Ocular Complications of HIV/AIDS in the Era of HAART

Millena G Bittencourt; Owhofasa O Agbedia; Hong T Liu; Rachel Annam; Yasir J Sepah; Henry Alexander Leder; Raafay Sophie; Mohamed Ibrahim; Abeer Akhtar; Anam Akhlaq; Diana V Do; Quan Dong Nguyen


Expert Rev Ophthalmol. 2012;7(6):555-564. 

In This Article

CMVR Before & After the HAART Era

CMVR is one of the most common types of retinopathy seen in immunocompromised patients. It was a relatively rare disease prior to the emergence of AIDS, seen primarily in patients with organ transplantations, a compromised immune system and congenital CMV infection.[1,8–11]

CMVR causes full thickness retinal necrosis, presenting as perivascular opaque white areas with a granular appearance and associated hemorrhages. It starts in the periphery of the retina and advances toward the optic disc along the arcade vessels (Figures 1 & 2).[10] CMVR causes considerable visual impairment and blindness in affected patients.[11,12] CMVR typically occurs at CD4 cell count <50 cells/µl; however, in the majority of cases, the mean CD4 count at diagnosis is 17 cells/µl.[11–14] In the pre-HAART era, the median survival after a diagnosis of CMVR was 6 weeks to 6 months. The incidence of CMVR among patients with a CD4 cell count <50 cells/µl is estimated to be 0.20/person-year (PY), with the lifetime probability of a patient with AIDS being diagnosed with CMVR estimated to be 20–40%.[11,12,15–17] Ocular complications are evident in approximately 80% of the patients coinfected with HIV and CMV.[18,19]

Figure 1.

Optos P200 imaging system (Optos PLC, UK) showing a wide field pseudocolor image of the left eye in a patient with HIV and cytomegalovirus retinitis. Some areas of retinal necrosis and hemorrhage are shown (arrows).

Figure 2.

Color photograph of the right eye in a patient with HIV and cytomegalovirus retinitis showing the classic 'pizza slice' appearance (arrows).
Color figure can be found online at www.expert-reviews.com/doi/suppl/10.1586/eop.12.65

The most important risk factor for CMVR is the severity of immunodeficiency as assessed by CD4 cell count, although other factors such as CD8 cell count, degree of retinal vascular damage (indicated by microangiopathy in the retina) and infection with Mycobacterium avium complex may contribute significantly. Jabs and colleagues reported that AIDS patients with CMVR had significantly lower CD8 cell count (152 cells/µl) compared with those without CMVR (296 cells/µl), after being matched for CD4 cell count.[1] The Johns Hopkins CMV Retinitis Cohort Study reported that the presence of HIV microangiopathy increased the odds of CMVR 1.46 times while another study conducted at The University of California, Los Angeles, CA, USA, reported that the majority (73%) of small and early CMV lesions were adjacent to retinal blood vessels.[15,20] In the MACS study and the Johns Hopkins CMV Retinitis Cohort Study, the relative risk for CMVR among patients with M. avium complex bacteremia was 3.94 and 3.04, respectively.[1,21] Without treatment, CMVR progresses at a median rate of 24 µm per day.[22] In most patients with CMVR, a rhegmatogenous detachment of the retina occurs within 3–6 months from the time of diagnosis.[16,23] The annual rate of retinal detachment ranges from 24 to 50% per year (PY).[24] Patients often require anti-CMV maintenance therapy during their lifetime to avoid further complications.[24]

In the HAART era, the incidence of CMVR has decreased by 80–90%, resulting in a substantial reduction in the risk of visual impairment and blindness due to CMVR.[9,25,26] The Longitudinal Studies of the Ocular Complications of AIDS estimates the incidence of CMVR in the HAART era as 5.6 cases/100 PY.[7] However, new cases of CMVR continue to occur, more often in HAART experienced patients, with a visual impairment rate of 0.10 case/eye-year (EY) and a blindness rate of 0.06 case/EY.[7,25–28] Visual loss in patients with CMVR can mostly be attributed to factors present in the pre-HAART era, including involvement of the fovea or optic nerve (zone 1 disease) and retinal detachment. Cataract is another substantial problem among patients with CMVR, accounting for 22% of visual impairment and 29% of blindness.[26] Patients with CMVR also have a higher risk of mortality, retinitis progression, visual impairment and blindness, even after immune recovery.[27] The majority of new cases of CMVR appear to occur in patients who cannot tolerate or are unresponsive to HAART.