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Ocular manifestations of hiv


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Ocular manifestations of hiv

  1. 1. Ocular Manifestations of HIV Beka Aberra C2
  2. 2. Outline Introduction Adnexal manifestations of HIV infection Anterior segment Posterior segment In Children In Developing countries Drug related ocular toxicity
  3. 3. Objectives• Know incidence and prevalence of ocular diseases in HIV patients.• Identify common ocular diseases in HIV patients.• Know the clinical manifestations of common ocular diseases.• Reach a diagnosis of common ocular diseases.• Know the outline of management and workup.
  4. 4. EpidemiologyA cross-sectional clinical evaluation of HIV/AIDS patients atGondar Hospital University was undertaken between Januaryand June 2004.Results: 125 adult patients were enrolled in the Hospital fromJanuary to June 2004. The majority were males (N=69) andthe mean age was 34 (range: 16-80 years). About 90% of thepatients were in clinical stages III & IV determined accordingto the WHO clinical staging method and 60% of them had atleast one ocular manifestation.
  5. 5. Ocular manifestations related to HIV/AIDS in 125 patients, Gondar UniversityHospital, Northwest Ethiopia, 2004Ocular diagnosis Number of patients (%)• Retinal Microvaculopathy 30 (24)• Neuro-ophthalmic disorders 12 (9.6)• Uveitis 9 (7.2)• Ophthalmic herpes zoster 7 (5.6)• Molluscum Contagiosum 6 (4.8)• Conjunctival carcinoma 5 (4)• Seborrheic blepharitis 3 (2.4)• Vernal conjunctivitis 1 (0.8)• Sub conjucnctival haemorrhage 2 (1.6)Total 75 (60)
  6. 6. Ocular manifestations of HIV/AIDS patients in Ethiopia and Other AfricanCountries Manifestation Ethiopia Burundi Malawi (N=125) (N=154) (N=99)• Frequency of ocular manifestation 60% 19% 20%• Retinal Microvasculopthy 24% 16% 17%• Herpes zonster Ophthalmicus 5.6% 1% NA• Anterior Uveitis 7.2% 4% 2%• CMV retinitis <1% 1% 1%• Neuro-ophthalmic disorders 9.6% NA NA• Conjunctival carcinoma 4% NA NANA: Not Available
  7. 7. Posterior segmentmanifestations•Retinal Vasculopathy•Opportunistic Infections•Unusual Malignancies•Neuro-Ophthalmologic abnormalities
  8. 8. Retinal Vasculopathy• Retinal microvasculopathy occurs in more than 50% of HIV-infected patients.• The most commonly observed manifestation is cotton-wool spots as in the figure , although intraretinal hemorrhages, micro aneurysms, and, uncommonly, retinal ischemia also occur.
  9. 9. • Hypotheses regarding the pathogenesis of retinal microvasculopathy is HIV induced increase in plasma viscosity, HIV-related immune complex deposition, and direct infection of the conjunctival vascular endothelium by HIV.• HIV-associated retinal microvasculopathy is typically asymptomatic, but may play a role in the progressive optic nerve atrophy, loss of color vision, contrast sensitivity, and visual field are observed in HIV-infected patients.
  10. 10. Opportunistic InfectionsCauses of infectious retinitis,includingCytomegalovirus (A),Varicella-zoster virus (B),Herpes simplex virus (C),Toxoplasmosis (D) in fourdifferent patients with AIDS.
  11. 11. Cytomegalovirus Retinitis• CMV retinitis affects 30% to 40% of HIV-infected patients.• CMV retinitis typically occurs at CD4+ T-lymphocyte counts of less than 50 cells/mm3, and almost always at counts less than 100 cells/mm3.• Affected patients typically report gradual visual field loss or the onset of floaters**. Clinical examination shows geographic retinal thickening and opacification.• Treatment of CMV retinitis is a complicated, rapidly evolving field. Current FDA-approved treatments for active retinitis include intravenous Gancyclovir, Foscarnet, and Cidofovir. Any of the same medicines or the recently approved oral formulation of Gancyclovir can be used for maintenance therapy.• Local therapy with intravitreal injection of Gancyclovir, foscarnet, or Cidofovir, or via implantation of a slow-release Gancyclovir-containing reservoir, is also possible.
  12. 12. Varicella-Zoster Virus Retinitis• VZV is the second most common cause of necrotizing retinitis in HIV-infected individuals, affecting approximately 5% of large cohorts with AIDS.• Like CMV, VZV produces retinal whitening , occasionally accompanied by intraretinal hemorrhages. However, VZV retinitis is usually distinguished by its rapid progression, multifocal nature, and initial involvement of deep retinal layers. The risk of retinal detachment is greater than observed with CMV retinitis.• Treatment involves the use of intravenous and intravitreal antivirals, typically combination therapy with acyclovir and foscarnet.Herpes Simplex Virus Retinitis• Herpes simplex virus is a rare cause of retinitis in HIV-infected patients. Like VZV retinitis, onset of symptoms and disease progression is rapid. Clinical appearance may mimic VZV retinitis.• Treatment should include prompt use of intravenous and intravitreal antivirals, again most typically acyclovir and foscarnet.
  13. 13. Toxoplasmosis Retinochoroiditis• Ocular toxoplasmosis affects less than 1% of HIV-infected patients in most countries. Toxoplasmosis retinochoroiditis in HIV-positive patients is usually distinguished by the occurrence of a moderate to severe anterior chamber and vitreous inflammation, a relative lack of retinal hemorrhage, and the presence of a smooth rather than granular edge.• Moreover, unlike toxoplasmosis retinochoroiditis in immunocompetent patients, HIV-infected patients often have multifocal and bilateral disease, with no evidence of inactive toxoplasmosis scars.• Testing should include serology for IgG and IgM toxoplasmosis antibodies, but may be negative in profoundly immunosuppressed patients.• Treatment consists of pyrimethamine in combination with a sulfonamide or clindamycin, either alone or in combination. Chronic or repeated therapy is often necessary.• Atovaquone has been used successfully in the treatment of toxoplasmosis retinochoroiditis in an HIV-positive patient, but it is expensive and has yet to be shown to be superior to more standard combination therapy
  14. 14. Bacterial and Fungal Retinitis• Ocular syphilis is the most common intraocular bacterial infection in HIV-positive patients, affecting up to 2% of patients. Patients may present with either an iridocyclitis or a more diffuse intraocular inflammation, with or without retinal or optic nerve involvement.• Laboratory testing should include both (RPR) or (VDRL) test and [FTA-ABS] or [MHA-TP]) test. Rarely, these test may be negative in HIV-positive patients despite active intraocular disease.• Treatment includes intravenous penicillin G, 24 million units/day for 7 to 10 days. Recurrences can occur even after adequate treatment.
  15. 15. INFECTIOUS CHOROIDITISInfectious choroiditis is uncommon inHIV-infected patients, accounting for lessthan 1 %.Up to one third of cases have concurrent CMV retinitis.Fig. 13. Acute (A) and healed (B)Pneumocystis carinii choroiditis in apatient with AIDS.
  16. 16. Unusual MalignanciesINTRAOCULAR LYMPHOMA• HIV-infected patients are at increased risk for developing non-Hodgkins lymphoma.• Although uncommon, cases of intraocular lymphoma have been reported in HIV-infected patients, and are composed primarily of B cells.• Treatment includes radiation and chemotherapy.
  17. 17. ORBITAL & NEURO-OPHTHALMICMANIFESTATIONS OF HIV INFECTIONOrbital Neuro-ophthalmicOrbital lymphoma PapilledemaOrbital cellulitis Optic neuritisOrbital Kaposis sarcoma Optic atrophy Cranial nerve palsies Ocular Motility disorders Visual field defects
  18. 18. ORBITAL MANIFESTATIONS OF HIV INFECTION• Orbital complications, most commonly orbital lymphoma or orbital cellulitis, occur in well under 1% of HIV-infected patients.• Treatment of orbital cellulitis includes systemic antibiotics and, as needed, surgical debridement.
  19. 19. NEURO-OPHTHALMIC MANIFESTATIONS OF HIV INFECTION• Neuro-ophthalmic manifestations occur in 10% to 15% of HIV-infected patients.• Most common findings include ONH edema related to either papilledema or direct optic neuritis; nonspecific optic atrophy; CN palsies (especially of the 6th nerve); occulomotor abnormalities, such as nystagmus, gaze palsies, internuclear ophthalmoparesis, and skew deviation (Strabismus) ; and visual field defects.• In most instances, evaluation includes MRI, followed by a LP for cell count, cytology, culture, and Ab and Ag testing.• Treatment includes radiation and chemotherapy in the case of lymphoma, and specific antibiotic therapy for identified infectious causes. There is currently no treatment for HIV encephalopathy or progressive multifocal leukoencephalopathy.
  20. 20. Fig. 14. Optic disc edema with surrounding cotton-wool spots and intraretinal hemorrhages due toneurosyphilis (A) and cryptococcal meningitis withpapilledema (B) in two different patients withAIDS.
  21. 21. OCULAR MANIFESTATION OF HIV INFECTION IN CHILDREN• Children appear to have fewer ocular manifestations of HIV infection and an especially low incidence of CMV retinitis.• The reason for this difference is unknown, but may relate to an altered immune response to HIV or a lower prevalence of CMV seropositivity in children.• HIV-infected children are, however, at increased risk for neurodevelopmental delay, a condition often associated with neuro- ophthalmic complications.• A fetal AIDS-associated embryopathy, with downward obliquity of the eyes, prominent palpebral fissures, hypertelorism, and blue sclerae, has also been described.
  22. 22. OCULAR MANIFESTATION OF HIVINFECTION IN THE DEVELOPING WORLD• The majority of HIV-infected persons live in the developing world, particularly in sub-Saharan Africa and Southeast Asia.• Studies of the ocular complications of HIV infection in these parts of the world are only beginning to appear, but suggest that CMV retinitis is less frequent than observed in developed countries, and that otherwise rare ocular opportunistic infections, such as toxoplasmosis and tuberculosis, affect 2% to 10% of patients with AIDS.
  23. 23. DRUG-RELATED OCULAR TOXICITY INHIV-INFECTED PATIENTS• Rifabutin- intraocular inflammation uveitis- 33%• Cidofovir- uveitis and intraocular hypotony - 25- 30%• Didanosine- retinal pigment epithelial abnormalities; mottling and hypertrophy accompanied by overall decreased retinal function .• Gancyclovir & Acyclovir- corneal epithelial inclusion termed corneal lipidosis.• Lastly, long-term Atovaquone can cause vortex keratopathy.
  24. 24. Workup• Detailed history and complete ophthalmologic examination• Fundoscopic examination (retinal nerve fiber loss in HIV retinopathy)• Fluorescein stain corneal dendrites with terminal bulbs.• VDRL for Syphilis.• India ink for fungal infections.• PCR, viral culture.• Gram’s stain; AFB; Giemsa staining.• Baseline investigations (before starting antiviral drugs)
  25. 25. Bibliography• Duanes Foundations of Ophthalmology.2007;• UNAIDS, AIDS epidemic update: Special report on HIV/AIDS: December 2006. Available from: en.pdf. [Last accessed on 2007 Oct 31]• Article on Ocular Manifestations of HIV/AIDS patients in Gondar University Hospital, north west Ethiopia• UNAIDS/WHO. ADIS Epidemic Update; 2004.• Disease Prevention and Control Department, MOH. AIDS in Ethiopia: Fifth Report. June 2004
  26. 26. ThankYou