Human immunodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS) is one of the most feared infectious diseases of the late 20 th century. It has made a profound impact on contemporary medical practice, public health priorities and every aspect of modern society. All medical practitioners must be aware of the basics of HIV/AIDS transmission, pathogenesis, clinical manifestations and the principles of management.
HIV/AIDS is undoubtedly a multisystem disorder but ophthalmic disease does affect 70-80% of patients with HIV infection sometime during the natural history of their infection. Various studies have demonstrated that 40-45% of HIV-infected patients do have some or other ophthalmic manifestations when examined by an ophthalmologist. HIV can affect the eye primarily or more often secondarily due to various opportunistic infections.
Due to the potentially devastating and rapid course of retinal opportunistic infections, all persons with HIV disease should undergo routine baseline ophthalmic evaluation. Any HIV-infected person who experiences ocular symptoms also should receive prompt and competent ophthalmic care as delay in therapy can lead to irreversible visual loss.
REVIEW OF LITERATURE HIV retinopathy and opportunistic ocular infections are common in AIDS patients, heterosexuality being the most common mode of transmission. Since no effective management is readily available, prevention through proper counseling appears to be the only defense against AIDS . HIV retinopathy was present in 34%, CMV retinitis in 39%, Herpes Simplex-related Acute Retinal Necrosis (ARN) and retinitis in 11%, tubercular choroiditis in 11%, while Herpes Zoster retinitis and presumed P. carinii choroidopathy each were observed in 2.5% of the eyes.1
The spectrum of HIV-associated ophthalmic disease is very broad and ranges from adnexal disorders to posterior segment diseases including the optic nerve and the optic tract.2
In Malawian patients with Tuberculosis presenting acutelywith fever, choroidal granulomas were found in 2.8%, and wereconcurrent with mycobacteraemia and AIDS. Ophthalmoscopy wasnot a useful aid in the diagnosis of mycobacteraemia. Another observation in the same study has been that Cytomegalovirus(CMV) retinitis is rarely seen in African AIDS patients. Thismay be the result of mortality early in the disease course,or probably differences in race, HIV subtype, or comorbidity.3
CMV Retinitis (20%) is still the most common manifestation of HIV infection in this series, even in the era of HAART, and is more common than HIV vasculopathy. Immune recovery uveitis is appears to be more common with the introduction of HAART in absence of affordable anti CMV therapy in India. 7% of patients present with ophthalmological features as the initial manifestation of HIV. As before, nearly (70%) of the ophthalmic manifestations of HIV infection are present when CD4 count is less than 200 cells/micro liter.4
Ocular manifestations are common in patients with AIDS. CMV retinitis represented a major vision-threatening problem in these patients. While available therapy was successful in initially controlling the retinitis, the phenomenon of relapse resulted in some degree of long-term visual loss. Preservation of the patient's visual acuity in at least one eye was generally successful. Other opportunistic ocular infections were substantially less common than CMV retinitis but require aggressive therapy.5
For the treatment of cytomegalovirus retinitis, the sustained-release ganciclovir implant is more effective than intravenous ganciclovir, but patients treated with ganciclovir implant alone remain at greater risk for the development of cytomegalovirus disease outside of the treated eye.6
The most common ocular neoplasm in individuals infected by the human immunodeficiency virus (HIV) is Kaposi's sarcoma. Other tumors in such patients include lymphoma and squamous cell carcinomas. Ocular manifestation of Kaposi's sarcoma and lymphoma may be the first sign of systemic dissemination of the neoplasm. Kaposi's sarcoma and squamous cell carcinoma develop in the conjunctiva and ocular adnexa. Lymphomas develop at these sites, in the orbit, and intraocularly.7
Cytomegalovirus retinitis is the most common ocular opportunistic infection in patients with AIDS. Since the advent of HAART its incidence has declined and rate of progression reduced, even in patients with low CD4+ T-cell counts. It also appears that the rates of second eye involvement and retinal detachment are less than in the pre-HAART era.8
In patients with AIDS, there does not appear to be at an increase in bacterial corneal but when they do develop, bacterial keratitis takes a more fulminant course than would be expected. Because these aggressive infections are often caused by Pseudomonas and contact lenses predisposed to infection with these organism, hence it is recommended that contact lenses be used very carefully, if at all, in patients with AIDS.9
Progressive necrotic retinal infection that occurs in the setting of AIDS is that of the ``progressive outer retinal necrosis (PORN)'' syndrome. This is an edematous whitening of the peripheral retina seen in herpes zoster infection and has an abrupt, rapid, and devastating onset. Within only 1 to 2 weeks these patients may progress to total retinal detachment or necrosis. Devastating recurrence appears to be the most prominent aspect of this infection.10
OBJECTIVE OF THE STUDY
Incidence of Ocular manifestations of HIV patients attending K. R. Hospital.
Visual status at the time of diagnosis, improvement or otherwise following therapy.
Assessing the response to HAART therapy.
Ocular side-effects of drug therapy.
7 MATERIALS AND METHODS
7.1 SOURCE OF DATA
HIV patients attending ART centre, and also inpatients and outpatients of various departments of K. R. Hospital, Mysore.
7.2 METHODS OF COLLECTION OF DATA
Sample size: A minimum of 400 patients is proposed for the present study.
Sampling method: Simple random sampling
INCLUSION CRITERIA: HIV patients attending K.R Hospital, Mysore .
Ocular manifestations due to HIV virus itself.
Ocular manifestations developing due to opportunistic infection in HIV patients
Ocular manifestations developing due to drugs used in HAART regimen and due to drugs used for treatment of opportunistic infections.
Patients with HIV with pre-existing ocular disease.
Patients with HIV developing ocular disease unrelated to the disease under study
Eg: traumatic corneal ulcer
Data will be collected using a piloted proforma meeting the objectives of the study, by means of personal interview with the patients, after informed consent.
Statistical method used: CHI- SQUARE TEST (ᵪ2)
7.3 INVESTIGATIONS: In all study subjects:
Rapid Enzyme Immunoassay(Serocard and Tridot Screening Test)
Fundus Examination by DO, IDO and Slit lamp biomicroscopy.
And relevant investigations when required.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION
YES ( Copy enclosed)
8.LIST OF REFERENCES
Sahu DK, Namperumalsamy P, Walimbe P, Rajalakshmi C. Ocular manifestations of HIV infection/AIDS in South Indian patients. Indian J Ophthalmol 1999;47:79-85
Soman R, Purandare B. Human immunodeficiency virus and the ophthalmologist. Indian J Ophthalmol 2008;56:355-6
Beare NAV et al., Ocular disease in patients with tuberculosis and HIV presenting with fever in Africa.Br J Ophthalmol 2002;86:1076-1079
Gharai S et al., 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
Jabs DA. Ocular manifestations of HIV infection. Trans Am Ophthalmol Soc. 1995;93:623-83.
Musch DC et al., Treatment of cytomegalovirus retinitis with a sustained-release ganciclovir implant. The New England Journal Of Medicine. 1997 Jul; Vol 337:83-90
Dugel PU, Thach AB: Ocular Neoplasms Related to Human Immunodeficiency Virus. In Ophthalmology. Ch 183, 2nd edition; Yanoff M, Duker JS, Augsburger JJ: Mosby 2003; 1229
Kanski JJ: Uveitis. In Clinical Ophthalmology: A systematic approach, Ch 14, 6th edition, Philadelphia: Butterworth Heinemann Elsevier 2007; 477
Ogawa GSH, Hyndiuk RA. Bacterial keratitis and Conjunctivitis: In Smolin and Thoft The Cornea. 3rd edition. Pg 126.