AIDS AND THE EYE

The AIDS and the Eye fact sheet was developed to assist in the co-management of patients with human immunodeficiency virus (HIV) and AIDS.  Health care for individuals with HIV requires a well coordinated, multidisciplinary team approach toward effective treatment and management.  Optometrists, as primary health care providers, have a unique opportunity to reduce the ocular complications of AIDS through early detection, management and appropriate referral.

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As of December 31, 1993 the World Health Organization estimates that there are more than 2.5 million cumulative AIDS cases worldwide, and 361,164 people in the U.S. had reportedly been diagnosed with AIDS.  It is estimated that around one million Americans are infected with HIV or one in every 250 Americans.

How is the eye affected?
Retinal infections due to cytomegalovirus (CMV) is the most common sight-threatening problem in advanced HIV disease ¹.  Other ocular manifestations of HIV disease include: cotton wool spots (CWS), intraretinal hemorrhages, herpes zoster, keratitis sicca, corneal ulcers, Kaposi's sarcoma and lymphoma of the conjunctiva, globe and/or lids, and neuro-ophthalmic lesions.

When the immune system is impaired as in HIV infection, cotton wool spots (CWS) can develop in the retina.  Cotton wool spots are the most frequent ocular manifestation in patients with AIDS ².  CWS may appear with or without intraretinal hemorrhages and other microvascular abnormalities.  CWS are rarely seen in the asymptomatic HIV positive patient with a CD4 count >200 ³.  In the majority of cases of HIV-associated retinal disease the patient is unaware of symptoms until the posterior pole, macula or optic nerve become involved in the infectious process and vision loss occurs.

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What is included in the clinical work-up?
Methods for ocular evaluation for the diagnosis of ocular disease include: case history, best corrected visual acuity, slit lamp, direct and indirect opthalmoscopy through dilated pupil, visual fields, and serial fundus photography.  Cotton wool spots must be differentiated from CMV retinitis, and scrial observations of a suspect lesion can help in the diagnosis.  CWS resolve with time while CMV retinitis lesions grow.

Currently the tests used to detect HIV are enzyme linked immunoassay (ELISA) and the Western blot.  Relevant laboratory work-ups are geared to ruling out other causes of posterior uveitis which may mimic CMV-retinitis, such as: syphilis, sarcoidosis, toxoplasmosis (toxo) and tuberculosis.  Lab testing routinely performed to help in the differential diagnosis of posterior uveitis include: RPR, FTA-ABS, ANA, toxo IFA, PPD with anergy panels, chest X-ray, and CMV blood and urine cultures.

What is the treatment for ocular complications?
Currently the two FDA licensed medications for the treatment of CMV retinitis are ganciclovir and foscarnet ¹.  Both of these virostatic medications are administered intravenously and are associated with significant systemic side effects which limit their use in large number of patients.  Discontinuance of therapy allows for advancement of the retinitis which increases vision loss.  For most patients IV therapy is the rule, but local and oral therapies are being evaluated for those patients unable or unwilling to undergo daily infusions of anti-CMV medications.  Serial intraocular injections of ganciclovir have been successfully used to avoid the toxicities associated with intravenous ganciclovir administration.  A sustained-release intraocular device, the Ganciclovir Implant, has also been studied.  The implant has the benefit of providing effective local therapy without the risk of systemic complications.  Unfortunately, with localized therapy CMV disease may manifest at extra-ocular sites.

Tear substitutes and/or punctal occlusion may be indicated to relieve symptoms of dry eye and maintain an intact epithelium.  Contact lenses may be contraindicated in some HIV patients with dry eyes due to increased risk of various surface infections ⁴.

What is the management of AIDS and HIV?
The management of AIDS and HIV changes as more is known about the natural course of the disease, the immune system's response to HIV infection, and when medical intervention is most appropriate.   Patients generally live longer and healthier lives after early diagnosis of HIV infection with prophylactic treatment for opportunistic infections.  Patients should receive a baseline eye examination upon diagnosis of HIV seropositivity and followed as indicated.  It is recommended that when CD4 counts are >500: patients be seen annually by an optometrist; 400-200: every 6 months; >200: every 3 months; new symptoms: examine patient as soon as possible and follow as indicated.  A referral to an infectious disease (ID) specialist is in order when an opportunistic infection is suspected.  Co-management with and ID specialist then occurs over the course of the infection, with communication as tot he status of the lesion(s) so that the dosage of medication(s) may be adjusted.

Educating the patient as to the subtle signs and symptoms of HIV-related eye disease, i.e., decreased vision, floaters, flashes, and field changes allows for the earlier detection of eye disease.  Earlier detection allows for treatment of inchoate disease which may contribute to lessened morbidity from vision loss.

References:

1. Jabs DA, Davis CD. Mowyer R.  Mortality in patients with the acquired immunodeficiency syndrome treated with either foscarnet or ganciclovir for cytomegalovirus retinitis.  N Eng J Med 1992: 326:324-330.

2. Wilson R  Cotton Wool Spots in AIDS: A review  J Am Optom Assoc 194; 65:110-116.

3. El-Sadr W, Oleske JM, Agins BD et al  Evaluation and management of Early HIV Infection,  Clinical Practice Guideline No 7.  AHCPR Pub. No. 94-0572. Rockville, MD: Agency for Health Care Policy & Research, Public Health Service, U.S. Department of Health and Human Services, January 1994, p.59

4. Wilson R  HIV and Contact Lens Wear. J Am Optom Assoc 1992; 63:13-15

Additional Information:
CDC National AIDS Hotline (800) 342-AIDS
CDC National AIDS Clearinghouse (800) 458-5231
HIV Consultation Service (800) 933-3413

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