Posterior Segment

Ocular manifestations of HIV

By Natnael Habtamu
2 Introduction

50-75% of HIV pts have ophthalmologic complications

Scope of disease: Posterior vs Anterior segment
3 Introduction

Posterior segment manifesations can be

1. Retinal Vasculopathy
2. Opportunistic infections:
Retinitis (CMV, PORN, Toxo, ARN, Crypto)
Choroditis (TB, Toxo)
3. Malignancies: NHL
4. Neuro-ophthalmology:
Perineuritis, Pailedema, Papilitis, Retrobulbar neuritis, Optic
Atrophy
4 1. Retinal Vasculopathy

Two types;
Microvascular (HIV Retinopathy) ..40%-60% of HIV +ve

Macrovascular
Rare
Associated with viral retinitis
Include;
CRVO
CRAO &
Branch veins & arteries occlusion
5 HIV Retinopathy

Commonest retinal manifestation of HIV/AIDS

Characterized by;
Cotton-wool spot (Represents infarct of nerve fiber layers)
---75%
Simulate Cotton wool spot of DM & HTN; and Early CMV retinitis
Microaneurysm
Retinal hemorrhage
Usually in posterior pole
6 HIV Retinopathy
7 HIV Retinopathy

Pathogenesis (not by direct infection of the retina

unlike CMV retinitis)
Immune complex deposition
Direct HIV retinal vascular cells Infection
Clinical presentation: Asymptomatic
Treatment
No need to treat (Treatment is based in delaying the
progression of the disease associated with HIV)
8 2. Opportunistic infections

Necrotizing Retinitis More common

Quiet Eye
Low CD4
CMV, PORN
Inflammed Eye
High CD4
ARN, Toxo, Syphillis, Cryptoccoccus

Choroiditis (Pneumocystic choroiditis, cryptococcal)

Unifocal
Multifocal
9 CMV Retinitis

Commonest intraocular ocular opportunistic infection in AIDS pts

Commonest cause of visual loss in HIV patient (exclusively seen
in <50 CD4 cells/ul)
Antibodies are found in almost 95% of adults
Causes a trivial illness in immunocompetent adults, however
severe immunosuppression causes viral reactivation and tissue
invasive disease
10 CMV Retinitis

Pathogenesis
Reactivation from extraocular sites leads to seeding in other
sites such as the retina
Epidemiology
The number of newly diagnosed cases of CMVR has decreased
since the introduction of the HAART
11 CMV Retinitis

Clinical Manifestations
Minor visual symptoms such as floaters, flashing lights or mild
blurred vision or be totally asymptomatic
Sight threatening
Clinical Forms:
Classical form
Granular lesion (indolent) form
Frosted branch Angiitis
12 CMV Retinitis clinical forms

Classical form
Confluent necrosis with hemorrhage
commonly in Posterior retina (Pizza Pie
Retinopathy or cottage cheese with ketchup)
Patients may present with
visual field & acuity loss
scotoma
13 CMV Retinitis clinical forms

Indolent form
More on peripheral retina
Little or no hemorrhage
Usually asymptomatic (sths. Floaters)
14 CMV Retinitis clinical forms

Frosted-branch angiitis
Uncommon
Associated with retinal
Macrovasculopathy
15 CMV Retinitis - Complications

Retinal Detachment
Irreversible visual loss
Immune recovery uveitis (Specially on HAART
initiation)
16 CMV Retinitis - Treatment

1. gancyclovir IV, 10mg/kg every 12 hrs for 2-3 wks

,ffed by 5mg/kg every 24 hrs untill retinits is
stable.thereafter lifelong oral maintenance dose of
300mg daily
2. foscarnet- IV 60mg/kg every 8 hrs for 2-3 wks daily
3. viterctomy, silicon oil temponade, Pneumatic retinopexy
17 CMV Retinitis - Treatment

If CMV is limited to the eye

ganciclovir relising intraocular implants
intravitrial injection of gancyclovir or foscarnet
Maintenance therapy is continued until CD4 >100
Note also standard ARTs
18 Necrotizing Herpetic Retinopathy

Causes
Herpes Vira (VZV is most common)
Two clinical forms;
ARN.VZV,HSV,CMV
PORNHSV
19 Necrotizing Herpetic Retinopathy
20 Necrotizing Herpetic Retinopathy

ARN PORN
21 Necrotizing Herpetic Retinopathy

Treatment
IV acyclovir 1500mg/m2/day in three divided dose for
7-10 days or by oral 800mg 5x/day for 6 wks
Treat RD
22 Questions to you?

Whats the most common cause of

central choroiditis?

What is the most common

presenting symptom in patients
with choroiditis?
23 Choroidal OIs

Pneumocystis
Sign of exrapulmonary systemic
dissemination
Flat, yellow, round, choroidal
lessions scattered throughout the
posterior pole
Tx: IV TMP-SMX or parentral
Pentamide
Cryptococcus
6% of pts with C.meningitis
Extends from the optic nerve or hematogenous
spread
Multifocal Choroditis with or without retinal and
optic nerve involvement at presentation
Tx: IV amphotericin, oral fluconazole.
24 Toxoplasmosis Retinochoroditis

Rare as compared to CMV retinitis

Complicates 20% of AIDs associated CNS toxo.
In immunocompromized
Extra ocular origin
Multifocal ,bilateral
Difference from CMV retinitis
More intra ocular inflammation
Less hemorrhage
25 Toxoplasmosis Retinochoroditis

Treatment:
1. Cotrimoxazole -960mg p/o bid for 4-6 wks
2. Atovaqone- 750mg tid p/o
3. Azitromycin- 500mg daily for 3 days
clindamycin, sulphadiazine,pyrimethamine are not
good in HIV pts
26 Ocular Tuberculosis

Incidence ---very low

Presentation;
Multifocal choroidal
tubercles
Yellow discrete lesions
Usually at posterior pole
Treatment..long term
anti TB
27 3 Malignancies - NHL

Presents as:
Necrotizing retinitis
Multifocal choroditis
Retinal Vasculitis
Vitritis
Sub retinal Mass
Tx: Radiotherapy; Chemotherapy
28 4. Neuro Ophthalmic Manifestations

Are usually indications of infection or lymphoma of the

brain or meninges
6% of AIDS patients
Clinically present as:
Perineuritis
Papilledema
Papillitis
Optic atrophy
29
Summary
Stage CD4+ External Anterior Posterior Neuro
eye segment part opthalmic
Seroconversio 1000 -Inflamed -Headache
n conjunctiva -Retino
-Dry eye Oribtal pain

Early HIV 500- -Allergic -Intermediate -HIV -Optic

infection 1000 Conjunctivitis Uveitits retinopathy neuropathy
-Retinal V.

Intermediate 200-500 -Dry eye -Herpes Z. -HIV -Aspergillosi

infection -Blephritis -Herpes S. retinopathy s
-Bacterial -Tbc Uveitis
and Viral
Conj.
-Mollscum C.
-Kaposis S.

Late 0-200 Opportunistic Is & tumors affecting all ocular structures

30 References

J.Kanski clinical ophthalmology 7th edition

Eye diseases in hot climate
Indian journal of ophthalmology
www.ophthalmic.ins.com