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.
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).
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 (firstname.lastname@example.org).
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.
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