Ocular Manifestations of HIV: A Hospital Based Study

Pai SG

ISSN 0972-5997

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Mangalore, India

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OJHAS Vol. 18, Issue 1: (January-March 2019)

Original Article
Ocular Manifestations of HIV: A Hospital Based Study

Authors:
Shobha G Pai, Professor, Department of Ophthalmology,
Vala Mounika, Post Graduate in Department Of Ophthalmology,
Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal.

Address for Correspondence
Dr. Shobha G Pai,
Professor,
Department of Ophthalmology
KMC Hospital,
Attavar, Mangalore - 575001
E-mail: shobha.pai@manipal.edu.

Citation
Pai SG, Mounika V. Ocular Manifestations of HIV: A Hospital Based Study. Online J Health Allied Scs. 2019;18(1):5. Available at URL: https://www.ojhas.org/issue69/2019-1-5.html

Submitted: Jan 31, 2019; Accepted: Apr 14, 2019; Published: Apr 30, 2019

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This work is licensed under a Creative Commons Attribution-No Derivative Works 2.5 India License

Abstract: Background: HIV is a global health issue of unparalleled proportions and unprecedented emergency, with diverse health and economic implications. As per 2017 global HIV statistics, 36.9 million people globally were living with HIV. It is estimated that 70% of adult HIV population will experience an ocular complication at some stage of life. Revelation of ocular complications can be the presenting sign of a systemic infection in an otherwise asymptomatic person. The clinical presentation may be modified by HAART, which dramatically improves prognosis. This study intended to outline the magnitude of the problem of HIV in our community and to determine the spectrum of ocular manifestations of HIV, and their clinical outcomes at our tertiary care centre. Materials and Methods: An observational cross-sectional study was done on 30 HIV-positive patients presented to ophthalmology clinic in a tertiary care centre. Data were collected using face-to-face interview, clinical examination with slit lamp biomicroscopy, direct and indirect ophthalmoscopy and laboratory investigations, and analyzed in terms of ocular manifestations and associated immune status. Conclusion: Dry eyes were the most common anterior segment manifestation encountered in our study. HIV retinopathy remained the most common posterior segment manifestation. CMV retinitis was the next common lesion and most common opportunistic infection in the study with poor immune status. In our study the most common coexistent systemic disease was Systemic tuberculosis.
Key Words: Acquired immuno deficiency syndrome, Human immunodeficiency virus, Ocular manifestations

Introduction:

Global burden of HIV currently is 36.9 million [1] and 2.09 million Indians are diagnosed with HIV, and approximately 1,45,000 are children [2].

The eye is an organ with a wide spectrum of HIV-related manifestations. It is estimated that 70% of adult HIV population will experience an ocular complication at some stage of their lives. Sometimes ocular manifestations can be the presenting sign in an otherwise asymptomatic HIV-positive person. The lifetime cumulative risk for developing eye manifestations in HIV patients ranges from 52% to 100% in various studies [3]. Anti Retroviral Therapy (ART) changed the scenario of life expectancy and eye manifestations of HIV patients for the better.

The prevalence of blindness in HIV patient ranges from 6.9%-23%, which endangers the life of people alive. [4,5]. The prevalence of HIV-related ocular manifestations increase as CD4+ T cells count decreases(6). Many patients diagnosed with HIV/AIDS are referred to the ophthalmologist to rule out ocular manifestations and for their management.

Detection of these ocular manifestations at an early stage and prompt treatment would minimize the ocular morbidity and improve patient’s visual quality of life. As majority of these conditions go undiagnosed until there is a substantial visual loss, this study intends to outline the magnitude of the problem of ocular morbidities in HIV in our community.

Materials and Methods:

Study Design: The present study was a hospital based observational cross-sectional study carried out at the Department of Ophthalmology of our tertiary care centre from July 2017 to July 2018 (1 year). The hospital has an ART centre affiliated to National AIDS Control Organisation (NACO).

Inclusion Criteria: HIV-positive patients who were referred to Ophthalmology OPD for ocular complaints were included in the study.

Data Collection: Data was collected from the patient’s history, clinical examination which included distant vision testing using Snellen’s chart and near vision testing using Jaeger’s near vision chart, Anterior segment examination was done with the help of slit lamp biomicroscope. Fundus examination with direct and indirect ophthalmoscopy was done in all patients.CD4-count was obtained in all cases.

Ethical Issues: This study was conducted after Ethical clearance from the Institutional Ethical Committee. A written informed consent was obtained from all patients before including them in the study.

Results:

We included 30 HIV-positive patients with ocular complaints in the study. There were 15 females and 15 males. Median age of study subjects at presentation was 43. All patients were on HAART.

Table 1: Anterior Segment Manifestations
Anterior segment manifestation	Number of patients
Meibomitis	3 (15%)
Dry eyes	7 (35%)
OSSN	1 (5%)
Anterior uveitis	4 (20%)
Immune recovery uveitis	2 (10%)
Complicated cataract	3 (15%)

A total of 20 patients (66.6%) had 5 types of anterior segment lesions. The most common anterior segment finding was dry eyes (35%). Next most common manifestation in our study population was uveitis seen in 30% (uveitis in 20% + immune recovery uveitis in 10%) followed by meibomitis and complicated cataract seen in 15% of patients each. Other lesions like ocular surface squamous neoplasia (OSSN) was seen in 5%. Blepharitis and recurrent styes was also seen in the study population.

Table 2: Posterior Segment Manifestations
Posterior segment manifestations	Number of patients
Intermediate uveitis	3(10%)
Toxoplasmosis	2(6.6%)
CMV retinitis	5(16.6%)
HIV retinopathy	5(16.6%)
HSV retinitis	1(3.3%)
HIV microangiopathy	3(10%)

Among 30 patients, 19 patients (63.3%) had 6 types of posterior segment manifestations. Opportunistic infections of the retina and choroid were the most common posterior segment finding seen in 8 patients followed by HIV retinopathy in 5 patients. The most common opportunistic infection was CMV retinitis (12.5%). Intermediate uveitis, old toxoplasmosis, HSV retinopathy and HIV microangiopathy were the other lesions noted.

Among 30 patients, only 1 patient(3.3%) had third cranial nerve palsy with ptosis.

Table 3: Association between ocular lesion and CD4 count
Ocular lesion	CD4 <100	CD4 100-200	CD4 >200	Total
Meibomitis	-	2	1	3
Dry eyes	-	3	4	7
OSSN	-	-	1	1
Anterior uveitis	-	2	2	4
Immune recovery uveitis	-	-	2	2
Complicated cataract	-	2	1	3
Intermediate uveitis	-	1	2	3
Toxoplasmosis	-	1	1	2
CMV retinitis	5	-	-	5
HIV retinopathy	1	2	2	5
HSV retinitis	-	1	-	1
HIV microangiopathy	-	1	2	3
3rd nerve palsy with ptosis	-	-	1	1

The association between anterior segment lesions and CD4-count of the patients was not significant. Posterior segment lesions showed significant association with low CD4-count with opportunistic ocular infection increasing as immunity of patient decreased. All the cases of CMV retinitis had CD4-count less than 100 cells/mm³. Patients of anterior segment lesions with CD4-count less than 100 cells/mm³ also had concurrent posterior segment lesions.

Discussion:

Ocular manifestations of AIDS were first reported in 1982(7). However, introduction of highly active antiretroviral therapy (HAART) was a game changer which restored the immune system, pattern and prevalence of ocular manifestations for better. Ocular manifestation can be orbital, adnexal, anterior segment, posterior segment and neurological.

In our case series, we studied various eye manifestations in 30 patients. Anterior segment manifestations were seen in 66.6% of cases. Dry eyes was the most common finding (35%) followed by anterior uveitis (30%). Dry eyes can be due to the autoimmune destruction of lacrimal gland tissue, or secondary to lid infections. However, 3 patients with dry eyes had meibomitis. Artificial tears were advised to combat dry eyes.

Of the 30% who had uveitis, 20% had anterior uveitis and 10% had immune recovery uveitis. Two patients had granulomatous uveitis of tubercular etiology. One patient had anterior uveitis secondary to toxoplasma retinochoroiditis probably because of spill over. Two patients, started on HAART recently, developed immune recovery uveitis with diminution of vision characterized by severe anterior uveitis and vitritis. With immune reconstitution, some patients develop heightened immunological reactions against CMV or other intraocular pathogens, resulting in ocular inflammation. The inflammation is most prominent in the vitreous cavity but can also involve the anterior segment. All 5 patients with uveitis responded well to topical steroids and cycloplegic treatment.

Next most common anterior segment finding was complicated cataract seen in 3 patients with uveitis with polychromatic lustres. The Longitudinal Study of Ocular Complications of AIDS (LSOCA) documented cataract as the second leading cause of visual impairment in among HIV subjects who did not have CMV retinitis at the time of enrolment.(8)

OSSN was seen in 1 patient in this case series. Patient had an elevated, well demarcated grey to red mass in the inter palpebral area, temporally with a feeder vessel. Age of the patient was 48 years. About 70-80% of patients under the age of 50 years with OSSN are HIV positive (9).

There was not even a single case of Kaposi’s sarcoma, molluscum contagiosum, herpes zoster ophthalmicus in our study, probably because study included only 30 patients. Systemic tuberculosis was the commonest systemic association seen in 40% of the subjects.

Posterior segment manifestations in HIV subjects can have disastrous consequences and may lead to blindness if not diagnosed in time.

In this case series, 66.6% of subjects had posterior segment manifestations. In the study done by Biswas et al., (10) most common posterior segment manifestation was HIV retinopathy. But in this case series both HIV retinopathy (16.6%) and CMV retinitis (16.6%) had equal incidence. However, CMV retinitis (16.6%) was the most common opportunistic infection seen, similar to that like in another study done by Gharai et al.(11)

Five patients (16.6%) had HIV retinopathy. All the patients had Cotton-wool spots. The earliest and most consistent finding in HIV retinopathy is presence of cotton-wool spots, occur in about 50-60% of patients with advanced HIV disease (12).


Figure 1: Fundus picture showing HIV retinopathy (Multiple cotton wool spots)	Figure 2: Fundus picture of a patient showing CMV retinitis.
	Figure 3: Fundus picture of a patient showing toxoplasmosis involving macula.

CMV retinitis was seen in 5 patients (16.6%). CMV retinitis is a disease of advanced immune suppression. All patients with CMV retinitis had a CD4 count less than 50. Our subjects were successfully treated with IV ganciclovir.

Three subjects (10%) had intermediate uveitis, 2 patients had immunity recovery uveitis with severe anterior uveitis with vitritis, 1 patient with ocular toxoplasmosis had vitritis with spill over anterior uveitis.

HIV microvascular disorder is characterized by microaneurysms, retinal haemorrhages and are seen near the optic disc in AIDS. There were 3 subjects(10%) with manifest HIV microangiopathy.

Ocular toxoplasmosis was the next most common manifestations seen in 2 subjects (6.6%). It was the second most common opportunistic ocular infection in our case series. One subject had acute macular chorio retinitis with vitritis and spill over anterior uveitis with profound visual loss. The other subject had a previous choroiditic scar at macula with visual loss.

HSV retinitis was seen in 1 subject (3.3%). One subject (3.3%) had third nerve palsy with ptosis.

Conclusion:

Dry eyes were the most common anterior segment manifestation encountered in our study. HIV retinopathy remained the most common posterior segment manifestation. CMV retinitis was the next common lesion and most common opportunistic infection in the study with poor immune status.

In our study the most common coexistent systemic disease was systemic tuberculosis. The percentage of posterior segment ocular manifestations increased as the CD4-count of patients decreased with profound visual impairment. As majority of these conditions go undiagnosed until there is substantial visual loss, routine screening should be made a norm to improve the visual quality of life in patients living with HIV.

References:

UNAIDS. 2017. UNAIDS Data 2017. Available at http://www.unaids.org/sites/default/files/media_asset/20170720_Data_book_2017_en.pdf
UNAIDS. 2011. World AIDS Day Report 2011. Available at http://www.unaids.org/en/resources/documents/2011/20111121_JC2216_WorldAIDSday_report_2011
Hodge WG, Seiff SR, Margolis TP. Ocular opportunistic infection incidences among patients who are HIV positive compared to patients who are HIV negative. Ophthalmology. 1998;105(5):895–900.
Shah SU, Kerkar SP, Pazare AR. Evaluation of ocular manifestation and blindness in HIV/AIDS patients on HAART in tertiary care hospital in western India. Br J Ophthalmol. 2009;93:88–90. doi: 10.1136/bjo.2008.149237.
Aratee P, Vinay K, Pallavi B. Ocular manifestations in HIV positive patients in Western India. http://www.aios.org/proceed08/papers/MIS/Mis9. Accessed on August 14, 2009.
Turner BJ, Hecht FM, Ismail RB. CD4+ T-lymphocyte measures in the treatment of individuals infected with human immunodeficiency virus type 1: a review for clinical practitioners. Arch Intern Med. 1994;154:1561–1573. doi:10.1001/archinte.1994.00420140022004.
Peeush P, Chaskar P, Rongpharpi SR. HIV and Eye –A mini review. Int. J .Curr. Microbiol. App.Sci 2014;3(5):530-536. Available at https://www.ijcmas.com/vol-3-5/Parimal%20peeush,%20et%20al.pdf
Thorne JE, Jabs DA, Kempen JH, et al. Studies of Ocular Complications of AIDS Research Group. Causes of visual acuity loss among patients with AIDS and cytomegalovirus retinitis in the era of highly active antiretroviral therapy. Ophthalmology. 2006;113:1441–1445.
Visser L. HIV and the eye. CME 2013;31:143-146.
Biswas J, Joseph A, Raizada S, Kumamsamy N, Solomon S. Ophthalmic manifestations of human immunodeficiency virus (HIV) infection in India. Indian J Ophthalmol. 1999;47:87-93. Available from: http://www.ijo.in/text.asp?1999/47/2/87/22798
Gharai S, Venkatesh P, Garg S, Sharma SK, Vohra R. Ophthalmic manifestations of HIV infections in India in the era of HAART: analysis of 100 consecutive patients evaluated at a tertiary eye care center in India. Ophthalmic Epidemiol. 2008 Jul-Aug;15(4):264-71.
Freeman WR, Lerner CW, Mines JA, Lash RS, Nadel AJ, Starr MB, Tapper ML. A prospective study of the ophthalmologic findings in the acquired immune deficiency syndrome. Am J Ophthalmol 1984; 97:133-42.