) with anterior or posterior uveitis or both were evaluated. After ineffective prolonged treatment with systemic and topical corticosteroids, specific systemic antiretroviral therapy with zidovudine was initiated in all patients. Aqueous humor was cultured in three eyes of three patients, and vitreous humor was cultured in one eye of one patient.

RESULTS

In all 10 eyes of six patients, there was resolution of inflammation in 10 to 42 days after commencement of treatment with zidovudine (600 to 800 mg/day), despite no or minimal response to corticosteroids. Cultures of aqueous humor from three eyes of three patients and culture of vitreous humor from one eye of one patient were positive for HIV; no other organism was isolated. Systemic evaluation disclosed no other identifiable cause for the uveitis in any patient.

CONCLUSIONS

Infection with HIV appears to be a cause of uveitis. A trial of zidovudine may be warranted in HIV-seropositive patients with uveitis that is poorly responsive to corticosteroid treatment when no other cause is identified. The efficacy of other retroviral agents was not determined.

Chronic multifocal retinal infiltrates in patients infected with human immunodeficiency virus

PURPOSE

To describe the clinical features of a disorder characterized by chronic multifocal retinal infiltrates and uveitis in individuals with human immunodeficiency virus (HIV) disease.

METHODS

We reviewed the medical records of HIV-infected patients with multifocal retinal infiltrates of unknown cause seen by investigators at four institutions. The following data were collected: demographic characteristics, presenting signs and symptoms, laboratory test results, and course of disease.

RESULTS

We identified 26 HIV-infected patients (50 involved eyes) with this syndrome. Median CD4+ T-lymphocyte count at presentation was 272 per microl (range, 7 to 2,118 per microl). The most common presenting symptom was floaters. Median visual acuity of involved eyes at presentation was 20/20 (range, 20/15 to 20/100) and remained stable (median, 20/20; range, 20/15 to 20/70) after a median follow-up period of 9 months (range, 0 to 110 months). Typical retinal lesions were gray-white or yellow, irregular in shape, and less than 200 microm in greatest dimension. All were located in the midperiphery or anterior retina and enlarged slowly or remained static in size. Mild to moderate anterior chamber or vitreous humor inflammatory cells were present in 47 of 50 eyes (26 of 26 patients). Retinal lesions possibly responded to zidovudine but not to acyclovir or ganciclovir. Anterior chamber and vitreous humor inflammatory reactions responded to topical or periocular injections of corticosteroid.

CONCLUSIONS

Uveitis with chronic multifocal retinal infiltrates is a distinct clinical entity of unknown cause that occurs in HIV-infected patients. Retinal lesions may respond to antiretroviral therapy. Visual prognosis is good.

Elevation of laser flare photometry in patients with cytomegalovirus retinitis and AIDS

PURPOSE

To investigate an alteration of the blood-ocular barriers by laser flare photometry in patients with acquired immunodeficiency syndrome (AIDS) diagnosed with cytomegalovirus retinitis.

METHODS

Serial laser flare photometry measurements from 31 eyes of 31 patients with AIDS and newly diagnosed cytomegalovirus retinitis were compared with measurements from 31 control patients with AIDS but without documented eye disease. Location and extent of retinitis, presence of visual symptoms, and CD4 lymphocyte counts were also compared with laser flare photometry readings.

RESULTS

Laser flare readings (mean +/- SE) were significantly higher in eyes with (13.0 +/- 1.5 photon counts per msec) than without cytomegalovirus retinitis (4.9 +/- 0.3 photon counts per msec) (P < .001). Lesions within the arcade vessels resulted in significantly higher laser flare photometry readings (17.3 +/- 2.5 photon counts per msec) compared with peripheral retinitis (9.8 +/- 1.5 photon counts per msec) (P = .01). A significant correlation was found between area of involvement of peripheral retinitis and laser flare photometry readings (P = .008). Readings in patients without cytomegalovirus retinitis increased significantly 10 months after the first measurement (9.5 +/- 1.9 photon counts per msec) (P = .04). Readings in patients with cytomegalovirus remained elevated 3 months after successful treatment of retinitis (12.3 +/- 2.3 photon counts per msec) (P = .6).

CONCLUSIONS

Laser flare photometry readings are significantly elevated in eyes with cytomegalovirus retinitis, suggesting a breakdown of the blood-ocular barriers. Increasing laser flare photometry readings over time in patients without known ocular disease suggests that HIV infection may cause progressive breakdown of the blood-ocular barrier.

Diagnostic imaging in pediatric AIDS

The manifestations of acquired immune deficiency syndrome (AIDS) in children are mainly secondary to opportunistic infection, lymphoproliferative diseases, and AIDS-related neoplasms. This article reviews the pathologic findings of various disorders afflicting children with AIDS and emphasizes the imaging of these disorders. Although many of the radiologic findings are not specific for a particular infection or neoplasm, the differential diagnostic possibilities for an abnormality can be narrowed down significantly with proper clinical correlation and knowledge of the imaging findings and pathologies specific to children with AIDS.

Uveitis associated with rifabutin and macrolide therapy for Mycobacterium avium intracellulare infection in AIDS patients

OBJECTIVE

Uveitis has been increasingly recognised as a side effect of rifabutin regimens in the prophylaxis and treatment of Mycobacterium avium intracellulare (MAI) infection. This study describes the clinical features and analyses the factors associated with rifabutin induced uveitis.

DESIGN

Retrospective observational study.

SETTING

Tertiary care institution, The Royal Hospitals NHS Trust, London.

PATIENTS

68 HIV seropositive individuals receiving rifabutin for prophylaxis or treatment of MAI infection.

RESULTS

11 episodes of uveitis occurred in 10 different individuals at a median of 62 days. The disease was bilateral in four and unilateral in the remainder. All subjects experienced ocular pain and photophobia and 9 individuals had a significant reduction in visual acuity. Uveitis was treated with mydriatics and topical steroids and resolved in all cases when rifabutin was stopped. The risk of uveitis was significantly increased with concurrent clarithromycin therapy, Odds Ratio 13.08, 95% Confidence Interval 1.98 to 83.12.

CONCLUSION

Rifabutin can cause a reversible uveitis. This risk is increased with concurrent clarithromycin therapy. Adverse drug interactions can be an important cause of morbidity in patients with advanced HIV disease.

Uveitis associated with rifabutin therapy

PURPOSE

To highlight the association of uveitis with the use of rifabutin.

METHODS

Retrospective study of two patients with acute anterior uveitis.

RESULTS

Both patients were receiving rifabutin for treatment of atypical Mycobacterium infection associated with AIDS when they developed unilateral acute anterior uveitis and arthritis. The inflammation resolved and vision improved with introduction of topical corticosteroids, mydriatics and cessation of rifabutin treatment.

CONCLUSION

Use of rifabutin with clarithromycin may precipitate acute uveitis in patients with AIDS being treated for systemic Mycobacterium avium complex infection. Uveitis produced by rifabutin may be analogous to Herxeimer reaction as seen in syphilis. Clarithromycin and fluconazole elevate levels of rifabutin due to inhibition of metabolism through cytochrome p-450 pathway. The differential diagnosis includes Reiter's syndrome, syphilis causing uveitis, metastatic endophthalmitis, and direct HIV-related uveitis.

Rifabutin-associated uveitis

OBJECTIVE

To review rifabutin-associated uveitis and discuss the mechanism and potential role of drug interactions with clarithromycin and fluconazole in contributing to this adverse event.

DATA SOURCES

A MEDLINE search (1991 through September 1994) of English-language literature using the main MeSH headings "rifabutin" and "uveitis" and the subheadings "adverse effects" and "chemically induced." Relevant articles also were selected from references of identified articles. Abstracts from recent medical conferences of infectious diseases, pharmacology, and HIV were screened for additional data.

STUDY SELECTION AND DATA EXTRACTION

All articles and abstracts reporting uveitis potentially related to rifabutin were considered for inclusion. Fifty-four cases were identified. Pertinent information from the case reports, as judged by the authors, was selected and synthesized for discussion.

DATA SYNTHESIS

Rifabutin is being prescribed increasingly for the treatment and prophylaxis of Mycobacterium avium complex (MAC) infection in the HIV-infected population. Uveitis was initially thought to be a rare, dose-limited complication of rifabutin therapy. In an early dose-ranging tolerance study, uveitis was associated with daily doses of 1200 mg or more. Because this toxicity appeared to be dose-related, lower dosages (300-600 mg/d) of rifabutin were selected for study in subsequent clinical trials. More recent reports noting the association of uveitis with these lower dosages of rifabutin have raised concerns about the prevalence of this adverse event. In the 54 identified cases, patients presented with symptoms of unilateral or bilateral uveitis from 2 weeks to more than 7 months following initiation of rifabutin therapy. In all reported cases, patients were receiving concurrent therapy with clarithromycin and/or fluconazole, both of which have inhibitory effects on rifabutin metabolism. In most cases, uveitis resolved within 1-2 months following discontinuation of rifabutin with or without administration of topical corticosteroids.

CONCLUSIONS

Rifabutin is prescribed frequently for the prophylaxis and treatment of MAC infection, especially in patients with HIV. Uveitis is a rare, dose-related toxicity of this therapy. The risk of rifabutin-associated uveitis may be increased in patients receiving concurrent therapy with clarithromycin or fluconazole because of drug interactions. Patients receiving therapy with combinations of any of these agents should be warned about signs and symptoms of uveitis and be monitored closely for the development of rifabutin toxicity. If uveitis develops, rifabutin therapy should be discontinued promptly.

Acute uveitis associated with rifabutin use in patients with human immunodeficiency virus infection

PURPOSE

We studied patients with a new anterior uveitis syndrome associated with rifabutin use.

METHODS

Nine patients with the acquired immunodeficiency syndrome (AIDS) who developed acute anterior uveitis were identified retrospectively from institutional ophthalmology, infectious disease, and AIDS primary care practices. Five patients initially had hypopyon; in three patients hypopyon was bilateral and recurrent. The medical history, initial signs and symptoms, diagnostic examination, clinical course, and response to therapy were ascertained by a review of the medical records.

RESULTS

All nine patients were being treated with rifabutin for treatment of, or prophylaxis against, Mycobacterium avium complex. In no patient was another untreated cause of uveitis found. In each patient the uveitis resolved rapidly without sequelae with treatment with topical corticosteroids alone. In eight patients uveitis resolved completely while treatment or prophylaxis for M. avium complex was maintained.

CONCLUSIONS

We studied a new hypopyon uveitis syndrome in patients with AIDS who are being treated with rifabutin. The interaction of multiple drugs may contribute to this uveitis syndrome. This uveitis is remarkable because it is fulminant yet responds rapidly to topical corticosteroids. Characterization of this syndrome is important because hypopyon in the immunocompromised patient generally mandates intensive, and sometimes invasive, ophthalmic and systemic examination and therapy. Additional study is required to determine whether immune status, underlying infection, or drug-related factors contribute to the development of this uveitis syndrome. Although this syndrome remains a diagnosis of exclusion, ophthalmologists must be aware of it, so that intervention is guided appropriately.

Intravitreal foscarnet for cytomegalovirus retinitis in a patient with acquired immunodeficiency syndrome

We treated a patient who had acquired immunodeficiency syndrome and cytomegalovirus retinitis of the left eye. After anesthetic had been topically administered, the patient received intravitreal injections of 1,200 micrograms of foscarnet. Plasma and vitreous foscarnet levels were measured by high-performance liquid chromatography. Systemic absorption of the drug was not evident. Elimination half-life from the vitreous after one injection was 54.0 hours. Vitreous levels remained above the mean 50% inhibition value for cytomegalovirus for approximately 56 hours and above the mean inhibition value for human immunodeficiency virus for approximately 241 hours. The patient's visual acuity improved from 20/30 to 20/25 in the left eye. Ophthalmoscopy showed the retinal lesion to have become inactive, and no reactivation occurred during the follow-up period of more than four months. The drug was well tolerated and no retinal toxicity was evident. We suggest an induction treatment regimen of two injections weekly for three weeks, followed by a maintenance treatment regimen of one injection weekly.

Systemic antiviral drugs used in ophthalmology

Over the past two decades, the recognition of viral enzymes and proteins that can serve as molecular targets of drugs has revolutionized the treatment of viral infections. Beginning with acyclovir, a number of systemically administered agents which are both relatively safe and effective for the treatment of herpetic infections and human immunodeficiency virus (HIV) infections have become widely available. Because of increased numbers of herpes virus infections, as well as the rising epidemic of HIV infections, the ophthalmologist is, more likely than ever before to be involved in the treatment of severe and frequent ocular infections caused by herpes viruses. In addition, the acute retinal necrosis (ARN) syndrome has been demonstrated to be caused by herpes viruses and a once rare retinal infection caused by cytomegalovirus is common in patients with the acquired immunodeficiency syndrome (AIDS). In this article, four systemic antiviral drugs (Vidarabine, Acyclovir, Ganciclovir, and Foscarnet) that have demonstrated usefulness in the treatment of ophthalmic disease are reviewed in detail with regard to their mechanisms, applications, effectiveness, and side effects.

Ocular tissue involvement in HIV infection: immunological and pathological aspects

The CNS afflictions in AIDS are myriad and suggest a tropism of HIV to neural tissue. Ocular involvement is a frequent manifestation of the HIV infection, resulting in a high incidence of blindness within this patient population. Ocular lesions include cotton wool spots, presumably from HIV-induced microvasculopathy, retinal hemorrhage in cytomegalovirus retinitis and conjunctival Kaposi's sarcoma. These manifestations have been noted in up to 71% of AIDS patients. In fact, ocular disease is often the presenting symptom in an HIV-infected individual. Despite the high incidence of ocular involvement in AIDS patients, the etiology and pathogenesis of these manifestations are not well understood. The immunosuppressive action of HIV is the most likely primary cause for the development of ocular complications in AIDS. Here we review some of the important immunological and pathological features of AIDS affliction in the eye.

Evidence for cytomegalovirus and human immunodeficiency virus infection of the retina in AIDS

Characteristic ophthalmopathological features of retinal lesions in a patient with the acquired immunodeficiency syndrome (AIDS) are reported. In situ hybridization, immunohistochemistry and electron microscopy revealed severe unilateral cytomegalovirus (CMV) retinitis. The opposite retina which was not involved by CMV showed nonspecific signs of ischaemia in the nerve fiber layer corresponding to cotton-wool spots. Occasional cells of both retinas were positively stained by a mouse monoclonal antibody to the p24 HIV-1 antigen indicating infection of retinal cells by HIV. It is suggested that HIV may directly or indirectly damage retinal tissue and interact with opportunistic pathogens, thus leading to a variety of ocular abnormalities associated with AIDS.

Retinal dysfunction as an initial ophthalmic sign in AIDS

Three cases of patients with AIDS in whom severe retinal dysfunction preceded the development of widespread funduscopic abnormalities are presented. The disparity between the minimal extent of visible retinal lesions and the severe loss of retinal function was confirmed by visual field and electroretinographic studies. This pattern of early visual loss in AIDS patients may represent infection of the retina by the HIV virus.

Ocular manifestations of acquired immune deficiency syndrome

The ocular complications of acquired immune deficiency syndrome (AIDS) include: (1) a noninfectious microangiopathy, most often seen in the retina, consisting of cotton-wool spots with or without intraretinal hemorrhages and other microvascular abnormalities; (2) opportunistic ocular infections, primarily cytomegalovirus (CMV) retinitis; (3) conjunctival, eyelid, or orbital involvement by those neoplasms seen in patients with AIDS (i.e., Kaposi's sarcoma and lymphoma); and (4) neuro-ophthalmic lesions. In a series of 200 AIDS patients evaluated clinically, AIDS retinopathy was present in 66.5%. Sixty-four percent had cotton-wool spots, and 12% had intraretinal hemorrhages. Cytomegalovirus retinitis was diagnosed in 28% of AIDS patients. Neuro-ophthalmic lesions were found in 8% of all AIDS patients and were present in 33% of those patients with cryptococcal meningitis. Acquired immune deficiency syndrome retinopathy was present in 40% of 35 patients with the AIDS-related complex (ARC) and in 1.3% of 232 patients with asymptomatic human immunodeficiency virus (HIV) infection, evaluated photographically. These results suggest that the prevalence of AIDS retinopathy increases with increasing severity of HIV infection, and that CMV retinitis presents a significant vision-threatening problem in AIDS patients.

The spectrum of optic nerve disease in human immunodeficiency virus infection

We studied four patients with HIV-associated optic neuropathies. One had syphilitic optic perineuritis, which responded promptly and completely to penicillin therapy. The second had cytomegalovirus papillitis and visual acuity subsequently deteriorated to no light perception. The third showed varicella zoster optic neuritis, which improved after intravenous acyclovir treatment. The fourth patient developed cryptococcal retrobulbar neuritis and died shortly thereafter. Optic neuropathy was among the initial symptoms of HIV infection in two of the four cases.