Ocular Manifestations of HIV

What is Ocular Manifestations of HIV?

The Human Immunodeficiency Virus (HIV), which is a type of virus called a retrovirus, causes a disease that affects many body systems known as Acquired Immune Deficiency Syndrome (AIDS). The first case of HIV was reported in Los Angeles in 1981. People living with HIV often experience eye-related problems, a fact first noted by Maclean over two decades ago. These eye problems could be due to opportunistic infections (infections that occur more often in people with weakened immune systems), irregularities in the blood vessels, tumors, conditions affecting the nerves of the eye, and unwanted side effects from medications.

What Causes Ocular Manifestations of HIV?

HIV is a type of virus that targets specific immune cells called CD4 T lymphocytes which are crucial for our immune response. This virus can be passed on to others through contact with infected blood or other body fluids.

If a person with HIV doesn’t receive treatment, their condition could progress through three stages. First, they may have a primary infection, which is when the virus first enters the body. After this, they may experience a period of ‘clinical latency’ – a time when the person may not have any symptoms, but the virus is still active in their body. Finally, they may develop severe illnesses, known as opportunistic infections, which can occur due to a weakened immune system. This stage is commonly referred to as AIDS.

The Centers for Disease Control and Prevention (CDC) considers a person to have AIDS if they have a disease associated with severe AIDS or if they have a CD4 T-cell count less than 200 microliters. CD4 T-cell count is a measure of how well your immune system is working.

Certain medical conditions that are not normal, such as ocular toxoplasmosis – an infection that affects the eyes – or a suspicion of cytomegalovirus (CMV) retinitis – a viral infection that can cause blindness, might make doctors consider performing an HIV test. These conditions might not respond to regular treatments, which could indicate an underlying problem like HIV.

Risk Factors and Frequency for Ocular Manifestations of HIV

The World Health Organization (WHO) reveals that HIV has affected more than 50 million people globally since the early 1980s, with a global rate of approximately 0.8%. Between 15,000 and 20,000 new infections are estimated to happen daily. A large number of these cases, over a million, are children. About three-quarters of people with HIV are likely to develop eye-related diseases. Most people suffering from HIV hail from developing countries where up to 25% might lose their sight.

The diseases that commonly affect people with HIV are those related to the retina and choroid, and these may cause vision loss.
Retinal micro vasculopathy and CMV retinitis are witnessed in nearly 30% to 40% of patients with HIV.
Though CMV retinitis is less frequent in developing countries compared to developed ones, those infected with HIV in these countries are more susceptible to infections by Toxoplasma, tuberculosis, Herpes zoster ophthalmic, and papillomavirus-related squamous cell tumors.
This discrepancy is due to higher exposure to these infection-causing agents and higher death rates at an early stage of the disease in developing countries.

Signs and Symptoms of Ocular Manifestations of HIV

HIV infection can affect different parts of the eye. For those affected, conditions may include herpes zoster ophthalmicus (HZO), Kaposi sarcoma, molluscum contagiosum, and conjunctival microvasculopathy.

HZO is a skin condition that affects the part of the face involved in the sensation of the eye. It’s caused by the Varicella zoster virus and may coincide with eye inflammations. It’s seen in 5% to 15% of HIV patients.
Kaposi sarcoma is a tumor that may present as painless, discolored lesions on the eyelid skin or conjunctiva.
Molluscum contagiosum is a skin condition characterized by multiple, small, painless lesions on the eyelid skin.
Conjunctival microvasculopathy is characterized by changes in blood vessels. It’s thought to be caused by immune complex deposition, increased plasma viscosity or invasion of vascular endothelium by HIV, and is found in 70% to 80% of HIV patients. It’s associated with retinal microangiopathy.

The front part of the eye can also be affected by HIV, which includes dry eyes, keratitis, and iridocyclitis.

Dry eyes are seen in approximately 20% of HIV patients and are thought to be caused by an HIV-mediated inflammation of tear glands.
Keratitis in HIV is rare but can lead to vision loss. Herpes simplex virus and varicella-zoster virus are the most common causes.
Iridocyclitis is a fairly common inflammation of the iris and ciliary body in HIV. It may occur due to various infections or the use of certain medications.

The back part of the eye is commonly affected in HIV and can lead to vision loss. Conditions affecting this part include retinal microangiopathy, CMV retinitis, VZV retinitis, toxoplasma retinchoroiditis, and bacterial and fungal retinitis.

People with HIV may also experience neurological and orbital manifestations like papilledema, cranial nerve palsies, ocular motility disorders, and visual field defects. Conditions affecting the orbit (the cavity containing the eye), are rare but can include orbital lymphoma and orbital cellulitis.

Medications used to treat HIV or opportunistic infections can also cause eye problems. Patients with CMV retinitis on HAART (a type of HIV treatment) may suffer from a condition called immune recovery uveitis which can decrease vision and is characterized by cataract, inflammation inside the eye, macular edema, swollen optic disc, and an epiretinal membrane covering the retina.

Children with HIV infection have different eye manifestations compared to adults. They have a lower incidence of CMV retinitis but a higher incidence of dry eyes and eye infection due to a parasite called Toxoplasma. They are also at risk of developmental delays.

Testing for Ocular Manifestations of HIV

If you have HIV, any changes to your eyes or vision should be assessed by a healthcare professional because the virus can affect the eye in a number of ways. This would involve a detailed discussion about your symptoms (a medical history), as well as a thorough eye check. Particular attention would be paid to your CD4 T-cell count, which is a type of immune cell that can indicate how the HIV is affecting your body. More recently, doctors can also look at the amount of virus in your blood (viral load) to see if there might be changes in your eyes related to HIV.

An eye exam might include several steps such as checking your vision, mapping your field of vision, examining your eye movements and pupil reaction, as well as looking at the back of your eye (fundus examination). These steps are important to catch any infections or conditions tied to HIV.

If you have symptoms of dry eye, or keratoconjunctivitis sicca, certain tests can be done to confirm, such as the Schirmer test which measures tear production, and Rose Bengal staining which highlights dry spots on the eye. If there’s inflammation of the cornea (keratitis) and it’s not clear why, your doctor might take a sample to identify the cause. The back section of the eye can also be examined using special devices for signs of infection. If necessary, lab tests for syphilis and tuberculosis might also be done as these infections are common in people with HIV.

If there’s reason to believe that the tissues around the eye are affected, then further tests might be required. These could involve a CT scan or MRI, taking a small sample of tissue (biopsy), or even growing out any organisms from a sample (culture). For patients with symptoms suggesting a brain or nerve-related condition caused by HIV, more advanced tests might be necessary. This could involve an MRI of the brain and a lumbar puncture, which is a procedure to collect fluid around your brain and spine for testing.

This extensive investigation approach helps ensure that any HIV-related eye problems can be identified and managed appropriately as early as possible.

Treatment Options for Ocular Manifestations of HIV

If you have an eye condition, how it’s treated will depend on the exact problem. For example, Herpes zoster ophthalmicus, an infection that might affect your eyes, is typically treated with oral medications like acyclovir, famciclovir, valacyclovir, and, in some resistant cases, a stronger medication given through an IV (a small tube in your vein) called foscarnet.

Kaposi sarcoma, a type of cancer that can affect your eyes, is often managed with radiation therapy and a treatment called HAART. Molluscum contagiosum, a viral skin infection that can spread to your eyes, can be treated with cryotherapy (a freezing technique), curettage (a type of surgery), and surgical removal.

If you have an issue called Keratoconjunctivitis sicca, symptoms can be relieved with artificial tears and long-acting eye lubricants. If you have an inflammation or infection of the eye called keratitis, treatment depends on what caused the issue. Viral causes are treated with antiviral medications, while bacterial and fungal causes are treated with appropriate antibiotics or antifungal medications.

Iridocyclitis, or inflammation of the iris, is usually treated with steroid eye drops, but only after starting appropriate treatment for the infection if one is suspected. If you have CMV retinitis, which is a retina infection, you may be treated with medications such as valganciclovir, ganciclovir, foscarnet, and cidofovir. Toxoplasma retinochoroiditis, another eye condition that can damage your eyes, is usually treated with a combination of pyrimethamine and sulfonamides.

A key thing to remember is that steroids are not recommended for this treatment. So, depending on the eye condition you have, a targeted treatment option will be recommended by your doctor to ensure the best outcome.

Here are some eye conditions that may need to be considered:

Bacterial retinitis
CMV retinitis
Fungal retinitis
Microangiopathy
Toxoplasma retinchoroiditis
VZV retinitis

Frequently asked questions

The prognosis for ocular manifestations of HIV is that about three-quarters of people with HIV are likely to develop eye-related diseases. Retinal micro vasculopathy and CMV retinitis are witnessed in nearly 30% to 40% of patients with HIV. In developing countries, those infected with HIV are more susceptible to infections by Toxoplasma, tuberculosis, Herpes zoster ophthalmic, and papillomavirus-related squamous cell tumors.

Ocular manifestations of HIV can occur due to various infections, such as herpes zoster ophthalmicus (HZO), Kaposi sarcoma, molluscum contagiosum, and conjunctival microvasculopathy. Other conditions affecting the eye in HIV include dry eyes, keratitis, iridocyclitis, retinal microangiopathy, CMV retinitis, VZV retinitis, toxoplasma retinchoroiditis, and bacterial and fungal retinitis.

Signs and symptoms of ocular manifestations of HIV include: - Herpes zoster ophthalmicus (HZO): a skin condition affecting the face and causing eye inflammations, seen in 5% to 15% of HIV patients. - Kaposi sarcoma: a tumor presenting as painless, discolored lesions on the eyelid skin or conjunctiva. - Molluscum contagiosum: a skin condition characterized by multiple, small, painless lesions on the eyelid skin. - Conjunctival microvasculopathy: characterized by changes in blood vessels, found in 70% to 80% of HIV patients and associated with retinal microangiopathy. - Dry eyes: seen in approximately 20% of HIV patients, caused by HIV-mediated inflammation of tear glands. - Keratitis: rare but can lead to vision loss, commonly caused by herpes simplex virus and varicella-zoster virus. - Iridocyclitis: a fairly common inflammation of the iris and ciliary body in HIV, can occur due to infections or certain medications. - Retinal microangiopathy: affects the back part of the eye and can lead to vision loss. - CMV retinitis: a condition affecting the back part of the eye, commonly seen in HIV patients and can cause vision loss. - VZV retinitis: a condition affecting the back part of the eye caused by varicella-zoster virus. - Toxoplasma retinchoroiditis: a condition affecting the back part of the eye caused by the parasite Toxoplasma. - Bacterial and fungal retinitis: conditions affecting the back part of the eye caused by bacterial or fungal infections. - Neurological and orbital manifestations: including papilledema, cranial nerve palsies, ocular motility disorders, and visual field defects. - Medication-related eye problems: medications used to treat HIV or opportunistic infections can cause eye problems, such as immune recovery uveitis in patients with CMV retinitis on HAART treatment. - Children with HIV infection may have different eye manifestations, including a lower incidence of CMV retinitis but a higher incidence of dry eyes, eye infections due to Toxoplasma, and a risk of developmental delays.

The types of tests that may be needed for ocular manifestations of HIV include: - Detailed discussion about symptoms and medical history - Thorough eye check, including vision, field of vision, eye movements, pupil reaction, and fundus examination - CD4 T-cell count to assess how HIV is affecting the body - Viral load test to see if there are changes in the eyes related to HIV - Schirmer test to measure tear production for dry eye - Rose Bengal staining to highlight dry spots on the eye - Sample collection to identify the cause of corneal inflammation - Examination of the back section of the eye for signs of infection - Lab tests for syphilis and tuberculosis, if necessary - Further tests such as CT scan, MRI, biopsy, or culture if tissues around the eye are affected - Advanced tests like MRI of the brain and lumbar puncture for brain or nerve-related conditions caused by HIV.

The doctor needs to rule out the following conditions when diagnosing Ocular Manifestations of HIV: - Opportunistic infections - Irregularities in the blood vessels - Tumors - Conditions affecting the nerves of the eye - Unwanted side effects from medications - Dry eye or keratoconjunctivitis sicca - Inflammation of the cornea (keratitis) - Infections such as syphilis and tuberculosis - Tissues around the eye being affected - Brain or nerve-related conditions caused by HIV

An ophthalmologist.

About three-quarters of people with HIV are likely to develop eye-related diseases.

Ocular manifestations of HIV, such as Kaposi sarcoma and CMV retinitis, are often managed with radiation therapy, a treatment called HAART, and medications such as valganciclovir, ganciclovir, foscarnet, and cidofovir. Steroid eye drops are usually used to treat inflammation of the iris (iridocyclitis), but only after starting appropriate treatment for the infection if one is suspected. It is important to note that steroids are not recommended for the treatment of ocular manifestations of HIV. The specific treatment option will depend on the exact eye condition and will be recommended by a doctor for the best outcome.

Ocular manifestations of HIV are eye-related problems that can occur in people living with HIV. These problems can be caused by opportunistic infections, irregularities in blood vessels, tumors, conditions affecting the nerves of the eye, and side effects from medications.