Since its discovery, HIV infection has become one of the world’s greatest public health problem in the recent years. AIDS is a multisystem disorder which is caused by the Human Immunodeficiency Virus (HIV) which belongs to the Lenti virus subfamily of retroviruses. HIV targets the CD4+ T cells, causing a steady decline in the absolute number of these cells, resulting in a progressive immune deficiency, particularly of the cell mediated type. A regular estimation of the CD4+ T cell count is therefore a useful measure of the disease progression.
The CD4+T cell counts are measured every 3 months and a count of less than 200/micro litre implies a high risk of HIV related disease. The ocular manifestations are among the most common clinical features of HIV infection/AIDS patients. These lesions are varied and they affect almost all the structures of the eye. These include:
- A non infectious retinal microangiopathy which consists of cotton wool spots with or without intraretinal haemorrhages and microvascular changes like microaneurysms and telangiectasiae.
- Opportunistic ocular infections, primarily CMV retinitis.
- Unusual neoplasms like Kaposi’s sarcoma.
- Neuro-ophthalmic lesions.
- Immune Reconstitution Inflammatory Syndrome (IRIS) is a well recognized complication which occurs during the initial weeks of the treatment with ART and HAART.
These ocular manifestations occur throughout the illness, with an increasing HIV virulence and a progressive loss of the CD4+ T cell numbers .
In our study, 37.6% of the patients had ocular findings which included both anterior and posterior segment findings, adnexal lesions and neuro-ophthalmic signs. Unusual findings like lid retraction and colour vision abnormalities were seen in these patients.
Ocular lesions occur in 40- 70% of the AIDS patients, according to various studies [3
]. Due to the increased numbers of ART centres, frequent monitoring of the CD4 counts and early initiation of ART, the incidence of ocular findings has decreased considerably. On the other hand, due to an increase in the life span of these patients, it has been estimated that 70-80% of the adult AIDS patients will experience an ocular complication at some point of their illness.
We encountered anterior segment and adnexal manifestations in 7% of the patients. However, reports indicate that > 50% of the HIV infected patients have anterior segment and adnexal manifestations [10
The most common anterior segment manifestation was recurrent lid infections. Severe blepharitis, styes and lid ulceration may be the initial involvement in AIDS [11
]. We observed that the lid infections tend to be more severe, bilateral and recurrent in these patients. Lid hygiene had to be maintained and antibiotics had to be continued for a longer duration in these cases than in normals. Three patients had Molluscum contagiosum of the lids and among these, 1 case had extensive bilateral lesions. A study which was done by Bardenstein DS et al., indicated the occurrence of these lesions in up to 5% of HIV infected cases [12
]. Five cases in our series had HZO. Among these, 2 patients presented with severe keratitis with iritis. The incidence of HZO in the HIV population is reported to be 5-15% [13
]. In young individuals, it may be the initial manifestation of HIV. Any patient who is less than 50 years of age, with HZO, is a suspect of HIV or any immunosuppression condition [14
]. The findings which were suggestive of healed uveitis in the form of posterior synechie, old KP’s and iris patches were seen in 5 patients, while 3 patients presented with active iridocyclitis. Studies have revealed that the incidence of anterior uveitis was less common than that of posterior uveitis and the causes included herpetic uveitis , drug induced and immune recovery uveitis. We encountered 2 patients who presented with rapidly growing conjunctival masses. An excision biopsy revealed the presence of conjunctival squamous cell carcinoma. Conjunctival squamous cell dysplasia and neoplasia have been associated with HIV infection and AIDS in the sub-Saharan African population. OSSN can be the initial manifestation of an asymptomatic HIV disease [15
]. We did not encounter any case of Kaposi’s sarcoma in our study. A study which was done by Biswas et al, who followed 100 HIV +ve individuals in India, did not observe a single case of Kaposi’s sarcoma. This could be due to the lower prevalence of homosexual behaviour and the low incidence of the human Herpes virus 8, which are known to be associated with Kaposi’s sarcoma [5
]. Pseudomembranous conjunctivitis and keratitis which were seen in 2 patients, were secondary to Steven Johnson’s syndrome. SJS is known to occur in the patients who are on treatment with Nevirapine, which is a part of HAART [16
]. Though SJS occurs as a side effect of a variety of drugs, the presence of HIV infection dramatically increases the risk.
Posterior segment manifestation was seen in 9.94% of our patients. This was in contrast to other reports which suggested the incidence of posterior segment lesions in more than 50% of the AIDS patients [17
HIV related microangiopathy was found to be the most common ocular lesion in AIDS before the introduction of HAART. Cotton wool spots occur in 25-50% of the patients with advanced HIV disease and they are the earliest and the most consistent finding in HIV retinopathy [18
]. In our study, HIV micro angiopathy was seen in only 5% of the individuals. Most of the cases presented with a single cotton wool spot. Two patients who were in the late stages of the HIV infection, with co-existent anaemia, presented with Roth spots. Similar lesions have been described in other studies and this could be due to the haemorrhagic abnormalities in these patients. Our study could be compared to Pathai S et al., ‘s study, that had analyzed the prevalence of HIV associated ophthalmic disease in patients who had enrolled for ART and the incidence of HIV microangiopathy was found to be 4.7% [9
]. The relative low incidence in our series could be due to the vast number of patients, which had included patients with high CD4+ counts, who were not yet on ART. One patient had superotemporal BRVO. BRAO and BRVO have been seen in patients with HIV [19
]. 2.53% of the patients presented with various stages of CMV retinitis. The disease was bilateral in 4 patients. Nine patients had active retinitis, while 5 patients had retinal detachment. CMV retinitis was the most common retinal infection in the patients with HIV, affecting 15 to 40% of the patients in the pre-HAART era [7
]. This disease classically occurs when the CD4+ count is < 100 cells per micro litre. Doan et al., in his study ,described CMV retinitis in 1.2% of the cases and this decrease in prevalence was found to have occurred due to the advent of HAART [21
Active toxoplasmosis was seen in 2 patients, while 2 cases had healed choroiditis. Studies have indicated that 1-2% of the HIV infected patients could present with toxoplasmic retinichoroiditis. Non specific, stippled fundi were seen in 7 patients. Surprisingly, these patients did not have any significant visual abnormalities.
Neuro-ophthalmic manifestations like diplopia, Papilledema, visual field defects, optic neuritis and optic atrophy are known to occur in 15% of the HIV patients [22
]. In our series, 5.78% of the patients had neuro-ophthalmic manifestations like optic neuritis, papilledema, disc pallor, lateral rectus palsy, ptosis and non specific pupillary abnormalities, without having any underlying ocular pathology. Papillo-oedema was seen in patients with meningitis in the late phase of HIV infection. We also came across 7 patients who had hyperaemic discs without any symptoms or signs which were suggestive of optic neuritis or papilledema.
Surprisingly, in our study, we observed the presence of lid retraction in 8.5% of the patients. A similar condition was described by Wang G [23
]. Weight loss and muscle wasting are frequent occurrences in HIV patients and they are independent markers of mortality. The causes could be multifactorial. However, poor nutrition and an altered metabolism have been implicated.Lid retraction in HIV patients could be secondary to orbicularis oculi weakness and wasting, leading to poor eyelid closure and ocular surface disorders.
All the patients in our study underwent colour vision assessment and 6.3% were found to have colour vision abnormalities without any significant retinal changes. A study which was done by Shah KH et al., revealed the presence of an abnormal contrast sensitivity and colour vision abnormalities in 7% and 9.9% of HIV patients, which were found to occur independently without the presence of any vision threatening retinal lesions or media opacities [24
]. These could be attributed to the thinning of the RNFL, which was secondary to damage of the small calibre axons in HIV infected patients [25
However, there were a few limitations in our study. The follow up findings were not included, as most of the patients were inconsistent or lost for follow up. Other factors like the duration of the HIV infection, any underlying systemic disease and the treatment schedule were not included. The correlation of the CD4+ counts with the ocular manifestations could not be assessed, as the time of the CD4+ count estimation did not coincide with the time of the ocular examination. Since the CD4+ count analysis was not done at the time of the ocular examination, the correlation between these two factors would be inappropriate.