Sophia L Zagora1, Angie N Pinto2,3, Peter J McCluskey 1.
1 Save Sight Institute, University of Sydney, Australia
2 Royal Prince Alfred Hospital, Sydney, Australia
3 Kirby Institute, UNSW, Sydney, Australia
Last reviewed: August 2019
Introduction
HIV infection and particularly HIV-induced immunodeficiency and its treatment may be complicated by a large number of ocular complications, especially opportunistic infections and cancers (Table 1). While ocular disease is encountered infrequently in HIV patients receiving antiretroviral therapy (ART), it is still an important consideration in HIV-infected patients who are not receiving ART or remain immunodeficient on ART. The occurrence and type of ocular disease can be predicted to a large degree by the CD4+ T cell count (Table 2). A fundal examination should be a routine part of the examination of HIV patients presenting with severe immunodeficiency. The management of eye disease should always be coordinated between an Ophthalmologist with experience in the ocular complications of HIV infection and a physician experienced in managing HIV-infected patients.
Table 1. Ophthalmic complications of HIV infection1
| Red flags | Infective | Neoplastic | Other | Investigations | |
| Adnexae2 | Blisters; Pain; Decrease in vision | Herpes zoster ophthalmicus
Molluscum contagiousum Preseptal cellulitis |
Kaposi’s sarcoma
Squamous cell carcinoma |
Conjunctival microvasculopathy | Viral swab: HSV PCR
Bacterial swab: MCS |
| Orbit | Pain; Redness; Swelling | Orbital cellulitis | Non-Hodgkin’s lymphoma | Bacterial swab: MCS | |
| Anterior segment | Pain; Decrease in vision | Viral keratitis (VZV, HSV)
Bacterial keratitis (S. aureus; S. epidermis, P. aeruginosa) Protozoan keratitis (microsporidia) Syphilis |
Conjunctival microvasculopathy
Allergic eye disease Vortex keratopathy Dry eye Disease Meibomian gland dysfunction Uveitis (HLA B27- related) |
Viral swab: HSV, VZV PCR Bacterial swab: MCSSmear: wet prep for free living amoebaTissue or fluid3: Amoeba PCR, Serum T. pallidum antibodies |
|
| Posterior segment | Decrease in vision; Floaters | CMV retinitis
VZV retinitis (PORN/ARN) HSV retinitis Toxoplasma retinitis Syphilis uveitis Pneumocystis choroiditis Cryptococcal choroiditis TB-related uveitis |
Ocular CNS Non-Hodgkin’s lymphoma | Retinal microvasculopathy
Ischaemic maculopathy Immune recovery uveitis Drug induced uveitis (Rifabutin) |
Detection of DNA in blood, vitreous fluid or tissue by PCR: CMV, VZV, HSV, Pneumocystis, Toxoplasma, M. tuberculosis
Serology: Toxoplasma, T. pallidum, CMV antibodies; Cryptococcal antigen |
| Neuro-ophthalmic | Decrease in vision; Pain | Cerebral toxoplasmosis
Cryptococcal meningitis Neuro-syphilis PML VZV encephalitis/radiculitis TB related neurological disorders |
Ocular CNS Non-Hodgkin’s lymphoma | Optic neuritis
Optic atrophy Ocular motility disorders |
Brain imaging: CT, MRI
CSF examination: – Opening pressure, protein, glucose, culture (bacterial, fungal, mycobacterial) – DNA by PCR: HSV, VZV, CMV, JC virus, Mtb, T. pallidum, Toxoplasma – Serology: T. pallidum, CrAg |
1) {ref}Denniston AKO, PL M. OXford Handbook of Ophthalmology. 3rd edition ed. United Kingdom: Oxford University Press; 2014{/ref}
2) Eyebrow, eyelids and lacrimal apparatus
3) Investigations include an anterior chamber tap (in young patients) and /or vitreous tap with PCR to identify underlying pathogen.
Abbreviations: MCS – microscopy, culture, sensitivity; PCR – polymerase chain reaction; PORN – progressive outer retinal necrosis; ARN – acute retinal necrosis; PML – Progressive multifocal leukoencephalopathy; HSV – herpes simplex virus; VZV – varicella zoster virus; CMV – cytomegalovirus
Table 2. Typical occurrence of ocular disease at different CD4+ T cell counts
| CD4+ T cell count (cells/mm3) | Ocular disease |
| 250-500 | Herpes Zoster Ophthlamicus
TB |
| 120-250 | Lymphoma
Kaposi’s sarcoma |
| 50-150 | Pneumocystis
Toxoplasmosis Microsporidiosis Varicella Zoster Virus retinitis |
| <50 | Cytomegalovirus retinitis |
- {ref}Denniston AKO, PL M. OXford Handbook of Ophthalmology. 3rd edition ed. United Kingdom: Oxford University Press; 2014{/ref}