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
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
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.
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
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
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.
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.
Wilson R Cotton Wool Spots
in AIDS: A review J Am Optom Assoc 194; 65:110-116.
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
Wilson R HIV and Contact
Lens Wear. J Am Optom Assoc 1992; 63:13-15
CDC National AIDS Hotline (800) 342-AIDS
CDC National AIDS Clearinghouse (800) 458-5231
HIV Consultation Service (800) 933-3413
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