Macular edema in acquired immunodeficiency syndrome-related microvasculopathy

Ocular association of HIV infection in the era of highly active antiretroviral therapy and the global perspective

Ocular involvement is a common complication of HIV infection. Since the late 1990s, widespread use of highly active antiretroviral therapy (HAART) has altered the spectrum, and reduced the incidence of ocular involvement in developed countries. The incidence of the most common ocular opportunistic infection, cytomegalovirus retinitis, has decreased tremendously. However, immune recovery uveitis secondary to HAART has emerged as a frequent visually threatening condition. Early diagnosis and treatment with periocular steroids is helpful in minimizing visual loss. Clinicians should also be aware that certain antimicrobial agents used to treat opportunistic infections in HIV-positive patients are associated with potentially serious ocular side effects. In developing countries, where most of the world's 40 million HIV-positive patients live, the spectrum and incidence of ocular involvement differ from those in developed countries. The lack of HAART availability is among the many causes of these differences, which may include nutritional factors, basic medical care availability and the levels of exposure to different infectious agents. These factors add to the already challenging task of treating ocular complications and preventing blindness in HIV-positive patients in developing countries.

Posterior segment manifestations of HIV/AIDS

The ocular posterior segment manifestations of AIDS may be divided into four categories: retinal vasculopathy, unusual malignancies, neuro-ophthalmologic abnormalities, and opportunistic infections. Microvasculopathy is the most common manifestation. Opportunistic infections, particularly cytomegalovirus retinitis and progressive outer retinal necrosis, are the most likely to result in visual loss due to infection or subsequent retinal detachment. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.

Cystoid macular edema in a patient with acquired immunodeficiency syndrome and past ocular history of cytomegalovirus retinitis after initiation of protease inhibitors

PURPOSE

To describe a patient with acquired immunodeficiency syndrome (AIDS) who presented with cystoid macular edema (CME) which was not associated with active cytomegalovirus (CMV) retinitis or AIDS-related microvasculopathy.

METHOD

A 32-year-old man with AIDS and a past ocular history of inactive CMV retinitis was placed on protease inhibitors when his CD4+ T lymphocyte counts dropped to 8 cells/mm3. Three months later, after his CD4+ T lymphocyte counts had increased to 196 cells/mm3 he complained of micropsia and metamorphopsia in his right eye of 1 week duration. The patient had a complete ocular examination including fluorescein angiography (FA).

RESULTS

Visual acuity (VA) was 7/10 OD. Fundus examination revealed CME and inactive CMV retinitis, and FA demonstrated CME and a hot disc. Two transseptal injections of corticosteroids were administered 2 weeks apart in the right eye as treatment of the CME. The patient reported gradual visual improvement and 6 weeks later, his VA was 10/10(-2). CME had resolved clinically and angiographically.

CONCLUSIONS

CME in our case is associated with inactive CMV retinitis and gradually increasing number of CD4+ T lymphocytes after initiation of treatment with protease inhibitors. It may be amenable to regional administration of corticosteroids without reactivation of retinitis.

Immune-recovery uveitis in patients with cytomegalovirus retinitis taking highly active antiretroviral therapy

PURPOSE

To investigate the clinical features associated with immune recovery in human immunodeficiency virus (HIV)-infected patients with cytomegalovirus retinitis who are taking highly active antiretroviral therapy.

METHODS

Sixteen patients were evaluated prospectively at the National Eye Institute, Bethesda, Maryland. Evaluation included a medical history and a complete ophthalmologic examination. The examination included best-corrected visual acuity score measured by means of logarithmic charts, slit-lamp biomicroscopy, dilated retinal examination, retinal photography, and fluorescein angiography. Immune-recovery uveitis was defined as the ocular inflammation associated with clinical immune recovery in patients taking potent antiretroviral regimens. The ophthalmic characteristics of immune-recovery uveitis were identified, and their effect on visual acuity was statistically analyzed.

RESULTS

The mean CD4+ T-lymphocyte count for the 16 patients taking highly active antiretroviral therapy at the time of evaluation was 393 cells/microl (range, 97-1,338 cells/microl). Immune-recovery uveitis was characterized by vitreitis and optic disk and macular edema. Clinically important complications of immune-recovery uveitis included cataract and epiretinal membrane formation. The visual acuity scores were significantly worse in the 23 eyes with cytomegalovirus retinitis (mean, 67.2 letters, 20/50) than in the nine eyes without cytomegalovirus retinitis (mean, 89.8 letters, 20/16) (P <.001). Regression analysis showed that a lower visual acuity score was associated with the presence of moderate to severe macular edema on fluorescein angiography and vitreous haze (P < or =. 001).

CONCLUSIONS

Immune-recovery uveitis is an important cause of visual morbidity in HIV-infected patients with cytomegalovirus retinitis in the era of highly active antiretroviral therapy. Although immune recovery associated with highly active antiretroviral therapy has allowed some patients to discontinue specific anticytomegalovirus therapy, the rejuvenated immune response can be associated with sight-threatening inflammation.

Cystoid macular edema in patients with acquired immune deficiency syndrome and cytomegalovirus retinitis

PURPOSE

To describe cystoid macular edema in patients with acquired immune deficiency syndrome treated with highly active anti-retroviral therapy, who had or had not already had cytomegalovirus retinitis.

MATERIALS AND METHODS

Case report.

RESULTS

Five acquired immune deficiency syndrome (AIDS) patients, successfully treated with highly active anti-retroviral therapy, were studied. Two had inactive cytomegalovirus retinitis and cystoid macular edema in both eyes. Two had inactive cytomegalovirus retinitis in both eyes and cystoid macular edema in one eye. One patient had inactive cytomegalovirus retinitis in one eye and cystoid macular edema in both eyes.

CONCLUSIONS

Cystoid macular edema may occur in AIDS patients treated with highly active anti-retroviral therapy even in cases without previous retinitis.

Decreased visual acuity in patients with cytomegalovirus retinitis and AIDS

PURPOSE

To investigate the causes of decreased visual acuity in patients with cytomegalovirus (CMV) retinitis in the acquired immunodeficiency syndrome (AIDS).

METHODS

All human immunodeficiency virus (HIV)-positive patients seen in two ophthalmology units over a 15 month period from September 1996 were included in this retrospective study. A detailed ophthalmic examination was performed on all patients and in addition those with CMV retinitis underwent serial fundus photography. Decreased visual acuity was defined as a best corrected visual acuity < or = 6/12. CMV and retroviral treatment, CD4+ count and HIV viral load were also documented for each patient.

RESULTS

Of 110 patients seen over the 15 month period, 26 (41 eyes) had a diagnosis of CMV retinitis. Twelve patients (16 eyes) with CMV retinitis had decreased visual acuity. The decreased visual acuity in 7 eyes was initially due to the CMV retinitis involving the macula and the optic nerve. Retinal detachment was responsible in 2 eyes and optic nerve atrophy in 1 eye. In 6 eyes (4 patients) the decreased visual acuity was due to a maculopathy--cystoid macular oedema and/or an epiretinal membrane in the presence of an inactive zone 2 or 3 CMV retinitis--with all these patients exhibiting a vitritis of varying grade. The decreased visual acuity in the maculopathy subgroup was irreversible in all except 1 eye, and 2 eyes in this category later developed a cataract.

CONCLUSION

In this series, CMV-retinitis-'related' maculopathy was a major (38%) cause of decreased visual acuity, occurring in the absence of zone 1 retinitis and despite inactive peripheral CMV retinitis. A varying degree of vitritis was an associated feature in all these patients. This study therefore highlights maculopathy as an important and previously unrecognised significant cause of visual morbidity in CMV retinitis.

Ocular manifestations of HIV infection

Ophthalmic abnormalities are common in HIV-infected patients. Serious ophthalmic diseases often result from opportunistic infections and can cause blindness in the absence of prompt diagnosis and therapy. We review recent advances in the diagnosis and management of HIV-associated ocular disease, including cytomegalovirus retinitis, the leading cause of vision loss in HIV-infected patients. The widespread use of highly active antiretroviral therapy (HAART) over the past 3 years has reduced the morbidity and mortality associated with HIV infection. HAART has dramatically altered the incidence and natural history of many opportunistic infections, and we discuss the impact of HAART on ophthalmic disease.

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.

Cystoid macular oedema and cytomegalovirus retinitis in patients with HIV disease treated with highly active antiretroviral therapy

BACKGROUND

Although cystoid macular oedema (CMO) is a rare cause of visual loss in AIDS related cytomegalovirus (CMV) retinitis, nine cases are reported of CMO occurring in HIV infected patients with a prior diagnosis of CMV who were receiving highly active antiretroviral therapy (HAART).

METHODS

Medical and ophthalmological records of nine AIDS patients with inactive CMV retinitis were retrospectively analysed. Ophthalmic examination data, laboratory findings, and the systemic antiviral treatment were studied. Ophthalmic examination included visual acuity, anterior chamber flare measured with the laser flare cell meter (LCFM), vitreous haze quantification according to the Nussenblatt grading system, and fluorescein angiography.

RESULTS

Nine HIV infected patients, eight men and one woman, mean age 39 years (range 29-53 years) presented with inactive CMV retinitis and CMO. On fluorescein angiography, CMO was present only in eyes (14 eyes) with signs of previous CMV retinitis. CMV retinitis was inactive in all of them. Visual acuity ranged from 20/200 to 20/30. In 10 eyes with CMV retinitis, anterior chamber flare measured with the LCFM ranged from 18.5 to 82 photons/ms (mean 35.42 ph/ms). A significant vitreous inflammation (1.5+) was observed in eight eyes. All patients had been treated with anti-CMV drugs for a mean period of 18 months (range 12-36 months). All nine patients received HAART with a combination of two nucleotide analogue reverse transcriptase inhibitors and one protease inhibitor for a mean period of 14 months (range 9-18 months). The HIV viral load was below detectable levels (< 200 copies/ml) in eight patients and low (3215 copies/ml) in one. At the time of CMO, the median CD4+ lymphocyte count was 232 cells x 10(6)/l (range 99-639).

CONCLUSION

In AIDS patients, the usual absence of intraocular inflammation in eyes affected by CMV retinitis has been tentatively explained by the profound cellular immunodeficiency. In these patients, treated with HAART, CD4+ counts were increased for several months (mean 14 months). In their eyes, CMV retinitis was associated with significant ocular inflammation and CMO. These findings could be related to the restoration of immune competence after HAART as recently shown.

Cystoid macular edema associated with cytomegalovirus retinitis in patients with the acquired immunodeficiency syndrome

PURPOSE

To describe the clinical and fluorescein angiographic appearance of cystoid macular edema associated with cytomegalovirus retinitis in patients with the acquired immunodeficiency syndrome (AIDS).

METHODS

We retrospectively examined the clinical and photographic records of four patients with AIDS and cytomegalovirus retinitis who developed cystoid macular edema.

RESULTS

Seven eyes of four patients with AIDS and cytomegalovirus retinitis experienced decreased vision associated with cystoid macular edema. Vitreous inflammation was mild in each patient. In all eyes, the retinitis involved zone 1, and in all but one eye, the cytomegalovirus retinitis was inactive. In one eye, the cystoid macular edema was worsened by formation of a dense juxtafoveal epiretinal membrane.

CONCLUSIONS

Although infrequently recognized, cystoid macular edema can cause visual loss in patients with AIDS and cytomegalovirus retinitis. Fluorescein angiography should be considered in any patient with cytomegalovirus retinitis and unexplained visual loss.

Macular serous exudation in patients with acquired immunodeficiency syndrome and cytomegalovirus retinitis

Central visual loss in cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome (AIDS) occurs in two forms: direct macular tissue destruction and secondary involvement as part of rhegmatogenous retinal detachment. We treated 32 patients (35 eyes) with macular exudation that caused reversible visual loss and initially manifested as neurosensory retinal detachment and lipid exudates. Of 35 eyes, 25 showed papillary or peripapillary active retinitis and ten showed retinitis 1,500 to 3,000 microns from the fovea. Of 23 eyes with reduced vision that were followed up until healing of the retinitis and resolution of subretinal fluid and lipid exudates, 22 (96%) showed visual improvement with anti-cytomegalovirus treatment. Our findings suggest that macular exudation is a reversible cause of visual loss in patients with cytomegalovirus retinitis.