Ocular Manifestations in HIV

Infections
• Clinically apparent ocular lesions seen in
94% of AIDS patients

• Four categories of involvement

– Neoplasms (kaposi’s sarcoma)
– Lesions related to microvascular disease
– Opportunistic ocular infections
– Neuro-ophthalmic abnormalities
 Kaposi sarcoma
• Vascular tumour occurring in patients with AIDS
• Usually associated with advanced disease
• Very sensitive to radiotherapy

Early Advanced

Pink, red-violet lesion May ulcerate and bleed

 Kaposi’s sarcoma
• May be overlooked unless lower lids are
pulled down during exam
• Ocular surface or eyelid usually first site for
development of this multifocal neoplasm in
4% cases
• Ocular lesion may be the initial or only lesion
 Kaposi’s sarcoma
• Appears as a bright red, firm subconjunctival
mass
• Small lesions are mistaken for simple
subconjunctival hemmorhage
• Site = inferior cul de sac (can also involve
bulbar / palpebral)
• Other sites - skin of the eyelid, lid margin,
orbit (rarely)
 Kaposi’s sarcoma
• Treatment
– Attentive neglect (enlarges very slowly)
– If large and bulky - excision
– Radiosensitive (but will not prevent development of
other tumors elsewhere)
– Chemotherapy) for visceral lesions / associated
lymphoma)
 Conjunctiva
• Dilated vessels at the limbus

• Isolated vascular segments of irregular caliber

• Sludging of blood flow

 Cotton wool spots
• Most common retinal manifestation (at
least 2/3 of AIDS cases)
• Nerve fiber layer swelling
• Stasis of axoplasmic flow
• Reflection of retinal ischemia
• Spontaneously regresses in 4-6 weeks
 Cytomegalovirus retinitis
• Early CMV difficult to distinguish from cotton
wool spots
• No spontaneous resolution
• Relentlessly progressive
• Individual foci coalesce and spread outwards
• Necrotic retina replaced by thin, gliotic
membrane -> retinal detachment
• NEED FOR SERIAL EXAMINATION
Cytomegalovirus retinitis
• Most common ocular infection (25%)
• Full thickness retinal necrosis
• Dry, granular, retinal opacification
(edema / necrosis)
• Hemmorhage and vasculitis
Cytomegalovirus retinitis
• Hematogenous spread

• Microvasculopathy ->damage vessel

wall ->allow access of viral particles to
retinal tissue

• Cotton-wool spots precede or occur

concurrently
Cytomegalovirus retinitis
• Early lesions adjacent to major vascular
arcades (vascular orientation)
• May also occur first in the peripheral
retina
• Little inflammatory reaction; vitreous
remains clear
Cytomegalovirus retinitis
• Treatment
– Ganciclovir (IV or intravitreal at 200
ug/0.1cc); watch out for neutropenia
– Foscarnet (IV); watch out for kidney damage
(need proper hydration)
– AZT (azidothymidine) effective against HIV
but no effect on CMV
– Laser - failure to prevent spread of CMV
retinitis
 CONGENITAL
CATARACT

• most are bilateral

• associated with maternal infection
– Rubella, Toxoplasmosis,
Cytomegalic Inclusion Disease
• may cause nystagmus
 Madarosis
Decrease in number or complete loss of lashes
Local causes
• Chronic anterior
lid margin disease
• Infiltrating tumours
• Burns, radiotherapy
or cryotherapy
Systemic causes
• Generalized alopecia
• Myxoedema
• SLE
• Syphilis
• Leprosy
Following removal
 Lagophthalmos
• Insufficient or weak
eyelid closure
• May result to
exposure keratitis
• Treatment: eyelid
taping when
sleeping; artificial
tears
 Fungal Keratitis
• Rare, but not in P.I.
• Farmers
• Causative agents:
– Aspergillus
– Fusarium
– Candida
 Fungal Keratitis
• Signs and Symptoms:
– Redness, pain, profuse
mucoid discharge ,
intense anterior chamber
reaction(non specific)
• Slow progression
• “feathery” borders
• Satellite lesions
• Endothelial plaque
 Fungal Keratitis
• Treatment:
– Difficult
– Drops:
• Natamycin 5%
• Amphotericin B 0.15% eye drops
– IV/ Systemic antifungal drugs
• If large and with impending perforation
 Fungal Keratitis
– Surgery
• Therapeutic
transplant
• Perforated ulcers
 Acanthamoeba
• Protozoa
• Contact lens wearers
– Differentiate from
Pseudomonas (fast
progression, corneal melt,
profuse discharge)
• PAIN
– Radial keratoneurtitis
– Disproportionate to clinical
signs
• Infiltrates
– Start out as satellite lesions
– Coalesce to form a central
ulceration
– “ring inflitrates”
 Acanthamoeba
• Slow progression
• Epithelium may be intact
• CLUES:
•Severe pain

•Cultures negative for bacterial or fungal

growth

•No response to typical antimicrobial or

antifungal therapy
 Acanthamoeba
• Treatment:
– Antiamoebic drugs
• Propamidine isothionate
• Polyhexamethylene biguanide
• chlorhexidine
– Steroids
• controversial
• May decrease pain but case delayed healing
• NSAIDS: better alternative
– Surgery
– Therapeutic transplants
– CONTRAINDICATED in inflamed eyes
 Sample Question
Which therapy is least appropriate for treatment of
dendritic epithelial keratitis due to herpes simplex
virus?

a. Vidarabine ointment 4 times a day

b. Trifluoridine solution 4 times a day
c. Oral acyclovir 2 grams a day
d. Prednisolone acetate 1% qid
e. Minimal debridement with a dry cotton-tipped applicator
 Viral Keratitis
• Herpes Simplex
– DNA virus
– Common: up to 90% of human population seropositive
– HSV1(face, lips, eyes)
– Primary infection
• In children, usually droplet
• subclinical
– Recurrence
• Immunocompromised state
 Viral Keratitis
• Herpes Simplex
Keratitis
– Two types
• Epithelial (HSEK)

• Disciform
keratitis
 Viral Keratitis
• HSEK
– Reduced corneal
sensation
– Epithelial ulceration
– Anterior stromal infiltrates
– Dendrites
• Terminal bulbs
• Centrifugal spread to
form geographic lesions
 Viral Keratitis
• Disciform Keratitis
– Reduced corneal
sensation
– Epithelial edema
overlying stromal
infiltrates
– DM folds
– Anterior uveitis
– IOP may be elevated
 Viral Keratitis
• HSEK • Disciform Keratitis
– Treatment: – Treatment:
• Topical Antivirals
– Ganciclovir 0.15%
– Trifluorothymidine 1% • Topical Antivirals
» Toxic

• Steroids
• Debridment
– Given with antivirals
• Systemic Drugs – Tapering dose
– Effect disappears
when drug is removed • Small lesions may be
– For those with 2 or observed
more attacks/year
 Viral Keratitis
• Herpes Zoster Ophthalmicus
(HZO)
– Caused by varicella (VZV)
– Face lesions (Vesicles)
follow nerve distribution,
respects midline
–Keratitis:
•Epithelial
–Dendrites with no
bulbs
•Nummular Hutchinson’s
Sign
–Subepithelial
opacities
•Disciform keratitis
–Similar to Herpes
simplex
 Viral Keratitis
• Herpes Zoster Ophthalmicus:
– Other findings
• Blepharoconjunctivitis
– Associated with lid vesicles
• Episcleritis
• Scleritis
• Anterior uveitis
– Sectoral iris atrophy
• Herpes Zoster Ophthalmicus
– Treatment:
• Systemic antivirals
– Valaciclovir 1 g or Famciclovir 250 mg
– Better if within 72 hours of symptom onset

• Topical steroid-antibiotic creams

– For skin lesions
– For lid scrubs (eye ointments)

• Pain relievers
– Post herpetic neuralgia