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

Other HIV–AIDS Chorioretinopathies Before & After the HAART Era

Progressive Outer Retinal Necrosis & Acute Retinal Necrosis

Progressive outer retinal necrosis (PORN) is an acute necrotizing retinal infection with secondary inflammation that is prevalent in immunocompromised patients, especially those with advanced AIDS (Figure 3).[62] PORN, which is a form of necrotizing herpetic-retinopathies, has been established as a clinically distinct form of viral retinitis in patients with AIDS, first reported by Foster and colleagues.[62] The most common etiology is varicella zoster virus, although CMV, herpes simplex virus and Epstein–Barr virus have also been implicated as etiological agents in PORN.[63] PORN was the second most common infectious retinopathy reported in patients with AIDS prior to the introduction of HAART in 1996.[64] PORN was reported to occur in up to 2% of patients with HIV infection and typically affects individuals in the late-stage disease (AIDS) with a profound reduction in the CD4 T-lymphocyte count; individuals were observed to have a median CD4 cell count of 21 cells/µl.[13] Reactivation of HZV virus infection has been reported to be a significant factor, resulting in a disease with an extremely rapid course that may lead to blindness in affected eyes within days to weeks.[62]

Figure 3.

Color photograph of the left eye in a patient with HIV and progressive outer retinal necrosis caused by varicella zoster virus.
Color figure can be found online at www.expert-reviews.com/doi/suppl/10.1586/eop.12.65

Another clinical syndrome that occurs in patients with HIV infection and may also be seen in immunologically competent patients is acute retinal necrosis (ARN). ARN can occur at any stage of HIV infection and is characterized by prominent anterior chamber reaction, marked vitritis, occlusive retinal and choroidal vasculitis, and full-thickness retinal necrosis.[62] It can lead to complex retinal detachment in 75% of cases and blindness in 64% of cases within 2–3 months.[65] ARN is most often secondary to HZV reactivation but may also be associated with herpes simplex virus infection.[66]

Less Common Choroidoretinopathies

Prior to the introduction of HAART, Toxoplasma retinochoroiditis was the third most common AIDS-associated chorioretinopathy with a prevalence of about 1–3% in patients with AIDS.[19,67] Ocular toxoplasmosis in AIDS is often bilateral, multifocal, and not associated with chorioretinal scars, suggesting that in most cases it is a result of a primary infection rather than a reactivation (Figures 4A & B).[68,69]

The incidence of Pneumocystis jirovecii choroiditis in patients with AIDS with CD4 cell counts <200 cells/µl has been reported to be up to 1%.[19] Prior to the introduction of HAART, the median survival following the diagnosis of pneumocystis choroiditis was 44 weeks.[70] Pneumocystis choroiditis is usually an indication of disseminated systemic pneumocystosis in severely immunosuppressed individuals, although several cases of ocular pneumocystis have been reported in relatively healthy patients taking aerosolized pentamadine prophylaxis for pneumocystis pneumonia (Figure 5).[71–73]

Figure 4.

Toxoplasmosis choroidoretinopathy in a HIV patient. (A) 30 degree color photograph showing inactive toxoplasmosis scars (arrows) in the right eye of a patient with toxoplasmosis retinochoroiditis. (B) 30 degree color photograph of the left eye of the same patient showing both active (candle in the fog, red arrow) and inactive (hyperpigmented, blue arrow) toxoplasmosis lesions.
Color figure can be found online at www.expert-reviews.com/doi/suppl/10.1586/eop.12.65

Figure 5.

Multiple choroidal lesions in the right eye (arrows) of a patient with HIV and pneumocystis choroiditis.

Syphilitic retinitis has been described as a complication of CNS involvement in patients with AIDS.[74] The clinical course of syphilis in patients with AIDS is rapidly progressive and clinical findings of primary, secondary and tertiary syphilis may be observed concurrently.[75,76] Ocular syphilis (Figure 6) may be associated with CNS involvement in 85–100% of AIDS patients as opposed to 35–40% of HIV-negative patients.[75,77] The incidence of symptomatic neurosyphilis in patients adequately treated with penicillin has been reported to be as high as 66% in HIV-infected patients.[78]

Figure 6.

Color photograph of the left eye in a patient with HIV and syphilis-associated panuveitis showing retinochoroidal lesion with focal areas of exudation and associated vitritis (arrows).
Color figure can be found online at www.expert-reviews.com/doi/suppl/10.1586/eop.12.65

Tuberculous choroiditis is due to hematogenous dissemination of Mycobacterium tuberculosis bacilli to the choroid (Figure 7). There are few case reports of tuberculous choroiditis in patients with AIDS.[79–81]Mycobacterium tuberculosis is an uncommon cause of multifocal choroiditis in patients with AIDS, although in most cases, the choroiditis is part of a widely disseminated terminal infection and the diagnosis of choroiditis is made at autopsy.[71]

Figure 7.

Color photograph of the right eye showing a single inactive tuberculous choroidal lesion (arrows) in a patient with HIV.
Color figure can be found online at www.expert-reviews.com/doi/suppl/10.1586/eop.12.65

Choroiditis caused by Cryptococcus neoformans is relatively uncommon.[71] However, as in other types of infectious multifocal choroiditis, ocular infection is believed to be the result of disseminated systemic infection. Although systemic cryptococcosis and ultimately ocular involvement is reportedly less common since the introduction of HAART, the impact of HAART is not fully understood in cryptococcal disease.[82]