1.. Amaha meshesha

2. INTRODUCTION AIDS is an infectious disease caused by the gradual decrease in CD4+ T lymphocytes causing subsequent opportunistic infections and neoplasia. Approximately 36 million persons around the world are infected. 70-75% of patients infected with HIV will develop some form of ocular involvement, ie: direct infection by HIV, opportunistic infections and neoplasia. 3. 50% of HIV pts have opthalmologic complications Its effect can direct,indirect,and drug related. 4. manifestations of HIV CAN BE ---anterior segment or posterior segment Posterior segment manifestations are the most common in the western society while anterior manifestations are more common in the African population, Anterior segment manifestations can be 1. infectious A. ViralHZV, viral keratitis, molluscum contagiosum B. Bacterialbaacterial keratitis,TB, C. Fungal- candidal, cryptococal,pneumocystic keratitis D. Protozoal-microsporidial and toxo keratitis 2. neoplastic- KS,SCC, lymphoma 3.drug induced-neverapin, rifabutin,cidofovir 4. IRIS- immune recovery uveitis 5.othersKCS,trichomegaly 5. POSRERIOR SEGMENT manifestations can be 1.retinal vasculopathyHIV retinopathy 2.opportunistic infections- retinitis(CMV,PORN,toxo,ARN,crypto) choroditis(TB, toxo) 3. malignancies- NHL 4.neuro-ophthalmology perineuritis,papiledema,papilitis,retrobulbar neuritis, optic atrophy 6. INTRODUCTION AIDS is an infectious disease caused by the gradual decrease in CD4+ T lymphocytes causing subsequent opportunistic infections and neoplasia. Approximately 36 million persons around the world are infected. 70-75% of patients infected with HIV will develop some form of ocular involvement, ie: direct infection by HIV, opportunistic infections and neoplasia. 7. Introduction Numerous ophthalmic manifestations of HIV infection may involve the adnexa, anterior segment, posterior segment, or neuro-ophthalmic parts of the eye Anterior segment: -tumors of periocular tissues -external infections Posterior segment HIV-associated retinopathy -opprtunistic infections 8. Introduction Due to the potentially devastating and rapid course of retinal OI, all persons with HIV disease should undergo routine ophthalmologic evaluations. In patients with early-stage HIV disease (CD4 count >300 cells/L), ocular syndromes associated with immunosuppression are uncommon. Nonetheless, eye infections associated with STDs such as HSV, gonorrhea, and chlamydia may be more frequent in HIV-infected persons, SO WATCHOUT! 9. Ocular manifestations correlating with immune status and stage of HIV infection 10. Adnexal manifestations1. MOLLUSCUM CONTAGIOSUSUM a highly contagious dermatitis caused by a poxvirus. Affects up to 20% of symptomatic HIV infected patients. Both the skin and the mucous membranes may be affected, with multiple, small, painless, umbilicated lesions, which produce a waxy discharge when pressured. Involvement of the eyelids occurs in up to 5 percent of HIV-infected patients. 11. mc 12. mc More common and tends to be more severe in HIV-positive persons than in HIV-negative persons, with larger, more numerous, and more rapidly growing lesions. Associated follicular conjunctivitis and superficial keratitis have been reported in immunocompetent patients but are uncommon in HIV-infected persons. Treatment options include cryotherapy, curettage, incision, and excision. 13. Adnexal manifestations2. HERPES ZOSTER OPHTHALMICUS is a vesiculobullous dermatitis caused by varicellazoster virus. affects 5 to 15 percent of HIV-positive patients The infection involves the ophthalmic distribution of the trigeminal nerve and pain may be severe. The occurrence of varicellazoster virus dermatitis in a person less than 50 years old is uncommon and should suggest the possibility of an immunosuppressive condition. 14. Hzo Concurrent or delayed keratitis, scleritis, uveitis, retinitis, or encephalitis may also occur. HIV infection appeared to correlate with more severe corneal involvement and postherpetic neuralgia. Treatment consists of oral Aciclovir 800mg 5 times /day, for 5-7 days In immunocompromised patients Aciclovir is given intravenously for two weeks. (10mg/kg 3x/day for a week followed by 800mg po 5x/day for 5- 7days) Ocular manifestations such as anterior uveitis, are treated with topical steroids and mydriatics 15. ADNEXAL MANIFESTATIONS3. HERPES SIMPLEX KERATITIS HSV can cause painful and often recurrent corneal ulcerations X-c branching or dendritic pattern on slit lamp exam. Often associated with corneal scarring and iritis, Require a prolonged course of treatment, and recurs frequently. Treatment consists of trifluorothymidine and cycloplegic drugs, with debridement of the ulcer using a cotton-tip applicator. Oral acyclovir (400 mg twice daily for 1 year) decreases the risk of recurrent HSV keratitis by 50%. 16. Adnexal manifestations 4. KAPOSIS SARCOMA is a highly vascularized, painless mesenchymal tumor affecting the skin and mucous membranes in up to 25 percent of HIV-positive patients Approximately 20% of symptomatic HIV- patients have asymptomatic Kaposi's sarcoma of the eyelids or conjunctiva which may mimic a chalazion or subconjunctival hemorrhage, respectively. Appears as a violaceous non-tender nodule on the eyelid or conjunctiva. Kaposi's sarcoma in AIDS tends to be more resistant to treatment than endemic KS. 17. KS 18. Ks KS does not invade the eye, and No treatment is necessary if it causes no symptoms and is Cosmetically acceptable. However, KS may cause discomfort through a mass effect and secondary corneal changes, and also may be disfiguring. 19. KSTreatment of ocular adnexal KS may be necessary for cosmetic and to relieve functional difficulties. The mainstay of treatment is radiotherapy. Other options include cryotherapy or chemotherapy. Ocular lesions accompanied by systemic Kaposi's sarcoma are often best treated with systemic chemotherapy. 20. Adnexal manifestations5. CONJUCTIVAL SCUAMOYS CELL CARCINOMA Common neoplasm associated to HIV infection. may be due to an interaction between HIV, sunlight and HPV infection. Appears as a pink, gelatinous growth, usually in the interpalpebral area. Often an engorged blood vessel feeding the tumor is seen. may extend onto the cornea, but deep invasion and metastasis are rare. 21. The treatment of choice is local excision and cryotherapy The presence of orbital invasion is an indication of exenteration CONJUNCTIVAL SCC 22. Adnexal manifestations6. CONJUNCTIVAL MICROVASCULOPATHY 70 - 80% of HIV-positive patients eventually have asymptomatic conjunctival microvascular changes, including: segmental vascular dilatation and narrowing, microaneurysm formation, the appearance of comma-shaped vascular fragments, and sludging of the blood column. These changes, which are best seen with a slit-lamp biomicroscope near the limbus, are correlated with the occurrence of retinal microvasculopathy. 23. CONJUNCTIVAL MICROVASCULOPATHY The cause of conjunctival microvascular changes is unknown, Increased plasma viscosity, HIV-related immune-complex deposition, and Direct infection of the conjunctival vascular endothelium by HIV have been proposed as possible causes. No treatment is indicated. 24. Adnexal manifestations7. TRICHOMEGALY Trichomegaly or hypertrichosis is an exaggerated growth of the eye lashes found in the later stages of the disease The cause is not known When symptomatic or for cosmetic reasons the eyelashes can be trimmed or plucked 25. HYPERTRICHOSIS 26. ANTERIOR SEGMENT MANIFESTATIONS The anterior segment includes the cornea, anterior chamber, and iris. More than half of HIV-positive patients have anterior-segment complications. The most common visually important complications include dry eyes (keratoconjunctivitis sicca), corneal infection (keratitis), and anterior-chamber inflammation (iridocyclitis). 27. ASD Although best seen with a slit lamp, anterior-segment complications are often detectable with a penlight. Common symptoms include irritation, pain, sensitivity to light, and decreased visual acuity. 28. ASD1. KERATOCONJUNCTIVITS SICCA Occurs in 10 to 20 percent of patients with HIV infection, typically at later stages of illness. Abnormal results on Schirmer's testing and interpalpebral rose-bengal staining help establish the diagnosis. Patients complain of burning uncomfortable red eyes. The cause is probably related to HIV-mediated inflammation, Blepharitis, and destruction of the primary and secondary lacrimal glands. 29. Kcs(dry eye syndrome) Symptoms include gritty, foreign body sensations, burning, photophobia, and decreased visual acuity If encephalopathy is also present, incomplete lid closure (lagophthalmos), a decreased blink rate, or both may exacerbate the condition. Treatment with artificial tears and long-acting lubricating ointments usually provides symptomatic relief. 30. Asd2. INFECTIOUS KERATITIS occur in less than 5 percent of HIV-infected patients, may result in permanent loss of vision. Decreased corneal sensation and elevated intraocular pressure provide clues to the diagnosis. Varicellazoster virus and herpes simplex virus are the most common causes of keratitis. Both VZK and HSK may recur more frequently and in some cases be more resistant to treatment in HIV-positive patients than in other patients. 31. INFECTIOUS KERATITIS Bacterial and fungal corneal infections do not appear to be more common in HIV-positive persons than in others but do tend to be more severe. candida species are particularly common in intravenous drug users Ocular microsporidiosis is uncommon but can produce a punctate superficial keratopathy often with a mild papillary conjunctivitis.. 32. Asd3. IRIDOCYCLITIS Mild iridocyclitis is common in HIV-positive patients usually observed in association with retinitis caused by CMV or VZV Severe iridocyclitis uncommon but can occur in association with toxoplasmic retinochoroiditis, syphilitic retinochoroiditis, or rarer forms of bacterial or fungal retinitis. 33. Iridocyclitis Medications used to treat OIs in HIV-positive patients, such as rifabutin and cidofovir, may also cause iridocyclitis. May be part of Reiter's syndrome, which may be more common in HIV+. Identification of iridocyclitis requires high-power slit- lamp examination. Treatment should be directed at a specific infectious cause. Topical corticosteroid drops should be used with appropriate antimicrobial treatment when infection is suspected. 34. Asd4.ANTERIOR UVEITIS Uvea = iris + ciliary body + choroid HIV related anterior uveitis can be: Direct manifestation of the HIV infection autoimmnune in origin drug induced ie: rifabutin, secondary to direct toxic effect upon the non-pigmented epithelium of the ciliary body Any of the different infections associated with AIDS, ie: HZV, HSV,CMV, T. gondii, Syphilis,. 35. Anterior uveitis Clinical signs of anterior uveitis include cells in the anterior chamber, keratin precipitates, posterior synechiae, and hypopyon. 36. Therefore: Causes of visual loss in AIDS can be due to comeal disease (eg, herpes simplex,varicella zoster uveitis (eg, toxoplasmosis, syphilis) retinal disease (eg, CMV, toxoplasmosis) optic neuropathy (eg, syphilis, lymphoma) 37. Kaposi sarcoma 38. HZO Characterized by rush,neuralgia, ass. With dendriform and stromal keratitis, conjuctivitis,blepharitis,uvetis leading to glaucoma,scleritis, episcleritis, retinitis, encephalitis Damage can be: 1. Direct 2. Indirect 3. hypoesthesia Clinical phases: A. Acute phase B. Chronic phase C. Relapsing 39. HZO A. Acute phase Clinical features: - neuralgia - skin rush/HZ sine herpete - Hutchinson sign - reduced corneal sensation - KP, nummular keratitis - uvetis,synechiea 40. Keratitis 1. Acute epithelial keratitis: - dendritic stellate lessions with out bulb 2. Numular keratitis: - subepithlial deposite with halo 3. Disciform keratitis: Other complications Conjuctivitis, episcleritis, scleritis, uvitis, CN palsy, optic nuritis, Iris atrophy, glaucoma. 41. B. Chronic phase Numular keratitis Desciform keratitis Neurotrophic keratitis Mucus plaque keratits Ptosis Scleritis Post herpetic nueralgia 42. Rx of HZO HZO with or with out occular involvement If no occular involvement Acyclovir 400mg 5x P.o for #7days or Valcyclovir 200mg or Famicyclovir 250mg tid - Topical steroids + antibiotic - Pain killers such as 5 % lidocaine cream or NSAIDS, amitryptiline or gabapentin 43. If there is ocular imvolvement IV acyclovir 10mg/kg every 8 hrs for 7 days, followed by maintenance dose of oral acyclovir 800mg for 3-6 weeks 44. viral keratitis HS Keratitis primary ocular infection - 6mon-5yrs - Bleopharoconjuctivitis - Rush - Topical acyclovir Epithlial keratitis - Dendritic opacity with bulb - Centrifugal enlargement - Decreased corneal sensation 45. RX Topical acyclovir 3% onitment for 1 wk( 5X a day) Gancyclovir 0.15% jel F3T(Triflorothymidine 1 % drops every 2 hrs for 2 wks) Debridment Prophylaxisis - 400mg bid for 1 yr 46. Posterior segment lesions Retinal vasculopathy HIV retinopathy most common ocular manifestation of HIV 40% cotton wool spots capillary abnormalities, ischemia retinal hemorrhage resolve spontaneously - Are asymptomatic 47. Cotton wool spots vs CMV retinitis Follow vascular arcades - dont follow vessels No iritis, vitritis, retinitis - present 48. CMV retinitis Most common occular infection in AIDS pts Usually in CD4 < 50/microlitre It is painless, progressive loss of vision with necrotic inflammatory process Clinical features 1. indolent retinitis 2.fulminant retinitis-classic 3.regression 49. SSX burred vision,progressive loss of vision, floaters, Bilateral, irreversible and can be complicated by RRD due to retinal atrophy Perivascular hemorrage, exudate Can occure as complication of IRIS 50. Rx 1. gancyclovir IV, 10mg/kg every 12 hrs for 2-3 wks ,ffed by 5mg/kg every 24 hrs untill retinits is stable. thereafter lifelong oral maintenance dose of 300mg daily 2. foscarnet- IV 60mg/kg every 8 hrs for 2-3 wks daily 3.viterctomy, silicon oil temponade 51. Rx continued If CMV is limited to the eye - ganciclovir relising intraocular implants - periodic injection of the antisense nucliec acid preparation foamivirsen - intravitrial injection of gancyclovir or foscarnet Meintenance therapy is continued until CD4 >100 CMV retinitis ass with IRIS topical steroids 52. Toxoplasma retinitis Immunocompetent and immunocompromised are affected. Ass. With anterior uvetis Focal retinitis manifested by - satellite lessions - headlight in the fog appearance - papilitis - atypical lesions-bilateral, multifocal confluent with out previous scar 53. Diagnostic tests Fundoscopy Any AB titer RX 1. Cotrimoxazole -960mg p/o bid for 4-6 wks 2. Atovaqone- 750mg tid p/o 3. Azitromycin- 500mg daily for 3 days clindamycin, sulphadiazine,pyrimethamine are not good in HIV pts 54. Acute retinal necrosis Rare,necrotizing retinits, usually at the periphery All ages,M>F Biphasic etiology-HSV-2 in < 15 yrs -HSV-1 and VZV in > 15 yrs Visual loss , floaters,pain , ass. With granulomatous anterior uvetis,RD 55. Rx IV aacyclovir 10mg /kg tid for 14 days, then orally 800mg 5x a day for 3 months Famicyclovir p/o 500mg tid for 3 months Asprin Lasre photocoagulation Vitreoretinal surgery 56. Progressive outer retinal necrosis(PORN) Caused by an agressive variant of VZV and HSV The second most common opportunistic infection in HIV Pts Rapily progressive bilateral visusal loss Multifocal deep, yellow/white retinal infiltrates with or with out vitritis, full thickness necrosis and early macular involvment 57. (PORN) 58. Rx IV ganciclovir with or with out foscarnet Poor prognosis RD, macular necrosis