HIV and the Eye

Human immunodeficiency virus infection affects the eye in up to 70 to 80 percent of untreated patients with advanced disease. Effective combination antiretroviral therapy has lowered the incidence of sight threatening infection by more than 80 percent, but eye disease still occurs in patients with late presentation, poor adherence, or drug resistance.

• Manifestations by site:
  • Adnexa and anterior segment: herpes zoster ophthalmicus (often early), molluscum contagiosum of lids, Kaposi sarcoma, conjunctival squamous neoplasia, dry eye, keratitis (herpetic, microsporidial, bacterial, fungal), and anterior uveitis (including drug induced, e.g. rifabutin, cidofovir).
  • Posterior segment: HIV microvasculopathy, cytomegalovirus retinitis, acute and progressive outer retinal necrosis, toxoplasma retinochoroiditis, syphilitic and tuberculous chorioretinitis, cryptococcal and candida infection, Pneumocystis choroidopathy, and immune recovery uveitis.
  • Neuro ophthalmic: cryptococcal meningitis with papilloedema and sixth nerve palsy, HIV-associated optic neuropathy, toxoplasma and lymphoma lesions, progressive multifocal leukoencephalopathy (field defects), and cranial neuropathies.
  • Orbital: lymphoma, orbital cellulitis, and Kaposi sarcoma.
• CD4 count guides risk: below 200 (microvasculopathy, zoster, Kaposi), below 100 (toxoplasma, cryptococcus), below 50 (cytomegalovirus retinitis, mycobacterium avium complex).

• Microvasculopathy: asymptomatic cotton wool spots and haemorrhages. Cytomegalovirus retinitis: painless floaters, blurred vision, field loss, necrotic white retinal lesions with haemorrhage along the vascular arcades, minimal vitritis, and progression with retinal detachment.
• Herpes zoster ophthalmicus: vesicular rash in the V1 distribution, Hutchinson sign (tip of nose), keratitis, uveitis, and pain; severe or recurrent in HIV.
• Progressive outer retinal necrosis: rapid loss of vision, multifocal outer retinal opacities starting peripherally, no vitritis.
• Toxoplasmosis: dense focal necrotising retinitis with vitritis, often multifocal.
• Syphilis: unilateral or bilateral uveitis, retinitis, or optic neuropathy.
• Cryptococcal meningitis: headache, papilloedema, and diplopia from raised intracranial pressure.
• Kaposi sarcoma: violaceous lid or conjunctival nodule.
• Immune recovery uveitis: vitritis and macular oedema after CD4 recovery.

• HIV testing with CD4 count and viral load; ophthalmic examination at diagnosis and when CD4 is below 100 (dilated fundus examination every 3 months), plus urgent examination for visual symptoms.
• Slit lamp, dilated fundus examination, optical coherence tomography, fluorescein angiography, widefield photography.
• Aqueous or vitreous polymerase chain reaction for cytomegalovirus, varicella zoster, herpes simplex, and toxoplasma when atypical.
• Systemic tests: syphilis serology, toxoplasma IgG, tuberculosis test, cryptococcal antigen (serum and CSF), lumbar puncture with opening pressure, chest imaging, and brain imaging.
• Biopsy of conjunctival or lid lesions.

• Start or optimise antiretroviral therapy (for example dolutegravir 50 mg with tenofovir and emtricitabine daily) in all patients; for opportunistic eye infections, start within 2 weeks (delay in cryptococcal meningitis and tuberculous meningitis).
• Cytomegalovirus retinitis: valganciclovir 900 mg orally twice daily for 21 days then 900 mg daily; or intravenous ganciclovir 5 mg/kg every 12 hours; plus intravitreal ganciclovir 2 mg in 0.05 mL (or foscarnet 2.4 mg) twice weekly for sight threatening lesions near the macula or disc; maintenance until CD4 above 100 for 3 to 6 months; retinal detachment: vitrectomy with silicone oil.
• Acute and progressive outer retinal necrosis: intravenous aciclovir 10 mg/kg every 8 hours or foscarnet, plus intravitreal foscarnet 2.4 mg or ganciclovir 2 mg, then oral valaciclovir 1 g three times daily.
• Herpes zoster ophthalmicus: valaciclovir 1 g three times daily for 7 to 10 days (or aciclovir 800 mg five times daily), topical steroid for keratitis and uveitis with antiviral cover, and long term suppressive aciclovir 400 mg twice daily if recurrent.
• Toxoplasma retinochoroiditis: pyrimethamine 200 mg then 50 to 75 mg daily with sulfadiazine 1 to 1.5 g four times daily and folinic acid 15 mg daily for 6 weeks or more, or trimethoprim-sulfamethoxazole 160/800 mg twice daily, with prednisolone after antimicrobial cover.
• Syphilis: aqueous benzylpenicillin 18 to 24 million units daily for 10 to 14 days. Tuberculosis: isoniazid 5 mg/kg (maximum 300 mg), rifampicin 10 mg/kg (maximum 600 mg), pyrazinamide 25 mg/kg and ethambutol 15 mg/kg daily for 2 months, then isoniazid and rifampicin daily for 4 months, with pyridoxine 10 to 25 mg daily and oral prednisolone 1 mg/kg daily cover for ocular inflammation.
• Cryptococcal meningitis: liposomal amphotericin B 3 to 4 mg/kg daily with flucytosine 25 mg/kg four times daily for 2 weeks, then fluconazole 400 to 800 mg daily; therapeutic lumbar puncture for pressure above 25 cmH2O to protect vision.
• Kaposi sarcoma and lymphoma: antiretroviral therapy, local therapy (radiotherapy, excision), systemic chemotherapy.
• Immune recovery uveitis: periocular or intravitreal triamcinolone, topical steroid, and antiviral cover.
• Regular screening, adherence counselling, prophylaxis (cotrimoxazole when CD4 is below 200), and low vision support.