Generality/Definition
Epidemiology
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More than 900,000 individuals are infected with HIV in the United States, and close to 40 million individuals carry the virus worldwide.
Among the individuals infected with HIV, approximately 70-80% will be treated for an HIV-associated eye disorder during the course of the illness.
Herpes Zoster Ophthalmicus affects about 5-15% of patients who are infected with HIV.
Molluscum contagiosum The eyelid is involved in 5% of HIV-positive patients.
Dry eyes (keratoconjunctivitis sicca) occurs in about 20% of HIV-positive patients, usually in the later stages of the illness.
Cytomegalovirus Retinitis:The seropositive prevalence of CMV is about 50% in adults and 95-100% in homosexual and AIDS patients. CMV retinitis occurs in as many as 40% of patients with advanced HIV infection.
Syphilis: Incidence of syphilis has been on the rise since 1985. Usually a 5% rate of ocular involvement in untreated cases occurs with rare ocular involvement within 6 months of primary infection.
Tuberculosis:Annual incidence of tuberculosis is close to 20,000 cases, with as many as 10 million infected individuals.The group at high risk for acquiring primary and/or secondary tuberculosis infection includes persons with HIV infection.
Toxoplasma Retinochoroiditis:Toxoplasmosis is the most common cause of retinochoroiditis, accounting for about 30-50% of all posterior uveitis.
Source: eMedicine - Ocular Manifestations of HIV : Article by Robert Copeland, MD (emedicine.com)
Prevention
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HIV can only be passed from person to person through body fluids, like blood, semen and vaginal fluid. The most common ways HIV is passed are: You may be at risk of getting HIV if you have any of the risk factors listed in the box below. Children born to infected mothers can also become infected during pregnancy.
Source: HIV and AIDS: How to Reduce Your Risk -- familydoctor.org (familydoctor.org)
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Symptoms
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Herpes zoster ophthalmicus: is characterized by a vesiculobullous rash over the ophthalmic branch of the trigeminal nerve and may be associated with keratitis, conjunctivitis, blepharitis, and uveitis.
Herpes simplex virus can cause painful and often recurrent corneal ulcerations with a characteristic branching or dendritic pattern on slit lamp exam. HSV keratitis often is associated with corneal scarring and iritis, appears to require a prolonged course of treatment, and recurs frequently.
Uveitis: occurs with, and may be the first sign of, several chronic infections seen frequently in patients with HIV disease, including tuberculosis, syphilis, histoplasmosis, coccidioidomycosis, and toxoplasmosis.
Syphilitic involvement:The findings are variable and include chorioretinitis, retinal perivasculitis, intraretinal hemorrhage, papillitis, and panuveitis.
Kaposi Sarcoma also occasionally may result in metastatic CNS involvement. CMV retinitis It is bilateral in 30-50% of patients. Clinically, lesions appear within the retina as multiple granular white dots with varying amounts of hemorrhage.
Toxoplasma Retinochoroiditis: Bilateral eye involvement also may be seen in patients with HIV disease.
Source: Ophthalmic Manifestations of HIV (hivinsite.ucsf.edu)
Diagnosis
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Syphilis: The most reliable laboratory studies for diagnosing ocular syphilis are the serum fluorescent treponemal antibody absorption test (FTA-ABS) and the microhemagglutination assay (MHA-TP), both of which provide evidence of past luetic infection and remain positive for years.Nontreponemal test results (rapid plasma reagent [RPR] and Venereal Disease Research Laboratory [VDRL]) are positive in 99% of patients with secondary syphilis, but the sensitivities of the tests are lower for tertiary disease.The nontreponemal test usually is confirmed with treponemal tests (either the FTA-ABS or MHA-TP) to avoid false positives.
CMV retinitis:It is uncommon to find CMV retinitis in HIV-infected patients with a CD4 count >40 cells/L, and a CD4 count >50-100 cells/L in an individual with retinitis should prompt a reconsideration of the diagnosis of CMV retinal infection.
Toxoplasma retinochoroiditis may be confused with other forms of retinitis, but it usually can be differentiated by the presence of intense, almost fluffy, areas of retinal whitening with accompanying vitritis.Serologic studies have been relatively unreliable for the diagnosis of toxoplasmosis in HIV-infected patients. IgG anti-Toxoplasma antibody titers in patients with toxoplasmosis are sometimes low in the presence of disease.
Source: Ophthalmic Manifestations of HIV (hivinsite.ucsf.edu)
Treatment
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Syphilis:Administration of intravenous penicillin for longer periods resulted in improvement of vision in HIV-positive patients with ocular syphilis.
Herpes zoster ophthalmicus:Although acyclovir may diminish ocular sequelae of HZO in immunocompetent patients, this treatment has not been evaluated systematically in HIV-infected patients.
In the presence of uveitis, topical prednisolone and a cycloplegic should be applied.
In cases of retinitis, choroiditis, or cranial nerve involvement, intravenous acyclovir and oral prednisone are indicated.
Herpes simplex virus: Treatment consists of trifluorothymidine and cycloplegic drugs, with debridement of the ulcer using a cotton-tip applicator.
CMV retinitis: With the introduction of effective ART, the incidence of CMV retinitis has been noted to decrease by about 75%.In the early years of the HIV epidemic, patients unable to tolerate systemic CMV therapy sometimes benefited from intravitreal injection of gancicloviror foscarnet.Direct intraocular administration of ganciclovir has the benefit of achieving therapeutic levels by bypassing the blood-retinal barrier.
Toxoplasma Retinochoroiditis:Treatment consists of pyrimethamine and either sulfadiazine or clindamycin in standard dosages.
Source: Ophthalmic Manifestations of HIV (hivinsite.ucsf.edu)
Illustrations
Information for specialists
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WHO, the UNAIDS Secretariat and their partners are working to develop specific policy recommendations for expanding and promoting male circumcision as a method of HIV prevention. The UN agencies have noted with considerable interest the announcement made by the US National Institutes of Health (NIH) in December 2006 on the results of two trials which showed an approximate halving of risk of HIV infections among men who were circumcised. The trials carried out in Kenya and Uganda, support results from earlier South Africa Orange Farm Intervention Trial in 2005, which demonstrated at least a 60% reduction in HIV infection among circumcised men.
Source: WHO | Male circumcision in HIV prevention (who.int)
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DaunoXome is a new treatment for advanced AIDS-related Kaposi's sarcoma, or KS. KS is a type of cancer that people with HIV may develop. KS is more commonly seen in men than in women. Although KS mainly affects the skin, the mouth, and the lymph nodes, it can also involve the bowels and lungs. If it becomes severe, it may lead to swelling or breakdown of the skin. KS growths, called lesions or tumors, can show up in a wide range of colors, from pink to red-violet to brown to blue. DaunoXome is a liposomal drug. Liposomal drugs are standard chemotherapy drugs used to treat KS that are put inside microscopic bubbles of fat called liposomes. When the drugs are used this way, it is hoped they will have fewer side effects and be more effective. DaunoXome is a liposomal version of the anti-cancer drug daunorubicin. DaunoXome is given intravenously, which means via a tube placed into your arm or chest, once every two weeks. The current standard treatment for advanced KS is a combination of chemotherapy using the drugs Adriamycin, bleomycin and vincristine (ABV). These drugs can have severe side effects including damage to the heart, and also the bone marrow. Your bone marrow makes white blood cells. When you lose white blood cells, you are more likely to get bacterial infections. Additional side effects, such as hair loss and nausea, may impact quality of life during treatment.
Source: Simple Facts Sheets: liposomal daunorubicin (DaunoXome) (atdn.org)
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On February 3 Ligand Pharmaceuticals announced that the FDA had approved Panretin Gel (alitretinoin) for topical treatment of Kaposi's sarcoma; an advisory committee had recommended approval by an 8-1 vote last November. The company has filed for approval in Canada and Europe. Patients apply the gel twice a day. According to Ligand, the cost of a four to six month course of therapy is between $3,900 and $5,800. The main side effect is skin irritation where the drug is applied; in seven percent of the patients, skin toxicity was severe enough to cause them to withdraw from the trials. Panretin capsules (for oral use) have been tested in phase II clinical trials for Kaposi's sarcoma, and tested for several cancers. The active ingredient, alitretinoin (also known as 9-cis retinoic acid), is a derivative of vitamin A, and also a hormone naturally present in the body.
Results of two trials involving 402 patients were presented at the recent Retroviruses conference.1
Source: Safer Sex Guidelines - The Body (thebody.com)
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