ocular manifestations of aids
TRANSCRIPT
ETIOLOGY
• HIV-1 & HIV-2
• Lenti virus sub family of retrovirus
• HIV-1 Most common
• HIV-1 two sub types M & O
• Sub types of M –A to H
• B,C,A – found in India
• CD4 < 200 cells/ul• Blood borne disease• Heterosexual , infected blood transfusion , transplacental ,iv
drug abuse• 36 million• 70% develop ocular manifestations
OCULAR MANIFESTATIONS
CD4 COUNT DISEASE
1000 cells/mm3 Normal
<500 Kaposi sarcoma
Lymphoma , T.B.
<250 Toxoplasma ,
Pneumocystis carni
<100 C.M.V. Retinitis
VZ Retinitis,HIV
retinopathy, sicca s
syndrome
ANTERIOR SEGMENT
MOLLUSCUM CONTAGIOSUM
• Pox virus - DNA virus• Umblicated nodules• Treatment- Excision , currettage or cryotheray
HYPERTRICHOSIS
• Exaggerated growth of eye lashes
• Cause unknown
• Treatment- trimming of eye lashes
- plucking
HERPES ZOSTER OPHTHALMICUS• Herpes Zoster virus
• Reactivation
• Dermatomal pain -> Rash
• Keratitis
• Conjunctivitis, episcleritis ,scleritis,
uveitis, glaucoma, pthisis bulbi
Treatment-Acyclovir 3 % e/o 5 t/d
Tab Acyclovir 800mg 5t/d
KAPOSI’S SARCOMA
• Vascular neoplasm
• Commonest anterior segment lesion
• Herpes virus – 8
• Eyelids - purple nodules
• Conjunctiva – red mass
• Uncommon in India
• Treatment Of Choice -RT
CONJUNCTIVAL SQUAMOUS CELL CARCINOMA• Interaction b/w HIV , sunlight , HPV
• Pink gelatinous growth
• Temporal bulbar conjunctiva
• Feeding blood vessel
• TREATMENT- Excision & cryotherapy
• Exenteration – if orbit inolved
KERATOCONJUNCTVITIS SICCA• Destruction of lacrimal glands• Burning uncomfortable red eyes• TREATMENT-artficial tear drops
- lubricating e/o
ANTERIOR UVEITIS
• Herpes simplex
• Herpes Zoster
• C.M.V.
• Toxoplasmosis
• Syphilis
• Drug induced - Rifabutin
HIV RETINOPATHY
• > ½ -3/4 patients
• Microangiopathy
• Asymptomatic
• Cotton wool spots
• Retinal haemorrhages
• Microaneurysms
• Differentiate from DM & HTN Retinopathy
CMV RETINITIS
• Commonest opportunistic infection
• Floaters – earliest to occur
• DOV , floaters , flashes or asymptomatic
• Cottage cheese with tomato ketchup appearance
• Progress in brushfield pattern
• Retinal detatchment
• Treatment – Photocoagulation
• Silicon oil tamponade
TREATMENT OF CMV RETINITIS• Gancyclovir
5mg/kg 12 hrly iv x 2-3 weeks
5mg /kg 24 hrly iv x stable retinitis
Oral 300-450 mg OD
• Gancyclovir implant- 1ug/hr x6-8 months
• Intravitreal injections – 200 -2000ug/0.1 ml
Every week
S/E - Bone marrow supression
Therefore TC –twice weekly
• Foscarnet – gancyclovir resistant cases
60 mg/kg iv 8 hrly x2-3 weeks
90-200 mg/kg iv 24 hrly
Intravitreally – twice /week –induction
(2.4mg/0.1 ml)once /week – maintainence
• Valgancyclovir – induction-900mg BD
- maintainence–900mg OD
• Cidofovir-5mg /kg iv once weeklyx2 wks
+ probenecid
ACUTE RETINAL NECROSIS
• Herpes Zoster infection
• Peripheral whitening lesions
• Vitritis & macular odema
• Resolution - multiple sieve like holes
• Confirmed by PCR assay of vitreal sample
• Treatment – acyclovir iv 10mg/kg 8hrly
X10-14 days
Oral acyclovir 5t/d x6-12 weeks
PROGRESSIVE OUTER RETINAL NECROSES (PORN)• Varicella Zoster virus
• White lesions in mid & peripheral retina
• Rapid loss of vision
• Treatment– iv gancyclovir or G+Foscarnet
• Or intravitreal foscarnet
• Poor prognosis
• resolution- cracked mud appearance
TOXOPLASMA CHORIORETINITIS• Toxoplasma gondii – protozoan
• Less common than encephalitis
• Floaters , flashes , DOV
• Head light in fog appearance
• Treatment – systemic steroids 1mg/kg +
1 Clindamycin 300 mg qid x 3-4 weeks
2 Sulphadiazine 1gm qid x 3-4 weeks
+ pyrimethamine + folinic acid
SYPHILIS
• MC - Uveitis
• Retinitis ,Optic neuritis , papillodema
• Treatment – high dose iv penicillin
FUNGAL INFECTION
• Candida & cryptococcus - MC
• Snowball like lesions
• Cryptococcus meningitis – papilledema , optic neuropathy
• DOC – Amphotericin B + Fluconazole
TREATMENT
• Along with specific HAART therapy
• HAART = Highly active anti retroviral therapy
• 3 drugs
• 2 nucleoside reverse transcriptase inhibitors + 1 protease inhibitor or 1 NNRTI