AIDS -OCULAR MANIFESTATIONS By Dr Nitish

ETIOLOGY

• HIV-1 & HIV-2

• Lenti virus sub family of retrovirus

• HIV-1 Most common

• HIV-1 two sub types M & O

• Sub types of M –A to H

• B,C,A – found in India

• CD4 < 200 cells/ul• Blood borne disease• Heterosexual , infected blood transfusion , transplacental ,iv

drug abuse• 36 million• 70% develop ocular manifestations

WORLDWIDE HIV1- Dec-2000

OCULAR MANIFESTATIONS

CD4 COUNT DISEASE

1000 cells/mm3 Normal

<500 Kaposi sarcoma

Lymphoma , T.B.

<250 Toxoplasma ,

Pneumocystis carni

<100 C.M.V. Retinitis

VZ Retinitis,HIV

retinopathy, sicca s

syndrome

ANTERIOR SEGMENT

MOLLUSCUM CONTAGIOSUM

• Pox virus - DNA virus• Umblicated nodules• Treatment- Excision , currettage or cryotheray

MOLLUSCUM CONTAGIOSUM OF EYE LID

HYPERTRICHOSIS

• Exaggerated growth of eye lashes

• Cause unknown

• Treatment- trimming of eye lashes

- plucking

TRICHOMEGALY

HERPES ZOSTER OPHTHALMICUS• Herpes Zoster virus

• Reactivation

• Dermatomal pain -> Rash

• Keratitis

• Conjunctivitis, episcleritis ,scleritis,

uveitis, glaucoma, pthisis bulbi

Treatment-Acyclovir 3 % e/o 5 t/d

Tab Acyclovir 800mg 5t/d

KAPOSI’S SARCOMA

• Vascular neoplasm

• Commonest anterior segment lesion

• Herpes virus – 8

• Eyelids - purple nodules

• Conjunctiva – red mass

• Uncommon in India

• Treatment Of Choice -RT

KAPOSI’S SARCOMA

CONJUNCTIVAL SQUAMOUS CELL CARCINOMA• Interaction b/w HIV , sunlight , HPV

• Pink gelatinous growth

• Temporal bulbar conjunctiva

• Feeding blood vessel

• TREATMENT- Excision & cryotherapy

• Exenteration – if orbit inolved

CONJUNCTIVAL SQUAMOUS CELL CARCINOMA

KERATOCONJUNCTVITIS SICCA• Destruction of lacrimal glands• Burning uncomfortable red eyes• TREATMENT-artficial tear drops

- lubricating e/o

ANTERIOR UVEITIS

• Herpes simplex

• Herpes Zoster

• C.M.V.

• Toxoplasmosis

• Syphilis

• Drug induced - Rifabutin

POSTERIOR SEGMENT

• Posterior segment > Anterior segment

• MC –CMV Retinitis

HIV RETINOPATHY

• > ½ -3/4 patients

• Microangiopathy

• Asymptomatic

• Cotton wool spots

• Retinal haemorrhages

• Microaneurysms

• Differentiate from DM & HTN Retinopathy

HIV Retinopathy

CMV RETINITIS

• Commonest opportunistic infection

• Floaters – earliest to occur

• DOV , floaters , flashes or asymptomatic

• Cottage cheese with tomato ketchup appearance

• Progress in brushfield pattern

• Retinal detatchment

• Treatment – Photocoagulation

• Silicon oil tamponade

TREATMENT OF CMV RETINITIS• Gancyclovir

5mg/kg 12 hrly iv x 2-3 weeks

5mg /kg 24 hrly iv x stable retinitis

Oral 300-450 mg OD

• Gancyclovir implant- 1ug/hr x6-8 months

• Intravitreal injections – 200 -2000ug/0.1 ml

Every week

S/E - Bone marrow supression

Therefore TC –twice weekly

• Foscarnet – gancyclovir resistant cases

60 mg/kg iv 8 hrly x2-3 weeks

90-200 mg/kg iv 24 hrly

Intravitreally – twice /week –induction

(2.4mg/0.1 ml)once /week – maintainence

• Valgancyclovir – induction-900mg BD

- maintainence–900mg OD

• Cidofovir-5mg /kg iv once weeklyx2 wks

+ probenecid

CMV RETINITIS

ACUTE RETINAL NECROSIS

• Herpes Zoster infection

• Peripheral whitening lesions

• Vitritis & macular odema

• Resolution - multiple sieve like holes

• Confirmed by PCR assay of vitreal sample

• Treatment – acyclovir iv 10mg/kg 8hrly

X10-14 days

Oral acyclovir 5t/d x6-12 weeks

ACUTE RETINAL NECROSIS

PROGRESSIVE OUTER RETINAL NECROSES (PORN)• Varicella Zoster virus

• White lesions in mid & peripheral retina

• Rapid loss of vision

• Treatment– iv gancyclovir or G+Foscarnet

• Or intravitreal foscarnet

• Poor prognosis

• resolution- cracked mud appearance

PRORESSIVE OUTER RETINAL NECROSIS

TOXOPLASMA CHORIORETINITIS• Toxoplasma gondii – protozoan

• Less common than encephalitis

• Floaters , flashes , DOV

• Head light in fog appearance

• Treatment – systemic steroids 1mg/kg +

1 Clindamycin 300 mg qid x 3-4 weeks

2 Sulphadiazine 1gm qid x 3-4 weeks

+ pyrimethamine + folinic acid

TOXOPLASMA ENCEPHALITIS

TOXOPLASMA CHORIORETINITIS

SYPHILIS

• MC - Uveitis

• Retinitis ,Optic neuritis , papillodema

• Treatment – high dose iv penicillin

SYPHILITIC RETINITIS

FUNGAL INFECTION

• Candida & cryptococcus - MC

• Snowball like lesions

• Cryptococcus meningitis – papilledema , optic neuropathy

• DOC – Amphotericin B + Fluconazole

CANDIDA RETINITIS

TREATMENT

• Along with specific HAART therapy

• HAART = Highly active anti retroviral therapy

• 3 drugs

• 2 nucleoside reverse transcriptase inhibitors + 1 protease inhibitor or 1 NNRTI

THANK YOU