THE ACQUIRED IMMUNE DEFICIENCY SYNDROME: OCULAR FINDINGS AND INFECTION CONTROL GUIDELINES

The acquired immune deficiency syndrome (AIDS) is characterised by a loss of normal cellular immunity in affected individuals which predisposes them to severe opportunistic infections and neoplasms 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 AlDS
This article reviews the ocular manifestations of ADS and concludes with infection control guidelines for ophthalmologists treating patients with AlDS and related conditions     

High-dose intravitreal gancyclovir for cytomegaloviral (CMV) retinitis

Abstract
A patient with acquired immune deficiency syndrome (AIDS) with bilateral cytomegaloviral (CMV) retinitis who had become neutropaenic from intravenous gancyclovir, was treated with a total of 16 intravitreal 2 mg/0.l ml doses of gancyclovir in each eye under topical anaesthesia. The injections were well tolerated with no evidence of retinal toxicity. A moderate vitreous haze which did not affect vision was the only complication. The patient retained useful vision until the time of his death, three months later.     

Acquired Immunodeficiency Syndrome (AIDS)

The Acquired Immunodeficiency Syndrome (AIDS), caused by the human immunodeficiency virus (HIV), also called the human T-lymphotropic virus type III/lymphadenopathy-associated virus [HTLV-III/LAV], has affected over 23,000 people; more than half of those with the disease have died. The actual case fatality rate approaches 100%. AIDS affects all groups and classes of people, although some are at special risk. Distribution of the disease is worldwide. The illness' effects on the body are widespread; of special interest are the ophthalmologic manifestations. The eye may be infected by various viruses (cytomegalovirus, varicella-zoster virus, herpes simples virus or HIV itself), toxoplasma gondii, candida sp, cryptococcus neoformans, M. tuberculosis, or M. avium-intracellulare. Kaposi's sarcoma may affect the eye as well. Retinal vascular abnormalities (e.g., cotton-wool spots, vasculitis) are not uncommon in AIDS. The syndrome may present with neuro-ophthalmologic manifestations. No effective treatment for the illness is currently available, although several hold promise and there is hope for an AIDS vaccine. Prevention of infection through reduction of risks appears to be the only defense against AIDS at this time.     

两种不同诱因所致巨细胞病毒视网膜炎预后的临床观察

目的探讨两种不同病因诱发的巨细胞病毒视网膜炎(CMVR)的预后情况。 方法观察2015年5月至2019年10月首都医科大学附属北京佑安医院眼科和北京朝阳医院眼科确诊为CMVR患者32例(52只眼)。其中,男性27例(44只眼),女性5例(8只眼),平均年龄(25.4±7.8)岁。根据常见病因,分为获得性免疫缺陷综合征(AIDS)组和造血干细胞移植(HSCT)术后组两组。全部患者均行更昔洛韦和(或)膦甲酸钠玻璃体腔注药联合全身治疗,随访6个月。检查并记录治疗前和治疗6个月后患者的最佳矫正视力(BCVA)、眼压、眼底彩色照相、房水中巨细胞病毒脱氧核糖核酸(CMV-DNA)含量及外周血CD4⁺T淋巴细胞计数等指标。眼压以均数±标准差描述,以t检验进行比较。BCVA、外周血CD4⁺T淋巴细胞计数、房水CMV-DNA含量以中位数(最小值,最大值)描述,以Wilcoxon秩和检验进行比较。注药次数用频数或率(%)表示,组间比较采用卡方检验。 结果治疗前AIDS组患者和HSCT术后组患者BCVA分别为0.36(0.02,1.00)和0.21(0.01,0.60);治疗后AIDS组和HSCT术后组患者BCVA分别为0.53(0.05,1.00)和0.36(0.02,0.80)。经秩和检验,治疗前两组患者BCVA比较,差异无统计学意义(Z＝-0.23,P>0.05);治疗后AIDS组患者BCVA高于HSCT术后组,差异具有统计学意义(Z＝-2.05,P<0.05)。治疗前AIDS组和HSCT术后组患者眼压分别为(11.9±2.8)mmHg(1 mmHg＝0.133 kPa)和(12.8±2.2)mmHg;治疗后AIDS组和HSCT术后组患者眼压分别为(13.4±2.7)mmHg和(13.9±3.5)mmHg。经t检验,治疗前和治疗后两组患者眼压比较,差异无统计学意义(t＝-0.94,-0.54;P>0.05)。治疗前AIDS组和HSCT术后组患者外周血CD4⁺T淋巴细胞计数分别为54(0,213)个/μl和47(2,87)个/μl;治疗后AIDS组和HSCT术后组患者外周血CD4⁺T淋巴细胞计数分别为139(32,371)个/μl和76(21,212)个/μl。经秩和检验,治疗前两组患者外周血CD4⁺T淋巴细胞计数比较,差异无统计学意义(Z＝-0.65,P>0.05)。治疗后AIDS组患者外周血CD4⁺T淋巴细胞计数高于HSCT术后组,差异具有统计学意义(Z＝-2.45,P<0.05)。治疗前AIDS组和HSCT术后组患者房水中CMV-DNA含量分别为2.74×10⁴(1.59×10³,5.14×10⁵)拷贝/ml和7.18×10³(3.17×10³,5.89×10⁵)拷贝/ml;治疗后AIDS组和HSCT术后组患者房水中CMV-DNA含量分别为1.24×10(0,2.23×10²)拷贝/ml和2.01×10(0,3.45×10²)拷贝/ml。经秩和检验,治疗前和治疗后两组患者房水中CMV-DNA含量比较,差异无统计学意义(Z＝-0.68,-0.27;P>0.05)。HSCT术后组患者在抗病毒治疗6个月内有3只眼出现CMVR复发,AIDS组患者在抗病毒治疗6个月内有1只眼出现CMVR复发。HSCT术后组患者玻璃体腔注药次数≥4次者占55%(11只眼/20只眼),AIDS组患者玻璃体腔注药次数≥4次者占18.8%(6只眼/32只眼)。经卡方检验,HSCT术后组和AIDS组患者玻璃体腔注药次数≥4次者的比较,差异有统计学意义(χ²＝6.231,P<0.05)。 结论较之于AIDS诱发的CMVR,HSCT术后诱发的CMVR局部联合全身抗病毒治疗后免疫功能恢复慢,视功能较差,可能需要更长时间的眼内抗病毒治疗。     

巨细胞病毒性视网膜炎与获得性免疫缺陷综合征

目的 探讨巨细胞病毒性视网膜炎与获得性免疫缺陷综合征的关系、临床表现及诊断、治疗。 方法 观察分析56例巨细胞病毒(cytomeglovirus,CMV)性视网膜炎合并获得性免疫缺陷综合征(acquired immunodeficiency syndrome,AIDS)患者95只眼，对其眼底、视力、T辅助细胞的细胞受体4（CD4 ＋）计数及预后进行观察随访2周～18个月。 结果 56例患者在诊断为巨细胞病毒性视网膜炎之前AIDS病程为4～26个月。95只眼56例患者中，眼底病灶表现为颗粒型者55只眼，其中46只眼位于周边部；爆发型者25只眼，均位于后极部，视网膜坏死灶致密伴斑片状出血和血管炎；颗粒型与爆发型病灶混合存在者15只眼；其中7只眼合并有视神经乳头炎；患者就诊时视力为眼前数指至0.5，病变广泛者及病变位于后极部者视力下降尤为严重。30例患者CD4 ＋细胞计数为0～30 个/μl,平均(15±9) 个/μl。患者存活时间为3～18个月。接受更昔洛韦(ganciclovir)治疗组患者视力多数提高，CD4 ＋T细胞计数明显升高，未治疗组患者92%病变呈进行性发展，视力显著下降。 结论 CMV性视网膜炎是AIDS病的主要眼部并发症，临床上以坏死性视网膜炎伴出血及血管炎为特征，目前治疗主要用更昔洛韦。 (中华眼底病杂志, 2002, 18: 89-91)     

THE SIGNIFICANCE OF OCULAR MORBIDITY IN VERY-LOW-BIRTHWEIGHT INFANTS TO THE AUSTRALIAN HEALTH SERVICE

The survival rate of very-low-birthweight (VLBW) infants has greatly increased due to the introduction of intensive-care methods to neonatal nurseries. It was feared that this would also cause an increase in the amount of ocular morbidity associated with prematurity. In order to estimate this, 111 very-low-birthweight infants (birthweights ≤ 1500 g) were reviewed at two years of age. They comprised 63% of the total number of long-term surviving babies born at, or transferred in the neonatal period to, the Royal Women's Hospital, Melbourne, in 1977 and 1978. In 33% a significant ocular problem was detected; 19% had strabismus. 17% had a significant refractive error, 10% had cicatricial retrolental fibroplasia (RLF), and 2.7% were blind, due to optic atrophy associated with cerebral palsy. Other studies have shown that 7% of VLBW infants develop severe (Stage III) RLF, and 18% of these (1.26% of VLBW infants) will be socially or totally blind. In order to estimate the significance of VLBW infants to the ophthalmic health services, and to the organisations for the care of the visually handicapped, these figures can be extrapolated. Based on 1980 figures, it would be expected that approximately 1105 VLBW infants would survive annually, and nine would become blind from RLF, while 110 would have been affected by RLF. Thirty-three children would be blind from optic atrophy associated with cerebral palsy, 210 would have strabismus, and at least 187 would have a significant refractive error. VLBW infants will contribute significantly to the number of children requiring ocular care, and because of the high incidence of ocular abnormalities, it is recommended that routine screening of all VLBW infants be carried out at one year and two years of age.     

Bilateral central retinal vein occlusions in a Chinese patient with HIV-infection

Purpose: To report a case of bilateral nonischemic central retinal vein occlusions as the initial presentation in a Chinese patient with HIV-infection. Methods: Complete ophthalmological examination and fundus fluorescein angiography were performed in the eyes of this patient.Results: Ophthalmic examinationand fundus fluoresceinangiography revealed bilateral nonischemic central retinal vein occlusions and optic disc edema in a 22-year-old man who was HIV-positive.The findings of fundus examination and fluorescein angiography were similar in both eyes.Conclusion: This case provides additional evidence that central retinal vein occlusion is probably part of the spectrum of HIV retinopathy.     

Ocular Surface Disorders in Patients with Human Immunodeficiency Virus (HIV) Infection

ABSTRACT

Purpose: To describe ocular surface disorders associated with human immunodeficiency virus (HIV). Methods: Narrative review. Results: Ocular surface neoplastic conditions, such as Kaposi’s sarcoma, conjunctival lymphoma and ocular squamous cell carcinoma along with blepharitis, dry eye disease, and vernal keratoconjunctivitis, constitute ocular surface complications in HIV-infected individuals. Conclusion: This review will provide a summary of clinical presentations and treatment options for the most common HIV-related ocular surface diseases, indicating the need for a comprehensive ocular examination including ocular surface in all HIV patients 22 SjoLD, RalfkiaerE, PrauseJU, et al. Increasing incidence of ophthalmic lymphoma in Denmark from 1980 to 2005. Invest Ophthalmol Vis Sci . 2008;49:3283e8. doi:10.1167/iovs.08-1768.[Crossref], [Web of Science ®] , [Google Scholar].     

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.     

Posterior segment manifestations of HIV/AIDS

The ocular posterior segment manifestations of AIDS may be divided into four categories: retinal vasculopathy, unusual malignancies, neuro-ophthalmologic abnormalities, and opportunistic infections. Microvasculopathy is the most common manifestation. Opportunistic infections, particularly cytomegalovirus retinitis and progressive outer retinal necrosis, are the most likely to result in visual loss due to infection or subsequent retinal detachment. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.     

LAK细胞对眼部恶性肿瘤的免疫治疗临床观察

本文应用 rIL-2体外诱导自身 LAK(Lynphokine-Activated Killing)细胞,对眼部恶性肿瘤病人进行瘤区局部治疗,取得较好的疗效,16例恶性肿瘤中,基底细胞癌5例;完全消退4例,部分消退1例,睑板腺癌4例,鳞状细胞癌2例,视网膜母细胞瘤,眶内非何杰金氏淋巴瘤,眶内血管外皮瘤,眶内纤维组织细胞瘤(生长活跃),汗腺癌各1例,都获完全消退.以上结果表明,病人自身 LAK 细胞局部治疗是一种有效的免疫方法.眼科学报 1993;9:51-54。     

Acquired immune deficiency syndrome. Pathogenic mechanisms of ocular disease

A gross, light, and electron microscopic study of the eyes from 35 consecutive autopsy cases of the acquired immune deficiency syndrome revealed cotton-wool spots (71% of cases), retinal hemorrhage in areas without cytomegalovirus infection (40%), cytomegalovirus retinitis (34%) with associated retinal detachment, Roth's spots (23%), retinal microaneurysms (20%), papilledema (14%), conjunctival Kaposi's sarcoma (9%), cryptococcal chorioretinitis (6%), Mycobacterium avium-intracellulare in retina and in choroidal granulomas (6%), ischemic maculopathy (6%), bilateral keratitis (3%), and herpes simplex retinitis (3%). Ocular infection with candida or toxoplasmosis were not found in this autopsy series. Immunocytologic studies demonstrated deposition of immunoglobulins in arteriolar walls, consistent with immune complex mediated disease. Ultrastructural studies showed a vasculopathy in the areas near cotton-wool spots. A mechanism is proposed linking the deposition of immune complexes with subsequent small vessel lesions, ischemia, cotton-wool spots and later spread of cytomegalovirus to retina via damaged vascular endothelium.     

Seven Years of HAART Impact on Ophthalmic Management of HIV-Infected Patients

Purpose: The widespread use of highly active antiretroviral therapy (HAART) has changed the clinical picture of HIV-associated eye disease. We evaluated the incidence of ocular manifestations of HIV infection since the introduction of HAART. Methods: Between January 1996 and December 2002, we examined 539 HIV-infected patients in our hospital. Follow-up of the patients was performed in case of ophthalmologic symptoms, regardless of current immunologic status, or for screening. Results: A total of 217 patients (40.3%) had HIV-associated eye disease. Of these patients, 42.0% had no eye symptoms. Fifty-eight (10.8%) of the 539 patients had cytomegalovirus (CMV) retinitis, most of whom had CMV retinitis before receiving HAART. Four patients developed immune-recovery uveitis. A total of 145 patients (26.9%) had HIV-related microangiopathy and 96 (17.8%) had dry-eye syndrome. Conclusion: The introduction of HAART had a major impact on the medical history of patients with HIV-related eye disease with improved survival time and decreased morbidity.     

Bilateral Central Retinal Vein Occlusions Combined with Artery Occlusions in A Patient with Acquired Immune Deficiency Syndrome

Purpose:This is the first report of a bilateral nonischemic central retinal vein occlusions combined with artery occlusions in a patient with acquired immune deficiency syndrome (AIDS).Methods:Case report.Results:A 22-year-old Chinese(male)with a positive human immunodeficiency virus (HIV) infection developed bilateral nonischemic central retinal vein occlusion combined with artery occlusions and severe vision loss.The manifestations of the fundus and fluorescein angiography were similar in both eyes.Conclusion:This case report provides the evidences that central retinal vein and artery occlusions are probably part of the spectrum of AIDS vascular diseases.     

Evaluation of Ocular Manifestations and Blindness in HIV/AIDS Patients in a Tertiary Care Hospital in South India

Purpose: To report the prevalence of ocular manifestations in patients with HIV/AIDS and their correlation with the clinical stage of disease as well as the CD4 cell count.

Methods: 100 HIV-positive patients, who presented to a tertiary care hospital, were included. The WHO clinical staging of HIV/AIDS, CD4 count, duration of disease, and presence and type of ocular manifestations were noted.

Results: Overall, 46 patients (46%) had ocular manifestations related to HIV/AIDS. The most common manifestations were HIV retinopathy (12%) and cytomegalovirus (CMV) retinitis (7%). The prevalence of ocular manifestations correlated significantly with the WHO clinical stages 3 and 4 of HIV/AIDS (p = .001) and with low CD4 count (p = .001).

Conclusions: CD4 cell counts and WHO clinical stage of HIV disease are important predictors for the occurrence of ocular morbidity in HIV-positive individuals. Routine comprehensive ophthalmic screening and appropriate initiation of therapy in these patients can potentially decrease ocular morbidity.     

Anterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome

Ocular complications are known to occur as a result of human immunodeficiency virus (HIV) disease. They can be severe leading to ocular morbidity and visual handicap. Cytomegalovirus (CMV) retinitis is the commonest ocular opportunistic infection seen in acquired immune deficiency syndrome (AIDS). Though posterior segment lesions can be more vision-threatening, there are varied anterior segment manifestations which can also lead to ocular morbidity and more so can affect the quality of life of a HIV-positive person. Effective antiretroviral therapy and improved prophylaxis and treatment of opportunistic infections have led to an increase in the survival of an individual afflicted with AIDS. This in turn has led to an increase in the prevalence of anterior segment and adnexal disorders. Common lesions include relatively benign conditions such as blepharitis and dry eye, to infections such as herpes zoster ophthalmicus and molluscum contagiosum and malignancies such as squamous cell carcinoma and Kaposi's sarcoma. With the advent of highly active antiretroviral therapy, a new phenomenon known as immune recovery uveitis which presents with increased inflammation, has been noted to be on the rise. Several drugs used in the management of AIDS such as nevirapine or indinavir can themselves lead to severe inflammation in the anterior segment and adnexa of the eye. This article is a comprehensive update of the important anterior segment and adnexal manifestations in HIV-positive patients with special reference to their prevalence in the Indian population.     

Branch retinal artery occlusion (BRAO) combined with branch retinal vein occlusion (BRVO) and optic disc neovascularization associated with HIV and CMV retinitis

Two vaso-occlusive events, branch retinal artery occlusion (BRAO) and branch retinal vein occlusion (BRVO), were observed in the retina of an HIV-infected patient with cytomegalovirus (CMV) retinitis who developed neovascularization of the disc (NVD). Although BRVO and reversible NVD have been reported in association with CMV retinitis, we have seen no reports of concomitant BRAO. CMV damages endothelial cells and causes an occlusive vasculitis. In HIV-infected individuals, damaged endothelial cells and rheologic problems result in increased blood viscosity. HIV infection has also been associated systemically with elevated levels of cytokines, including tumor necrosis factor alpha (TNF-). In vitro, TNF- exerts effects that decrease fibrinolytic potential; this activity in the circulation of a patient with AIDS may lead to vascular occlusive events. In the patient reported here, the retinal changes were not reversed by induction therapy with ganciclovir and the NVD did not regress.Supported in part by an individual National Research Service Award grant F32-EY06193 (MDC) from the National Eye Institute, National Institutes of Health, Bethesda, Maryland and an unrestricted grant from Research to Prevent Blindness, Inc., New York, NY. Presented in part at the Midwest Fluorescein Conference, Door County, Wisconsin, August, 1992     

Fluocinolone Acetonide Implant (Retisert) for Chronic Cystoid Macular Edema in Two Patients with AIDS and a History of Cytomegalovirus Retinitis

Purpose: To report the authors’ experience using fluocinolone acetonide (Retisert) to treat cystoid macular edema (CME) resulting from immune recovery uveitis (IRU) in 2 acquired immunodeficiency syndrome (AIDS) patients with a history of cytomegalovirus (CMV) retinitis.

Design: Interventional case series.

Methods: Medical records were reviewed of 2 patients who received Retisert implantation in 3 eyes for IRU-associated inflammation and CME. Suppression of CMV disease was achieved with oral medication in one patient and with simultaneous implantation of a ganciclovir implant in the other patient.

Results: After Retisert implantation in 3 eyes in AIDS patients on HAART, improvement in CME was seen in 2 eyes. No CMV reactivation was detected during the several-month follow-up period.

Conclusions: Retisert may be an effective treatment for CME in AIDS patients with IRU reactivation and a history of CMV retinitis.     

Low Concentration Eserine Therapy for the Tonic Pupil (Adie) Syndrome

Very dilute solutions of the reversible anticholinesterase physostigmine salicylate provided varying degrees of symptomatic relief to three of five patients with the tonic pupil (Adie) syndrome. The therapeutic implications of the physiology of denervation supersensitivity and the pathophysiology of the tonic pupil are discussed.