人类免疫缺陷病毒感染及获得性免疫缺陷综合征患者眼部病变的诊断与治疗

目的 探讨人类免疫缺陷病毒(HIV)感染及获得性免疫缺陷综合征(AIDS)患者的眼部病变特点、临床症状及治疗原则.方法 回顾性系列病例研究.回顾性分析110例(220只眼)HIV感染和AIDS患者的临床资料,包括患者视力、眼前节、眼底检查和荧光素眼底血管造影及外周血CD_4~+T淋巴细胞检测结果,其中2例(4只眼)AIDS合并巨细胞病毒(CMV)性视网膜炎患者施行了更昔洛韦玻璃体腔注药治疗.患者年龄、HIV感染时间与HIV视网膜病变及CMV性视网膜炎的相关性采用Pearson相关分析法,性别与HIV视网膜病变及CMV性视网膜炎的相关性采用Pearson ChiSquare分析法,正常眼底组、HIV视网膜病变组、CMV性视网膜炎组间CD_4~+T淋巴细胞计数比较采用多个独立样本的秩和检验.结果 患者初诊视力为无光感者5只眼,光感至0.04者10只眼,0.05～0.2者14只眼,0.3～0.7者62只眼,0.8及以上者129只眼.110例(220只眼)HIV感染和AIDS患者中,有25只眼角膜后有灰白色细小或色素性沉着物.22只眼房水闪光(+)或(++).4只眼虹膜后粘连.28只眼晶状体混浊.34只眼确诊为HIV视网膜病变,眼底表现为棉絮斑、视网膜出血及微血管瘤.32只眼确诊为AIDS合并CMV性视网膜炎,26只眼的眼底表现为沿血管分布的浓厚黄白色病损区,其上片状出血,边缘有不规则黄白色颗粒.3只眼为眼底病变晚期,表现为视网膜萎缩、视网膜血管硬化和狭窄、视神经萎缩.3只眼合并视网膜脱离.正常眼底的HIV感染者及AIDS患者CD_4~+T淋巴细胞计数中位数为100.0个/mm~3,HIV视网膜病变患者CD_4~+T淋巴细胞计数中位数为41.0个/mm~3,CMV性视网膜炎患者CD_4~+T淋巴细胞计数中位数为18.0个/mm~3.CD_4~+T淋巴细胞计数比较,正常眼底组与HIV视网膜病变组相比,差异有统计学意义(x~2=4.848,P=0.028);正常眼底组与CMV性视网膜炎组相比,差异有统计学意义(x~2=15.696,P=0.000);HIV视网膜病变组与CMV性视网膜炎组相比,差异有统计学意义(x~2=4.860,P=0.027).2例(4只眼)CMV性视网膜炎患者行更昔洛韦(400 μg)玻璃体腔注药后,视力提高,眼底病变明显消退.结论 视网膜微血管病变是HIV感染及AIDS常见的眼部并发症,CMV性视网膜炎是AIDS晚期最严重的眼部并发症.高效抗逆转录病毒治疗可重建患者的免疫功能,更昔洛韦玻璃体腔注药可有效治疗CMV性视网膜炎并挽救患者视力.

Diagnosis and treatment of eye diseases associated with HIV infection and AIDS

Objective To investigate the manifestations and treatment principles of ocular diseases associated with human immunodeficiency virus infection (HIV) and acquired immunodeficiency syndrome (AIDS).Methods It was a retrospective case series.One hundred and ten patients were recruited.Two hundred and twenty eyes underwent ophthalmologic examination that included vision acuity,anterior segment and fundus examinations with papillary dilation and fundus fluorescein angiography.CD_4~+T-lymphocyte was counted in peripheral blood of 110 patients.Intravitreal injection of ganciclovir 400 μg was performed in 4 eyes (2 patients) with cytomegalovirus (CMV) retinitis associated with AIDS.All statistical analyses were performed using SPSS 13.0 software.The association between the age,duration of HIV infection and HIV/AIDS related ocular manifestations was analyzed by Pearson Correlation Analysis.The association between the gender and HIV/AIDS related ocular manifestations was analyzed by Pearson Chi-Square test.For comparison of the CD_4~+T cells counts of the patients with normal fundus,HIV retinopathy,CMV retinitis,Kruskal-Wallis Test for Several Independent Samples was used.Results Baseline visual acuity:no light perception (NLP) 5 eyes;light perception (LP) to 0.04,10 eyes;0.05 to 0.2,14 eyes;0.3 to 0.7,62 eyes and≥0.8,129 eyes.Small grayish keratic precipitates or pigment keratic precipitates were present in 25 eyes,22 eyes had positive aqueous flare,4 eyes had posterior synechia of the iris,28 eyes had cataract.HIV retinopathy was present in 34 eyes.Cotton-wool spots,retinal hemorrhages,and retinal microaneurysms were found in eyes with HIV retinopathy.CMV retinitis was present in 32 eyes.The fundus manifestations of CMV retinitis included retinal vaaculitis;dense,full-thickness,yellow-white lesions along vascular distribution with irregular granules at the border,and hemorrhage on the retinal surface in 26 eyes.Late stage retinopathy was demonstrated in 3 eyes characterized as atrophic retina,sclerotic and attenuated vessels,and optic nerve atrophy.Retinal detachment was found in 3 eyes.The median of CD_4~+T-lymphocyte counts of the patients with normal fundus was 100.0/mm~3.The median of CD_4~+T-lymphocyte counts of the patients with HIV retinopathy was 41.0/mm~3.The median of CD_4~+T-lymphocyte counts of the patients with CMV retinitis was 18.0/mm~3.The difference of CD_4~+T-lymphocyte counts between patients with normal fundus and HIV retinopathy was statistically significant(x~2=4.848,P=0.028).The difference of CD_4~+T-lymphocyte counts between patients with normal fundus and CMV retinitis was statistically signifieant(x~2=15.696,P=0.000).The difference of CD_4~+T-lymphocyte counts between patients with CMV retinitis and HIV retinopathy was statistically significant (x~2=4.860,P=0.027).Four eyes (2 patients) with CMV retinitis underwent intravitreal injection of ganciclovir 400 μg.After intravitreal injection of gancielovir,visual acuity was improved and fundus lesions disappeared in 4 eyes.Conclusions HIV retinopathy is a common intraocular complication in HIV-infeeted patients.CMV retinitis is the severest intraocular complication in patients with AIDS.Highly active anti-retroviral therapy allows immune reconstitution.Intravitreal injection of ganciclovir can effectively control CMV retinitis and save the vision.