获得性免疫缺陷综合征的眼部表现

自从1981年第一例获得性免疫缺陷综合征(AIDS)被诊断以来,全球感染人类免疫缺陷病毒(HIV)的病例数一直在持续增长。在中国HIV／AIDS正以惊人的速度蔓延,因此每一个医务工作者包括眼科医护人员必须加强对HIV／AIDS的了解。该文对HIV／AIDS的眼部表现进行一综合介绍,重点讨论HIV／AIDS眼后段的表现和治疗,包括HIV视网膜炎、机会性感染、罕见肿瘤和神经眼科表现;简略介绍了眼前段的临床表现、发展中国家HIV／AIDS眼部表现的特点及眼科临床实践中的预防要点。     

以眼部表现首诊的获得性免疫缺陷综合征二例

人感染免疫缺陷病毒（HIV）及获得性免疫缺陷综合征（AIDS）患者中有30％～40％出现眼部并发症，2％的患者以眼部为首发病变。然而，大多数眼科医师对其眼部表现的临床诊治经验还不多。我们报告以眼部表现首诊的AIDS病并发巨细胞病毒性视网膜炎（CMV）分别被误诊为Behcet病及视网膜血管炎的患者各1例，并探讨HIV感染与AIDS并发CMV的临床特点、诊断、鉴别诊断及治疗原则。     

获得性免疫缺陷综合征并发视网膜病变的眼部表现

眼部表现往往是获得性免疫缺陷综合征(AIDS)患者全身播散性感染的首要表现,大约45%～75%的AIDS患者眼部会受到侵犯[1].AIDS的眼部表现包括人类免疫缺陷病毒(HIV)视网膜微血管病变,病毒、细菌、真菌等各种机会性感染及眼内淋巴瘤等[2-4].其中以HIV视网膜微血管病变和巨细胞病毒性视网膜炎(CMVR)最为常见[2,5].近年来,AIDS患者逐渐增多,正确认识其眼部表现对早期珍治该病有着重要的临床意义.为此,我们观察了一组AIDS患者的典型眼部表现及治疗情况,现将结果报道如下.     

人类免疫缺陷病毒感染的眼部并发症

近年来,随着高效抗逆转录病毒治疗法(HAART)的广泛应用,人类免疫缺陷病毒(HIV)和获得性免疫缺陷综合征(AIDS)相关眼部并发症的发病率显著降低。而HIV感染者和AIDS患者数量逐年增加,且生存率提高、生存时间延长,这导致发生眼部并发症的患者绝对数增多。其相关眼部并发症临床表现多变,几乎影响所有眼部结构。目前我国对HIV感染者和AIDS患者的眼部病变缺乏大样本和长期的系统观察,且临床诊疗中有误诊和漏诊的情况发生,这不但延误治疗,而且极易引起医源性传播,故医务工作者应加强对HIV/AIDS的了解。本文对HIV/AIDS患者常见眼部非感染性、机会性感染并发症和免疫重建炎症反应综合征(IRIS)进行综述,探讨HIV/AIDS眼部并发症的表现和研究进展。     

获得性免疫缺陷综合征的眼部并发症概述

随着获得性免疫缺陷综合征（ＡＩＤＳ）发病率增高，生存期延长，眼部并发症也越来越多见。ＡＩＤＳ在眼部的表现大致包括微血管病变，感染和恶性病变。微血管形态和功能异常为基本病变，其意义在于标志着ＣＤ４＾＋细胞计数的减少及严重的并发症；而视网膜坏死是致盲的首要原因，其中巨细胞病毒感染是最常见的致病因素，其特点是病程发展呈进行性，不易控制，治疗依靠应用全身或局部抗病毒制剂。手术治疗主要针对继发的视网膜脱离；     

与获得性免疫缺陷综合征相关的卡波济肉瘤在眼部的临床表现

目的提高对获得性免疫缺陷综合征(AIDS)患者眼部卡波济肉瘤(KS)的认识及诊断处理能力。方法回顾系列病例研究。回顾分析10例AIDS并发KS患者的眼部临床表现及其治疗随访结果。结果10例患者均为汉族男性;年龄21~71岁,平均(38.60±15.66)岁;病程10 d^7个月,平均(2.68±2.41)个月。CD4^+T淋巴细胞2~348个/μL,平均(62.30±105.86)个/μL。临床表现:眼睑合并结膜KS4例、结膜KS 4例、眼睑KS 2例。眼睑KS表现为紫黑色局部结节,质韧,边界不清,无移动性,无压痛;结膜KS呈暗红色,片状。仅1例为单纯眼部KS,余9例均为全身多发性KS,累及皮肤、口腔、淋巴结、肺、肝、心包等。治疗:1例单纯眼部睑结膜KS未合并其他部位肿瘤患者行手术切除,高效抗逆转录病毒治疗(HAART),未行化学治疗(简称化疗),观察1年未复发;余9例均给予HAART和多柔比星脂质体或紫杉醇化疗。2例治疗过程中全身衰竭死亡,8例患者随访8~19个月,平均(12.50±4.28)个月,眼部病变6例完全缓解,2例部分缓解。结论随着HIV/AIDS感染日益增多,汉族人种AIDS患者KS发病逐渐增多,且多为多器官累及。HAART合并化疗可提高患者眼部病变缓解率。     

人类免疫缺陷病毒感染合并获得性免疫缺陷综合征眼部病变的眼底特征

目的 观察人类免疫缺陷病毒感染合并获得性免疫缺陷综合征(HIV/AIDS)的眼部病变眼底特征.方法 1041例HIV/AIDS患者纳入研究.其中,男性882例,占88.70％;女性159例,占11.30％;年龄12～73岁,平均年龄41岁.发现HIV感染时间为1个月～10年,平均HIV感染时间为12个月.传播方式为性传播475例,占45.63％;针头注射传播508例,占48.80％;输血传播44例,占4.25％;母婴传播14例,占1.34％.所有患者均进行视力、裂隙灯显微镜及眼底检查;发现眼底异常改变时行眼压、眼底照相及荧光素眼底血管造影(FFA)检查.观察不同眼部病变的眼底特征.结果 1041例HIV/AIDS患者中,发现眼部病变247例,占23.73％.其中,HIV视网膜微血管病变是最为常见的眼部病变,共132例,占眼部病变患者的53.44％;其次为巨细胞病毒性视网膜炎(CMVR),共70例,占眼部病变患者的28.34％.眼底检查发现,HIV视网膜微血管病变眼底表现为视网膜微动脉瘤,沿血管走行的灶状出血、棉绒斑;CMVR眼底表现为不规则干燥外观,颗粒状边沿,有的累积视神经.FFA检查发现,HIV视网膜微血管病变表现为出血斑呈遮蔽荧光,出血中心轻度强荧光,无荧光渗漏;CMVR表现为大片出血遮蔽荧光,血管荧光渗漏和(或)脉络膜透见荧光,视盘及病变区域荧光着染.结论 HIV/AIDS可发生多种眼部病变,以HIV视网膜微血管病变和CMVR最为常见.HIV视网膜微血管病变主要表现为灶状出血和(或)棉绒斑,CMVR主要表现为不规则干燥外观病变,有时合并大片出血.     

与获得性免疫缺陷综合征相关的卡波济肉瘤在眼部的临床表现

目的 提高对获得性免疫缺陷综合征(AIDS)患者眼部卡波济肉瘤(KS)的认识及诊断处理能力。方法 回顾系列病例研究。回顾分析10例AIDS并发KS患者的眼部临床表现及其治疗随访结果。结果 10例患者均为汉族男性;年龄21~71岁,平均(38.60±15.66)岁;病程10 d~7个月,平均(2.68±2.41)个月。CD4 ⁺T淋巴细胞2~348 个/μL,平均(62.30±105.86)个/μL。临床表现:眼睑合并结膜KS4 例、结膜KS 4例、眼睑KS 2例。眼睑KS表现为紫黑色局部结节,质韧,边界不清,无移动性,无压痛;结膜KS呈暗红色,片状。仅1例为单纯眼部KS,余9例均为全身多发性KS,累及皮肤、口腔、淋巴结、肺、肝、心包等。治疗:1例单纯眼部睑结膜KS未合并其他部位肿瘤患者行手术切除,高效抗逆转录病毒治疗(HAART),未行化学治疗(简称化疗),观察1年未复发;余9例均给予HAART和多柔比星脂质体或紫杉醇化疗。2例治疗过程中全身衰竭死亡,8例患者随访8~19个月,平均(12.50±4.28)个月,眼部病变6例完全缓解,2例部分缓解。结论 随着HIV/AIDS感染日益增多,汉族人种AIDS患者KS发病逐渐增多,且多为多器官累及。HAART合并化疗可提高患者眼部病变缓解率。     

带状疱疹性眼病与获得性免疫缺陷综合征

对 2 6例带状疱疹性眼病的特点及其与 AIDS病关系进行研究 ,以期对其并发症进行合理治疗 ,减轻视功能损害。患者年龄为2 3— 5 6岁 ,平均 3 3岁 ,男女各 13例。常见眼部并发症为角膜炎和前葡萄膜炎 ,其发生率分别为 69.2 3 %和 5 3 .85 %。其他并发症有继发青光眼 15 .3 8% ,白内障 11.5 4 % ,视神经炎 3 .84 % ,眼外肌麻痹 11.5 4 % ,疱疹后神经痛 3 0 .7%。 2 0例病人 ( 76.92 % )产生永久性视力损害 ,视力低于 0 .5者 14例 ( 5 3 .84 % )。 10例病人行血清 HIV检测均为阳性 ,其中 8例合并有 AIDS病相关全身表现。与 AIDS病有关的带状疱疹性眼病多发生在年轻患者 ,眼部并发症发生率高且重 ,治疗困难 ,视力损害明显 ,它不仅是AIDS病的常见并发症 ,也是最早期表现之一。     

Effect of individualized therapy for AIDS patients with cytomegalovirus retinitis in intravitreal ganciclovir injections

The effect of intravitreal ganciclovir injection combined with intravenous infusion on acquired immune deficiency syndrome (AIDS) patients with cytomegalovirus retinitis (CMVR) was investigated. A total of 32 eyes in 23 AIDS patients diagnosed as CMVR from 2017 to 2018 were included in the retrospective study. All patients underwent induction therapy by using intravenous drip of the anti-cytomegalovirus (CMV) agent ganciclovir (5 mg/kg q12h) combined with intravitreal ganciclovir injection (3 mg/time, 2 times/wk). The visual acuity, fundus photographs, lesion location, and number of intravitreal injections were observed preoperatively and postoperatively. Totally 14 eyes were cured during induction therapy. The number of injections [4.13 (2 to 6)] in CMVR patients with peripherally fundus lesions were significantly lower than those with central lesions [4.89 (2 to 6)]. The individualized therapy of intravitreal ganciclovir injections for AIDS patients with CMVR can effectively reduce the numbers of intravitreal injections.     

Concurrent Herpes Simplex and Cytomegalovirus,Retinitis and Encephalitis in the Acquired Immune Deficiency Syndrome (AIDS)

We present a case of bilateral herpes simplex and cytomegalovirus retinitis and concurrent encephalitis following acyclovir therapy in a homosexual male with the acquired immune deficiency syndrome (AIDS). At autopsy, herpes simplex virus antigens were readily detected in all retinal layers, retinal pigment epithelium, and choriocapillaris, using an immunoperoxidase technique, whereas herpes simplex antigens in the brain were localized in restricted foci of vascular and subependymal parenchymal cells. Cytomegalovirus antigens were identified in cells in all layers of retina, in retinal pigment epithelium, and in subependymal parenchymal cells in the brain. No cytomegalovirus antigens were detected in any vascular endothelium, in choroid, or anterior to the ora serrata. The widespread expression of herpes simplex virus antigens in this patient's retinas is in marked contrast to the restricted foci of herpes simplex antigens limited to the subependymal region of the brain, and is similar to that seen in murine models of herpes simplex retinitis produced by acyclovirresistant viral mutants.     

Fundus manifestations and HIV viral loads of AIDS patients before and after HAART

AIM: To investigate the fundus manifestations and human immunodeficiency virus (HIV) viral loads of acquired immune deficiency syndrome (AIDS) patients before and after highly active antiretroviral therapy (HAART). METHODS: This retrospective study included 21 AIDS patients (42 eyes) who presented to the Department of Ophthalmology, Peking Union Medical College Hospital, from 2007 to 2011. Among the patients, 16 showed a good response to HAART, 3 presented drug resistance and 2 were pre-HAART. All patients underwent comprehensive ophthalmic examinations. The HIV viral loads and the CD4+ T-cell counts were also determined. RESULTS: The best-corrected visual acuity (BCVA) of 38 eyes (19 patients) was improved, and cytomegalovirus retinitis (CMVR) in 5 eyes (3 patients) regressed after HAART. Furthermore, 16 patients treated with effective HAART had decreased plasma HIV viral loads (<78 copies/mL) and increased CD4+ T-cell counts (343±161 cells/μL, P<0.005), but the HIV viral load in tears was still detected at 2404 copies/mL. The CD4+ T-cell count was lower in the CMVR group than in the non-CMVR group (P=0.022), but the HIV viral load in the tears was not significantly different between the two groups (P=0.439). CONCLUSION: Most patients with AIDS show a good viral response with a decreased HIV viral load and an increased CD4+ T-cell count in plasma after HAART. However, the HIV viral load remain quite high in the tear samples. Based on our results, we suggest that AIDS patients undergo long-term HAART that should not be interrupted.     

Immune recovery uveitis in an HIV-negative individual

Immune recovery uveitis (IRU) is an intraocular inflammatory disorder originally described in individuals with human immunodeficiency virus (HIV) and inactive cytomegalovirus retinitis following highly active antiretroviral therapy. Although relatively common in individuals with acquired immune deficiency syndrome in the United States it is an extremely uncommon presentation in Australia. IRU also occurs in iatrogenically immunosuppressed individuals with a similar incidence to HIV-infected individuals. We report one case of IRU in an HIV-negative individual following a volunteer unrelated donor allogeneic stem cell transplant for non-Hodgkin's lymphoma. In the context of tapering the immunosuppression the patient developed bilateral IRU, consisting of panuveitis and macular oedema. The visual acuity (VA) at presentation of IRU was limited to counting fingers bilaterally. The IRU resolved with the re-intensification of the immunosuppression. VA restored to right 6/18 and left 6/12.     

Infection control guidelines for Optometrists and Contact Lens Practitioners

Isolation of the AIDS virus from tears has heightened awareness of the continued need for optometrists to maintain office procedures that prevent cross-infection between patients and between the optometrist and the patient. Infection control procedures are presented that minimise or eliminate the risk of contamination and enable contamination to be handled safely when it occurs. Guidelines for individual practitioners and institutions can be formulated from the information presented.     

未经抗巨细胞病毒治疗时艾滋病合并巨细胞病毒性视网膜炎的临床特征及其预后

目的 了解未经抗巨细胞病毒治疗时获得性免疫缺陷综合征（艾滋病）合并巨细胞病毒性视网膜炎的临床特征及其预后。设计 回顾性病例系列。研究对象 11例未经抗巨细胞病毒治疗的艾滋病合并巨细胞病毒性视网膜炎患者。方法 所有患者查矫正视力、非接触眼压、裂隙灯显微镜检查、动态视野、散瞳间接检眼镜检查、眼底照相,并行CD4 T淋巴细胞检测。随访2个月~5年（平均26.2±23.8个月）,观察病程过程中各项指标的变化。主要指标 矫正视力、眼前后节情况。结果 11例（21眼）发病,其中14眼无光感,矫正视力＜0.05者2例（2眼）,0.05≤矫正视力＜0.3者1例（1眼）,矫正视力≥0.3者3例（4眼）;21眼中,5眼仅有不同程度的角膜后色素性KP,余16眼除角膜KP外,均有不同程度的白内障;21眼中13眼有不同程度虹膜前后粘连,2例（3眼）合并角膜白斑、角膜血管翳,影响外观。眼底能窥入者9眼,表现为不同程度眼底瘢痕性改变,合并视网膜脱离者2眼。结论 未经抗巨细胞病毒治疗的艾滋病合并巨细胞病毒性视网膜炎患者视力预后差,除眼底病变外,还可引起眼前节病变。     

艾滋病合并巨细胞病毒性视网膜炎的误诊分析

目的分析艾滋病合并巨细胞病毒性视网膜炎的误诊病例,以减少误诊。设计回顾性病例系列。研究对象具有误诊史的艾滋病合并巨细胞病毒性视网膜炎的患者9例。方法回顾性分析在北京地坛医院确诊的具有误诊史的艾滋病合并巨细胞病毒性视网膜炎患者的眼部和全身情况。主要指标误诊眼疾病,误诊时间,合并全身疾病。结果艾滋病患者巨细胞病毒性视网膜炎误诊为其他眼病的患者9例（12眼）,其中误诊为Coats病者1例,视网膜中央静脉阻塞者1例,Eales病者1例,孔源性视网膜脱离者1例,视盘血管炎者2例（3眼）,葡萄膜炎者2例（4眼）,曾先后误诊为急性视网膜坏死、葡萄膜炎和玻璃体混浊者1例。发病一周内误诊者3例,1周~3个月内误诊者2例,3个月以上病程者误诊4例。9例误诊患者中5例不曾进行高效抗逆转录病毒治疗（HAART）的患者CMV-IgM检测阳性;5例患者合并有贫血,5例患者合并其他部位的感染,4例患者合并肝肾功能异常,9例患者的CD4均〈200个/μL,其中6例患者的CD4〈50个/μL。结论艾滋病合并巨细胞病毒性视网膜炎受到病程、艾滋病抗病毒治疗和我们对疾病的认识等多种因素的影响易出现误诊。对于临床诊断有困难的疾病应考虑到这种疾病的可能,其正确的诊断需要结合全身情况综合判断。     

艾滋病并发巨细胞病毒性视网膜炎32例临床分析

【摘要】 目的 分析获得性免疫缺陷综合征（艾滋病）患者发生巨细胞病毒性视网膜炎及免疫恢复 性葡萄膜炎的疾病特征。设计 回顾性病例系列。研究对象 北京佑安医院眼科诊治的艾滋病合并巨 细胞病毒性视网膜炎患者32例。方法 对上述患者进行与艾滋病相关的免疫学检测;并进行视力、 眼压、眼前节检查、彩色眼底照相及荧光素眼底血管造影等眼科检查,并观察其临床特征。主要指 标 视力、眼压、眼底、CD4+T细胞计数。结果 32例患者的视力为光感～1.0;眼压8~16 mm Hg;眼 前节检查8例患者（4例为免疫恢复性葡萄膜炎）可见眼前节反应阳性（前房闪辉及角膜后KP）;32 例患者彩色眼底像均可见典型巨细胞病毒性视网膜炎眼底改变;8例（25%）CD4+T细胞＜10个/μL ,视力为光感～0.8,其中3例发生免疫恢复性葡萄膜炎,1例发生视网膜脱离;15例（46.88%） CD4+T细胞在10～50个/μL,视力为眼前指数～1.0,其中1例发生免疫恢复性葡萄膜炎,1例发生视 网膜脱离;9例（28.12%）CD4+T细胞＞50个/μL,无患者发生免疫恢复性葡萄膜炎及视网膜脱离。 19例患者（含4例免疫恢复性葡萄膜炎患者）合并其他全身机会性感染。结论 CD4+T细胞＜50个/μ L的患者更易患巨细胞病毒性视网膜炎,其视力预后差; CD4+T细胞
＜10个/μL的患者更易发生免疫恢复性葡萄膜炎,且眼前节反应明显,更易合并其他全身机会性感 染。（眼科, 2012, 21: 405-408）     

Superior Ophthalmic Vein Thrombosis as an Initial Manifestation of Antiphospholipid Syndrome

ABSTRACT

Purpose: To report an uncommon case of superior ophthalmic vein occlusion secondary to antiphospholipid syndrome.

Method: Interventional case report.

Result: A 41 year old man who presented with acute proptosis and ophthalmoplegia who was initially treated for orbital cellulitis. His CT scan showed changes consistent of that a superior ophthalmic vein thrombosis. He was managed with high dose intravenous steroid and commenced on anticoagulant therapy. He was subsequently diagnosed with antiphospholipid syndrome.

Conclusion: Although superior ophthalmic vein occlusion is rare it is an important differential. This is the first reported case secondary to antiphospholipid syndrome.     

OCULAR INVOLVEMENT IN THE ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)

The acquired immune deficiency syndrome (AIDS) has reached epidemic proportions in the USA and the incidence of this potentially fatal viral infection is increasing rapidly in Australia. The loss of normal cellular immunity in affected individuals predisposes them to severe opportunistic infections and neoplasms, especially Kaposi's sarcoma. Both of these pathological processes may affect the eye, and ocular involvement with an opportunistic infection or malignancy may be the first clue to the presence of AIDS. We present here the first Australian report of a patient with AIDS presenting with ocular involvement. The case is discussed in relation to current concepts of AIDS.