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By,

Rishil Patel

8/3/2019 rishil


BackgroundThe immunosuppression caused by HIV infection increasesthe incidence of eye infections. However, the risk of seriouseye problems associated with advancedimmunosuppression, such as blindness caused by cytomegalovirus (CMV) retinitis, is much lower in patientstreated with effective antiretroviral therapy (AR T).Common problems not unique to HIV-infected patientsinclude dry eye, blepharitis, keratitis, and presbyopia.Infections that may affect the eye include herpes simplex

virus (HSV), herpes zoster virus (HZV), and syphilis. Moreseverely immunocompromised patients (CD4 count <100cells/µL) may experience CMV retinitis, Toxoplasma retinochoroiditis, cryptococcalchorioretinitis, and other conditions. Retinal detachmentcan result. Kaposi sarcoma (KS) also can affect the eye.

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Immune reconstitution inflammatory syndrome (IRIS) may

affect the eye in patients with advanced HIV disease soonafter the initiation of effective AR T. IRIS may lead toexacerbation of a previously treated opportunistic infectionor a new presentation (often with unusual manifestations)of a previously subclinical infection. In the case of CMV,

IRIS may present as retinitis, or less commonly as uveitis or vitreitis. IRIS retinitis typically occurs in patients whoseCD4 counts have increased from <50 cells/µL to 50-100cells/µL while receiving AR T.

Drug-induced ocular toxicity can be caused by rifabutin,ethambutol, and cidofovir, and less often by high-dosedidanosine (ddI, Videx), IV ganciclovir, IV acyclovir, andatovaquone.

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S: Subjective

The patient complains of dry eyes,blurred vision, floaters, sharppains, flashing lights, central vision

loss ("black holes"), vision fielddefects ("can only see half thepage"), or peripheral vision loss("looks like I'm in a tunnel"). Ascertain the following during the

history:

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Pain: clarify type and characteristics Unilateral or bilateral problem Visual defects (central or peripheral vision loss ordistortion), scotomata (an area of lost or depressed visionsurrounded by an area of less depressed or normal vision); occurs with reading, distance, or both? T

ime course of symptoms Fever Headache Previous eye or vision problems Medications (prescription and over-the-counter) and

herbal supplements, current and past Use of corrective lenses Date of last eye examination Recent or current varicella-zoster virus (VZV) or HSV infection

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O: ObjectiveConsider the patient's age.

Check vital signs, including blood pressure and temperature. Administer a visual acuity examination using the Snellen chart. Testthe patient's ability to read small print, such as classified ads.Consider using an Amsler grid to locate areas of retinal pathology.Examine the eyelids for lesions, inflammation, and swelling.

Examine the external eye for edema, ptosis, conjunctival injection,and corneal clarity.

Test cranial nerves II, III, IV, and VI.

Perform funduscopic examination with pupillary dilatation, if available. Note retinal appearance, lesions, and condition of the disc, vessels, and macula.

Examine the temples and scalp for tenderness.

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A/P: Assessment and Plan

Refer to an HIV-experienced ophthalmologist fordilated retinal or slit-lamp examination anddefinitive diagnosis. If symptoms raise suspicion of

serious or vision-threatening conditions such asherpes ophthalmicus, CMV retinitis, or retinalnecrosis, ophthalmologic evaluation should occur within 24-72 hours. Note that patients with HSV or

VZV lesions in the V1 distribution (including theforehead, eyelids, or nose) should receive urgentophthalmologic evaluation.The differential diagnosis includes the following

conditions

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Dry Eye (Keratoconjunctivitis

Sicca)The patient may complain of intermittent eye pain,intermittent blurred vision that clears withblinking, and mild eye irritation. The condition worsens with extended reading or computer use.Keratoconjunctivitis sicca is related to HIV-mediated inflammation with damage to thelacrimal glands. It occurs in 10-20% of HIV-infected patients, most often in those withadvanced HIV disease. In patients with a CD4count of >400 cells/µL and no other signs orsymptoms, confirm that results of a recent eyeexamination were normal or refer for same,

rescribe artificial tears, and monitor.

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Blepharitis

Blepharitis is inflammation of theeyelids, a common condition with dry eyes. The patient may complain of

discharge and erythema of the eyes oreyelids. Of the bacterialcauses, Staphylococcus aureus is the

most common. Treatment includescleaning of the eyelashes with warm water and mild shampoo, and applying

antibiotic ointment if indicated.

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Infectious KeratitisThe patient may complain of photophobia, eye

pain, decreased vision, and irritation. Infectiouskeratitis may be caused by VZV, HSV, CMV,bacteria, fungi, or Microspor idia. VZV and HSV are the most common infectious causes of

keratitis in HIV-infected patients. Bacterial andfungal keratitis occur equally in HIV-infected andHIV-uninfected persons. Fungal infections arecaused most frequently by Candid a species,especially in intravenous drug users. Keratitis may be more severe and may recur more frequently inHIV-infected patients than in HIV-uninfectedpersons. Evaluation should include slit-lampexamination by an ophthalmologist.

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Ref raction Problems

The patient may complain of blurring vision with near or

distance vision. Other findingsinclude an abnormal Snellen testor inability to read fine print. The

condition may be attributable topresbyopia or other causes. Referfor ophthalmologic examination.

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Iridocyclitis/Anterior Uveitis

The patient may complain of redness or wateringof the eyes, constriction of the pupil, and blurred vision. Anterior-chamber inflammation is fairly common among patients with HIV infection and

is often associated with CMV or HSV retinitis.Ocular bacterial infections, syphilis,toxoplasmosis, and tuberculosis can cause severesymptoms. Fungal retinitis rarely causes

iridocyclitis. Other causes include other systemicconditions (e.g., reactive arthritis, sarcoidosis) anddrug toxicity (e.g., rifabutin, cidofovir,ethambutol). Evaluation should include slit-lamp

examination by an ophthalmologist.

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HIV Retinopathy

The patient typically has no symptoms, butmay complain of blurred vision, visual fielddefects, floaters, or flashing lights. Cotton

wool spots on the retina appear as smallfluffy white lesions with indistinct bordersand without exudates or hemorrhages.

Usually, these findings are benign and donot progress. Refer for ophthalmologicexamination to rule out other causes.

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CMV RetinitisPatients with retinitis caused by CMV infection may be

asymptomatic or may experience blurred vision, floaters,scotomata, or central or peripheral vision loss ordistortion. Retinal examination shows creamy to yellowish lesions, white granular areas with perivascular

exudates, and hemorrhages ("cottage cheese andketchup"). The abnormalities initially appear in theperiphery, but progress if untreated to involve the maculaand optic disc. CMV is a common complication of advanced HIV infection in patients with CD4 counts of

<50 cells/µL. Vision loss usually is permanent. Urgentophthalmology consultation and initiation of anti-CMV therapy are required. See chapter CytomegalovirusDisease .

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Acute Retinal Necrosis

The patient may complain of eyepain, decreased visual acuity, and

floaters. Rapidly progressingperipheral necrosis frequently causes blindness. Retinal necrosis

usually is caused by VZV, althoughHSV and CMV also have beenimplicated. Treatment should be

initiated ur entl .

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Retinal Detachment

The patient may complain

of flashes of light, suddenloss of vision, or both.This condition requiresimmediate referral to anemergency department.

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Patient Education

Patients should report any changes in vision to their health care provider as soonas possible.

Routine eye examinations should be partof the patient's primary care.

Patients with CD4 counts of <50 cells/µLshould be examined by an ophthalmologistat baseline and every 6 months thereafter.

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