Journal Reading

Ocular Manifestations in HIV Patients attending a

Tertiary Care Hospital in Eastern India and
Correlation of Posterior Segment Lesions with
CD4+ Counts
Jyotirmayee Swain, Pramod Kumar Sharma, Loknath Mohanty, Pradeep Kumar Panigrahi

Presented by :
dr. Usamah Haidar

Supervised by:
dr. Dina Novita, Sp.M(K)
Introduction
a spectrum of disorders resulting from infection with HIV, a
HIV/AIDS retrovirus.

Signs  A gradual ↓ in circulating CD4+ T‑lymphocytes and

subsequent development of various opportunistic infections and
neoplasms.

Transmission Unprotected sex (anal and oral sex), contaminated blood transfusions,
hypodermic needles, and from mother to child during pregnancy,
delivery, or breastfeeding.
Introduction
Ocular
involvement
Posterior segment manifestations:
• HIV retinopathy
• Opportunistic infections
• Neuro-ophthalmic lesions
• Unusual neoplasms
• Very common
• Ocular lesions in AIDS in India : first reported in 1995
• Ocular manifestations in AIDS  both anterior and
posterior segments of eye
Ocular lesions  more common with low CD4+
cell count.
There is significant correlation between low
CD4+ counts & severe ocular manifestations.
Purpose To study ocular manifestations in HIV patients &
correlation of posterior segment lesions with CD4+ count.
Methods

Study design
Hospital-based, Setting
Ophthalmology Department of a Tertiary Care Hospital in
cross sectional study Eastern India  November 2017 to October 2019

Sample size Statistical Analysis

• Raosoft sample size The Chi‑square (χ2) test  the strength of association.
calculator, CL of 95%  180 P value < 0.05  significant.
samples was required.
• Final samples: 184 patients.
Methods
Inclusion
Patients with HIV positivity  by enzyme-linked immunosorbent assay (ELISA) and/or western
blot assay

Exclusion
• Systemic diseases : diabetes, hypertension, sickle cell disease, severe
anemia, etc.
• A bedridden or debilitated condition.
• Dense cataract & other media opacities  prevent proper posterior
segment examination.
Methods
Data
 Demographic profile (age, sex, income, occupation, marital status, history of TB, and history of
drug abuse).
 Any ocular or systemic symptom.
 The socioeconomic status  3 groups on the basis of their annual income 
low (<Rs.50,000), middle (Rs.50,000-2 lakhs), and high (>Rs. 2 lakhs).
 Education level  illiterate, primary education, secondary education, and graduate & above.
 CD4+ count  at the time of diagnosis.
Methods
Data
 Comprehensive ophthalmic evaluation.
 BCVA  using Snellen’s chart.
 Anterior segment examination  using slit lamp.
 IOP  using noncontact tonometer.
 Dilatation of eyes  using a combination of 10% phenylephrine & 0.5% tropicamide.
 Fundus examination  using slit‑lamp biomicroscopy with 78 D lens & indirect ophthalmoscopy
using 20 D lens.
 Fundus photographs  using nonmydriatic fundus camera. OCT  done as and when required.
Results

• A total of 184 known HIV-positive

patients were included. Ocular
manifestations were noted in 62
cases (33.69%).
• The mean age was 34.8 ± 10.77 years
(range 8-60 years); the male patients
outnumbered female patients 2:1
ratio (21.74% vs. 10.87%) and 1.08%
transgenders;
Results
• BCVA was between 6/12 and 6/6: 225 eyes
• BCVA worse than 6/60: 31 eyes

• Most common symptom : Decreased vision Pain (9.7%)

(85 patients).
Floaters (8.1%)
• 20 patients (32.25%) with ocular
manifestations: asymptomatic.
Redness (4.8%)
• Many patients presented with more than
one symptom. Foreign body
sensation (3.2%)

Vesicles (1.6)

Photophobia (1.6%)
Results

Ocular manifestations 43 (69.35%) posterior

(62 cases) segment manifestation

26 (41.93%) anterior
segment manifestation

5 (8.06%) adnexal lesions

Results

• Anterior uveitis  most common

anterior segment manifestation (in 13
eyes).
• HIV retinopathy consisting of retinal
hemorrhages and cotton wool spots 
most common posterior segment
manifestation (in 25 eyes).
Results
Results

• Out of 43 patients with posterior segment manifestations  26 patients had CD4+ counts <
200/mm3. 17 patients had counts >200/mm3.
• Only 3 patients  CD4+ counts less than 50/mm3 (2 CMV retinitis, 1 HIV retinopathy).
• Significant positive correlation was noted between severities of posterior segment findings and
CD4+ counts  increase with decrease in CD4+ counts (P < 0.001).
Discussion
This Study : From 184 HIV‑positive patients  62 cases had ocular manifestations. The
prevalence of ocular manifestations in this study was 33.69%.

• Kumar et al: positive ocular findings were noted in 43 (34.4%) patients out of a total of
125 HIV‑positive patients.
• Similar incidence rate of 35.3% was reported by Sharma et al. in their study conducted
on 150 HIV‑positive patients.
• A slightly higher incidence rate of 40% was reported by Singh et al.
Discussion
This Study :
Maximum number of patients with ocular manifestations were in the 30–39 years age group.

This is in agreement to the findings of other studies conducted by Bekele et al. and Singh et al.

This Study :
The prevalence of ocular manifestations in the pediatric age group was 1.61%

This is very less compared to the 10% incidence reported in the pediatric age group by Gogri
et al. The lower prevalence in our study could be due to the very less number of pediatric
patients enrolled in the study.
Discussion
This Study : ocular lesions  predominantly found in male patients (64.51%).
The male: female ratio in our study was 2:1.

This ratio is similar to the majority of studies  reported a male preponderance. Predominance
of male patients  because they attend the hospital for treatment more voluntarily. On the other
hand, women may not seek medical help even if they might be suffering from infection

This Study : maximum number of patients enrolled in the study (74) had an education till the
primary education level and low socioeconomic status was majority.
Ravinder and Madhav reported that HIV infection was mostly seen in uneducated patients. Ocular
manifestations were predominantly seen in patients of low socioeconomic status (66.12%).
Discussion
This Study :
Good vision in the range of 6/6–6/12 was seen in most of the patients. Severe visual impairment
(worse than 6/60) was found in 22.6% cases in the right eye and 16.1% cases in the left eye.

• Purushottam et al. reported 94.2% of patients to have good visual acuity better than 6/18.
• Bekele et al. reported 97.2% of patients with visual acuity better than 6/18.
• None of the patients in the present study were found to be blind in either eye. Bekele et al.
reported monocular blindness in 2.6% of their cases.
Discussion
This Study:
The most common presenting symptom  diminution of vision in 54.8% cases with ocular lesions and in 42%
of cases without any ocular manifestations.
• Diminution of vision without floaters was the commonest symptom (13.6%) reported in the study by
Kumar et al.
• Study from Sharma et al. the most common symptoms were irritation, decreased vision, watering, and
redness.

This Study:
Posterior segment manifestation  most common ocular finding in 69.35% of the cases  followed by
anterior segment and adnexal lesions seen in 26 and 5 cases, respectively.
• Similar high preponderance of posterior segment lesions has been reported in the study by Yogeswari et
al. (64.3%).
• Gogri et al. reported higher preponderance of anterior segment lesions (65%) in their study. Higher
posterior segment manifestations in the present study could be due to low CD4+ count, increased viral load
level, and later initiation of ART in some patients
Discussion

This Study:
• Anterior uveitis  most common
anterior segment manifestation (in 13
eyes).
• HIV retinopathy consisting of retinal
hemorrhages and cotton wool spots was
the most common posterior segment
manifestation (in 25 eyes).
Discussion

• This is in line with other studies [Table 4]  reported HIV retinopathy to the most common
posterior segment manifestation.
• This differs from the study conducted by Biswas et al  reported CMV retinitis to be the most
common posterior segment manifestation  followed by HIV retinopathy.
Discussion

• CSCR  in 3 patients. Purushottam et al  reported CSCR in 2% of cases. CSCR noted in our

study might not be directly associated with HIV infection.
• 9 patients had evidence of active/healed choroiditis at the time of ophthalmologic
examination, but an etiological diagnosis could not be reached at in our patients.
Discussion

This Study
• Significant correlation  between the severities of posterior segment lesions & decrease in
the CD4+ count (P < 0.001).
• 47% of patients with ocular manifestations had CD4+ counts between 51 and 200.
• CD4+ count >500 was seen in 13% cases.

• Sudharshan et al., a CD4 + count limit of 200  a better clinical correlation with HAART & the
occurrence of ocular lesions. In their study, 47.7% of patients were not on HAART at the time of
diagnosis of ocular lesions and 69% of them had CD4+ counts less than 200.
• Gogri et al., majority of patients with posterior segment lesions  CD4+ counts less than 200.
• Narasimhaiah et al., found that majority of patients with ocular manifestations  CD4+ count
in the range of 51–199 (<200).
Limitation of Study
• The relatively small sample size is a limitation of our study.
• A bigger sample size and a population‑ or community‑based study
would have provided a more accurate picture.
• Cross‑sectional design of the study is another drawback of the study.
Conclusion
• Patients with low CD4+ counts are at an increased risk of acquiring
severe manifestations such as posterior segment changes.
• CD4+ T‑cell count of <250 cells/mm3 was found to be an
independent risk factor for developing ocular manifestations.
• A detailed ophthalmic evaluation including fundus examinations is a
must in all cases of HIV/AIDS patients  it may help in early
diagnosis, treatment, and prevention of sight-threatening
complications due to opportunistic infections.
Critical Appraisal
JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies
1 Were the criteria for inclusion in the Yes (✔ ) No ( ) Unclear ( ) Not Applicable ( )
sample clearly defined? • All patients with HIV positivity confirmed
by enzyme‑linked immunosorbent assay
(ELISA) and/or western blot assay were
included in the study.
2 Were the study subjects and the Yes (✔ ) No ( ) Unclear ( ) Not Applicable ( )
setting described in detail? • Ophthalmology department of a tertiary
care hospital in Eastern India.
• HIV‑positive patients referred from the
antiretroviral therapy (ART) center and
other departments of the hospital from
November 2017 to October 2019.
JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies
3 Was the exposure measured in a valid Yes ( ) No ( ) Unclear ( ) Not Applicable (✔ )
and reliable way? There is no any exposure mentioned in this tudy
4 Were objective, standard criteria used Yes (✔) No ( ) Unclear ( ) Not Applicable ( )
for measurement of the condition? • All patients underwent comprehensive
ophthalmic evaluation
5 Were confounding factors identified? Yes ( ) No (✔) Unclear ( ) Not Applicable ( )
• Patients suffering from other systemic diseases
like diabetes, hypertension, sickle cell disease,
severe anemia, etc were excluded.
6 Were strategies to deal with Yes ( ) No ( ) Unclear ( ) Not Applicable (✔ )
confounding factors stated? • Confounding factors were excluded.
JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies
7 Were the outcomes measured in a Yes (✔ ) No ( ) Unclear ( ) Not Applicable ( )
valid and reliable way? • All patients underwent comprehensive ophthalmic
evaluation. BCVA. Anterior segment examination was
done using slit lamp. IOP was measured using NCT.
Fundus examination was done using slit‑lamp
biomicroscopy with 78 D lens and indirect
ophthalmoscopy using 20 D lens. CD4+ count
determined at the time of diagnosis was noted.
8 Was appropriate statistical analysis Yes (✔ ) No ( ) Unclear ( ) Not Applicable ( )
used? • Categorical variables have been represented as actual
numbers and percentages. The Chi‑square (χ2) test
was used to test the strength of association. P value <
0.05 was considered significant
Thank You