0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letters |

Ophthalmic Manifestations of Human Immunodeficiency Virus Infection in the Era of Highly Active Antiretroviral Therapy FREE

Rebecca L. Sorenson, BA; Bennie H. Jeng, MD, MS
[+] Author Affiliations

Author Affiliations: University of Illinois College of Medicine at Rockford (Ms Sorenson); and Department of Ophthalmology, San Francisco General Hospital (Ms Sorenson and Dr Jeng) and Department of Ophthalmology and Francis I. Proctor Foundation, University of California, San Francisco (Dr Jeng), San Francisco.


Arch Ophthalmol. 2012;130(12):1621-1623. doi:10.1001/archophthalmol.2012.1900.
Text Size: A A A
Published online

Before the advent of highly active antiretroviral therapy (HAART), the rate of ophthalmic manifestations of human immunodeficiency virus (HIV) infection was very high. The lifetime risk of cytomegalovirus (CMV) retinitis, the most notorious of these complications, was once estimated at 30% in individuals with AIDS.1 In addition, before the widespread use of HAART in 1996, the 10-year cumulative incidence of CMV retinitis among HIV-positive patients at the San Francisco General Hospital, a large, urban, tertiary care medical center with a comprehensive HIV treatment center, was found to be 77.7%.2

In the current era of HAART, however, the incidence of CMV retinitis in individuals with AIDS has decreased by 80% nationwide, with an estimated incidence of 5.6/100 patient-years.1,3 Following the widespread introduction of HAART, the number of new cases of CMV retinitis in patients with AIDS decreased from 46 in 1994 to 4 in 1997 at the San Francisco General Hospital.4 Given these new data, we sought to determine whether the rates of other opportunistic infections as well as other known complications of HIV infection have continued to decrease at the San Francisco General Hospital.

In this follow-up to the study performed at the same institution prior to the HAART era,2 we retrospectively reviewed the records of all HIV-positive patients who visited the eye clinic of the San Francisco General Hospital from July 1, 2008, to June 30, 2009. Records were reviewed for diagnoses of active ophthalmic manifestations of HIV infection, including HIV retinopathy, opportunistic infections, uveitis, and neoplasms, during this 1-year period. If no active ophthalmic manifestations of HIV infection were noted during the study period, the first CD4+ lymphocyte count was recorded. However, if any ophthalmic manifestation of HIV infection was noted, the CD4+ lymphocyte count that was drawn in closest proximity to the date of diagnosis of the active ocular manifestation was recorded.

The records of 231 HIV-positive patients were available for review, and data were collected from all visits during this period. The age range of our study population was 22 to 74 years, with a mean age of 47 years. Forty patients (17.3%) were female and 191 patients (82.7%) were male. The most common ocular manifestation of HIV disease was HIV retinopathy, defined by the presence of cotton-wool spots and intraretinal hemorrhages and found in 7 patients (3.0%). Of these patients, 3 were newly diagnosed as having HIV infection, 1 was not currently receiving HAART, 2 recently underwent treatment for systemic AIDS-defining disease, and 1 had a CD4+ lymphocyte count of 7/μL (to convert to ×109 per liter, multiply by 0.001). Herpes simplex virus keratitis was found in 4 patients (1.7%), 3 of whom had epithelial keratitis and 1 of whom had stromal keratitis. One patient (0.4%) had neurosyphilis with ocular involvement. No cases of active CMV retinitis were found, although 8 patients had prior disease. Eight cases of active uveitis (5 anterior and 3 posterior; 3.5%) were found, none of which were immune recovery uveitis or had a confirmed infectious cause despite appropriate testing. Seven of these cases were newly diagnosed and 1 was recurrent and chronic. Two of these 8 patients were newly diagnosed as having HIV infection, and another 2 were not using HAART. Ocular surface neoplasm was found in 1 patient (0.4%): a single case of conjunctival squamous cell carcinoma. One patient had a conjunctival Kaposi sarcoma that had been excised several months prior, when he was diagnosed as having HIV infection; since then, he has been receiving HAART with no recurrences of the conjunctival lesion (Table 1 and Table 2).

Table Graphic Jump LocationTable 1. Comparison of the Incidence of Ocular Manifestations of HIV Infection at the San Francisco General Hospital From July 2008 to June 2009 vs 1984 to 1995

Table Graphic Jump LocationTable 2. Clinical Characteristics of 21 Patients With Active Ocular Manifestations of HIV Infection at the San Francisco General Hospital From July 2008 to June 2009

Our findings suggest an overall decline in the last 2 decades in the incidence of ocular manifestations of HIV infection at the San Francisco General Hospital, where an aggressive HIV treatment program using HAART is in place (Table 1). The absence of active CMV retinitis and varicella-zoster virus keratitis in our study suggests a significant decline from the pre-HAART era, during which 10-year cumulative incidences were found to be 77.7% and 10.4%, respectively.2 This trend is more difficult to assess for other opportunistic infections in our relatively smaller study population. However, while the previous study was a large retrospective cohort study consisting of 1800 HIV-positive patients observed from 1984 to 1995 with 5200 person-years of follow-up, the average patient actually had less than 3 years of follow-up.2 Furthermore, whereas most HIV-positive patients in the original study developed AIDS during the study period,2 patients in our study have largely not been diagnosed as having AIDS.

For individuals with HIV infection, HAART has seemingly decreased the rate of ophthalmic manifestations of this disease. However, sight-threatening manifestations can still occur, especially in those patients with newly diagnosed HIV or who were not using HAART. Therefore, patients still need regular ophthalmologic examinations, and ophthalmologists must still be aware of the potential ophthalmic complications of HIV infection.

Correspondence: Dr Jeng, Department of Ophthalmology, University of California, San Francisco, 10 Koret Way, K-304, San Francisco, CA 94143-0730 (jengb@vision.ucsf.edu).

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported in part by grants from Research to Prevent Blindness and That Man May See.

Previous Presentation: This paper was presented in part at the 44th Annual Meeting of the Ocular Microbiology and Immunology Group; October 20, 2010; Chicago, Illinois; and at the 2011 Annual Meeting of the Association for Research in Vision and Ophthalmology; May 3, 2011; Fort Lauderdale, Florida.

Holland GN. AIDS and ophthalmology: the first quarter century.  Am J Ophthalmol. 2008;145(3):397-408
PubMed   |  Link to Article
Hodge WG, Seiff SR, Margolis TP. Ocular opportunistic infection incidences among patients who are HIV positive compared to patients who are HIV negative.  Ophthalmology. 1998;105(5):895-900
PubMed   |  Link to Article
Jabs DA, Van Natta ML, Holbrook JT, Kempen JH, Meinert CL, Davis MD.Studies of the Ocular Complications of AIDS Research Group.  Longitudinal study of the ocular complications of AIDS, 1: ocular diagnoses at enrollment.  Ophthalmology. 2007;114(4):780-786
PubMed   |  Link to Article
Jacobson MA, Stanley H, Holtzer C, Margolis TP, Cunningham ET. Natural history and outcome of new AIDS-related cytomegalovirus retinitis diagnosed in the era of highly active antiretroviral therapy.  Clin Infect Dis. 2000;30(1):231-233
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Comparison of the Incidence of Ocular Manifestations of HIV Infection at the San Francisco General Hospital From July 2008 to June 2009 vs 1984 to 1995
Table Graphic Jump LocationTable 2. Clinical Characteristics of 21 Patients With Active Ocular Manifestations of HIV Infection at the San Francisco General Hospital From July 2008 to June 2009

References

Holland GN. AIDS and ophthalmology: the first quarter century.  Am J Ophthalmol. 2008;145(3):397-408
PubMed   |  Link to Article
Hodge WG, Seiff SR, Margolis TP. Ocular opportunistic infection incidences among patients who are HIV positive compared to patients who are HIV negative.  Ophthalmology. 1998;105(5):895-900
PubMed   |  Link to Article
Jabs DA, Van Natta ML, Holbrook JT, Kempen JH, Meinert CL, Davis MD.Studies of the Ocular Complications of AIDS Research Group.  Longitudinal study of the ocular complications of AIDS, 1: ocular diagnoses at enrollment.  Ophthalmology. 2007;114(4):780-786
PubMed   |  Link to Article
Jacobson MA, Stanley H, Holtzer C, Margolis TP, Cunningham ET. Natural history and outcome of new AIDS-related cytomegalovirus retinitis diagnosed in the era of highly active antiretroviral therapy.  Clin Infect Dis. 2000;30(1):231-233
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 1

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Ocular manifestations seen in HIV. Dis Mon 2014;60(6):268-75.
[Eye exams in HIV patients]. MMW Fortschr Med 2014;156 Suppl 1():26-8.
JAMAevidence.com