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Table of Contents   
ORIGINAL ARTICLE  
Year : 2012  |  Volume : 5  |  Issue : 5  |  Page : 474-478
Ocular manifestations in human immunodeficiency virus/acquired immuno deficiency syndrome patients and their correlation with CD4+ T-lymphocyte count


1 Department of Ophthalmology, IGMC, Shimla, Himachal Pradesh, India
2 Department of Medicine, IGMC, Shimla, Himachal Pradesh, India

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Date of Web Publication27-Dec-2012
 

   Abstract 

Aim: To study the various ocular manifestations in HIV/AIDS patients and their correlation with CD4+ cell count. Materials and Methods: In this study, 125 HIV-positive patients were studied for ocular features of HIV in the Department of Ophthalmology and Department of Medicine, for a period of 1 year. Statistical Analysis: Correlation of ocular findings with CD4+ cell count was analyzed using the Chi-Square test and 'P' valve was calculated at 95% confidence limit. Results: Out of 125 HIV-positive patients, 70 were men and 55 were women. Ninety-seven (78%) were in the age group of 21-40 years. Ocular findings were seen in 41(33%) patients. Heterosexual transmission was the most common risk factor 118(94%). HIV retinopathy was the most common ocular lesion in 19 patients (46%) followed by anterior uveitis in 4 patients (10%). Among systemic lesions, pulmonary tuberculosis was common in 27 (22%) patients followed by oral candidiasis in 15 (12%) patients. Out of 41 (33%) ocular finding positive patients, 35 (85%) had CD4+ cell count less than 200 cells/mm 3 . Conclusion: HIV retinopathy and opportunistic ocular infections were common in HIV/AIDS patients. Ocular lesions were more common when CD4+ cell count was less than 200 cells/mm 3 . All patients who had CD4+ cell count less than 200 cells/mm 3 must undergo complete ophthalmic checkup to rule out ocular lesions.

Keywords: Acquired immuno deficiency syndrome, Human immunodeficiency virus, ocular manifestation

How to cite this article:
Sharma RL, Panwar P, Gupta R, Sharma A, Chaudhary K. Ocular manifestations in human immunodeficiency virus/acquired immuno deficiency syndrome patients and their correlation with CD4+ T-lymphocyte count. Ann Trop Med Public Health 2012;5:474-8

How to cite this URL:
Sharma RL, Panwar P, Gupta R, Sharma A, Chaudhary K. Ocular manifestations in human immunodeficiency virus/acquired immuno deficiency syndrome patients and their correlation with CD4+ T-lymphocyte count. Ann Trop Med Public Health [serial online] 2012 [cited 2018 Aug 18];5:474-8. Available from: http://www.atmph.org/text.asp?2012/5/5/474/105136

   Introduction Top


HIV infection is the first major pandemic of 20 th century faced by mankind. This potentially lethal multi system disorder is caused by retro virus the Human Immunodeficiency virus (HIV).The virus infects the T-lymphocytes, resulting in profound immunodeficiency leading to opportunistic infections and neoplasm. It was first described in 1981 in Los Angeles, USA. HIV was detected in India in 1986. [1] Ocular lesions were first described by Holland et al in 1982. [2] First two cases of ocular lesions in AIDS patients from India were reported by Biswas et al in 1995. [3] According to National AIDS control organization (NACO, New Delhi), the number of HIV-positive patients in India was 5.2 million at the end of the of 2006, [4] and number of AIDS cases reported up to August 2006 were 124,995. [5] The life time cumulative rate of developing ocular lesions in HIV patients is 52-100% in various studies. [6] The role of Ophthalmologist in the management of HIV-infected patients is therefore becoming increasingly important. The present study was conducted to evaluate the various ocular lesions in HIV positive patients. As CD4 + T-lymphocyte count proved a reliable predictor of immune status of patient for the risk of various infections, [7] so in this study we correlated the ocular lesions with CD4 + cell count.

Ocular manifestations in HIV/AIDS patients …………..


   Material and Methods Top


This was a prospective study which included 125 HIV-positive patients, who reported in the Department of Ophthalmology or in the Department of Medicine during this period (June 2006-May 2007). Diagnosis of HIV was based upon the (1) Capillus test (latex agglutination test) (2) HIV-COMB or ALON test (immune- chromatography), and (3) ELISA test under World Health Organization (WHO), strategy III. While classifying the HIV disease, CD4+ T-lymphocyte count and recommendations of centers of control and stage guidelines were applied [8] All HIV-positive patients were examined for ocular findings on the day of presentation and later called for follow up accordingly. The ophthalmic examination included: visual acuity, external eye examination, ocular motility, pupillary reflexes, anterior segment examination by slit lamp biomicroscopy and dilated fundus examination by indirect Ophthalmoscopy. Ultrasound was performed in those eyes where the view of fundus was not possible due to hazy media. Systemic evaluation of patients was done in the Department of Medicine. Relevant laboratory and radiological investigations were carried out in all patients and information was recorded on Performa. CD4 + T-lymphocyte count was obtained in all cases and correlation of ocular findings with CD4 + cell count was analyzed using the chi-square test.

The patients were divided into four groups (I, II, III, IV) on the basis of range of CD4 + cell count

Group 1- patients with CD4 + cell counts more than 500 cell/mm 3

Group II - with CD4 + cell count between 200-499 cells/mm 3 .

Group III - patients with CD4 + cell count between 51 and 199 cells/mm 3 .

Group IV - with CD4 + cell counts less than 50 cells/mm 3 .

Ocular findings were grouped according to CD4 + cell count, among the 125 HIV positive patients, enrolled for the study CD4 + cell count of 115 patients was taken as 10 patients did not come for follow up.

Ocular manifestations in HIV/AIDS patients …………..


   Results Top


Total of 125 HIV-positive patients were examined for their ocular findings. Out of 125 cases, 70 (56%) were men and 55 (44%) were women. The age of patients ranged between 3 and 55 years, with median age being 29 years and most common age group infected was 21-40 years in 97 (78%) patients [Figure 1]. The common complaints were irritation, decreased vision, watering, and redness. HIV infection was acquired through heterosexual transmission in 118 (94%) and 7 children (6%) acquired the disease through perinatal transmission.
Figure 1: Graphical representation of age and sex distribution of HIV positive patients with and without ocular finding

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The various professions of patients included: drivers 41 (61%), hotel worker 9 (13%), and army men 8 (12%) [Figure 2]. The most common systemic disorder was pulmonary tuberculosis in 27 (22%) patients. Next to follow were oropharyngeal candidiasis in 15 (12%) patients, extrapulmonary tuberculosis in 6 (5%), pyogenic meningitis in 6 (5%), HIV enteropathy in 5 (4%), pneumocystis carinii pneumonia in 4 (3%), cryptococcal meningitis in 3 (2%), genital ulcers in 2 (2%), and syphilis in 2 (2%) patients. One patient (1%) was each of herpes zoster skin lesion, herpes labialis, and of Steven Johnson syndrome [Figure 3].
Figure 2: Graphical representation of profession of the HIV-positive male patients

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Figure 3: Graphical representation of systemic lesions in HIV-positive patients

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Ocular lesions were seen in 41 (33%) patients. Most common ophthalmic manifestation was HIV retinopathy in 19 (46%) patients. Next most common lesion was anterior uveitis in 4 (10%) patients. Other lesions seen were ocular toxoplasmosis in 3 (7%), corneal opacity in 3 (7%), acute retinal necrosis in 2 (5%), cytomegalovirus (CMV) retinitis in 2 (5%), choroidal tubercles in 2 (5%), papilledema in 2 (5%), herpes zoster ophthalmicus in 2 (5%), optic atrophy in 1 (2%), keratitis in 1 (2%), ulcerative blepharitis in 1 (2%), stye in 1 (2%), and 6th nerve palsy in 1 (2%) patient [Figure 4].
Figure 4: Graph showing ocular manifestations in HIV-positive patients

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With the use of CDC criteria, out of 125 HIV/AIDS cases, 85 (68%) patients had AIDS and 40 (32%) patients had not yet developed AIDS. Out of these 85 AIDS cases, 35 (41%) patients had ocular lesions, whereas out of 40 HIV-positive cases without AIDS, only 6 (15%) patients had ocular findings. In our study, HIV retinopathy was manifested by cotton wool spots and intraretinal hemorrhages. Out of 19 HIV retinopathy patients, 18 patients had CD4 + cell count less than 200 cell/mm 3 . Anterior uveitis was present in four (10%) patients while two HIV positives had involvement of both eyes and two had uniocular involvement. Posterior segment was normal in all four patients. Two patients were on highly reactive anti retroviral therapy with CD + cell counts less than 200 cells/mm 3 . Investigations did not reveal any specific cause. Three (7%) patients had corneal opacities. All of them had peripheral corneal involvement with normal vision. CD4 cell count of only one patient was less than 200 cells/mm 3 .

Ocular toxoplasmosis was seen in three (7%) patients. All three patients had unilateral retinitis. Two patients had chorioretinal lesion with vision better than 6/36 and one had multifocal lesions over posterior pole vision less than 6/60. On serological examination, IgM antibodies were raised in all. All of them had CD4 + cell counts less than then 200 cells/mm 3 . Two patients responded to septran, whereas one did not came for follow up. CMV retinitis was seen in 2(5%) patients. Both had unilateral involvement with vision HM in involved eyes, other eyes were normal with 6/6 vision. Fulminant type of retinitis was seen in these patients. CD4 + cell count of both patients was less than 50 cells/mm 3 . The finding of acute retinal necrosis was seen in 2 (5%) patients. In one case both eyes were involved with vision 2/60 and 3/60. In second one, only one eye had retinitis with sever visual loss (PL+). CD4 + cell count of both cases was less than 200 cells/mm 3 . Choroidal tubercle was seen in two (5%) patients. Both patients were diagnosed pulmonary tuberculosis. Both of these patients had unilateral diseases with 6/24 and 6/36 vision in infected eyes. CD4 + count was 41 and 183 cells/mm 3 , respectively.

Bilateral papilledema was seen in 2 (5%) patient who were suffering from cryptococcal meningitis. Visual acuity was normal in both with CD4 + cell count more than 200 cells/mm 3 . One (2%) patient had optic atrophy. She was on antitubercular treatment for tubercular meningitis, so possibility of post papilledema optic atrophy was kept. Vision was 6/36 in both eyes with CD4+ cell count 147 cells /mm 3 .One patient (2%) had 6 th nerve palsy of left eye with normal vision in both eyes. She was diagnosed as pyogenic meningitis and on treatment with CD4 + cell count 47 cells/mm 3 . HZO was seen in two (5%) patients. One patient had active disease with CD4 + cell count 143 cell/mm 3 , where as other patient presented with phthisis bulbi and scars over right forehead. His CD4 + cell count was 25 cell/mm 3 . One (2%) patient had infective keratitis in right eye with visual acuity 6/60. Corneal scrapping and repeated culture were negative with CD4 + cell count 25 cells/mm 3 . Adnexal infections were ulcerative blepharitis and stye each in one (2%) patient.


   Discussion Top


Since its first report in 1981, AIDS had spread rapidly across the continents. Worldwide there are about 37.2 million adult and 2.8 million children are infected with HIV [9],[10] and about 5.2 million are in India. The incidence of HIV is increasing in this country since 1986, when first case of HIV was reported from Chennai. [4] The life time cumulative rate of developing ocular lesion in HIV patients is 52-100% in various study. [6] The role of Ophthalmologist in the management of HIV-infected patients is therefore becoming increasingly important.

In our study, the majority of patients were men 70 (56%), and most of them (78%) were in the age group of 21-40 years. Heterosexual transmission was the most common (94%) mode of transmission of HIV infection, which is reported 85% in national figure. [5] None of the patient was infected by blood transfusion, intravenous drug abuse, or by homosexual contact. In our series, 41(58%) male patients were drivers, suggesting that the people of this profession are under high risk of acquiring the disease. Most of them possibly acquired the disease through contact with commercial sex workers during their visit away from home. In our study, all positive females (51) acquired their disease from their positive husband.

The most common systemic disorder among our patients was pulmonary tuberculosis in 27 (22%) patients. Study by Chacko et al[11] on clinical profile of AIDS in India reported 30% cases of pulmonary tuberculosis, because pulmonary tuberculosis is widely prevalent in India. The ocular involvement in HIV was seen in lesser no. of patients (33%) as compared to the other studies in the US where (50%) [12] and Africa (66%) [13] had ocular features of the disease. This might be due to that patients infected with HIV in India do not undergo routine ophthalmic evaluation. They are often referred for ophthalmic examination only if they complain of problem associated with vision. This may result in under estimation of HIV.

Ocular manifestations in HIV/AIDS patients ………

retinopathy and early peripheral CMV retinitis, which can be asymptomatic. Further it was reported [14] that ocular lesions were more common in homosexual patients with AIDS and in our study, there was no case of homosexual transmission.

HIV retinopathy in 19 (46%) patients was the most common lesion seen in our patients, which was slightly less as compared to study done by Jab. [12] As HIV retinopathy does not cause much visual impairment, so it possibly remains undetected. The incidence of HIV retinopathy was more common in AIDS patients; out of 19 HIV retinopathy patients, 18 had CD4 + cells count less than 200 cells/mm 3 . The correlation of retinopathy with CD4 + cells count was statistically significant as P value was 0.02; when the CD4 + cells count decreases in patients of HIV there is an increase in immune complexes in peripheral circulation which blocks the small vessels such as retinal arterioles and leads to HIV retinopathy.

CMV retinitis was seen in two (5%) patients. Number of patients who had CMV retinitis in our series (5%) was much lower than the rate reported by Jabs et al[12] in United States (37%). Lower proportion of CMV retinitis in our patients may be due to unavailability of routine ophthalmic check of HIV infected patients. CD + cell count of both these patients was less than 50 cells/mm 3 , as reported in earlier studies. [7] Ocular toxoplasmosis was seen in 3 (7%) patients.

Toxoplasma gondii in HIV is usually seen as reactivation of old chorioretinal lesion as a result of immune-suppression. All the three patients seen in present study had severe depletion of immunity as all fell in group III (CD4 + cells count between 51 and 199 cells/mm 3 ). These results show that opportunistic ocular infection due to toxoplasma gondii increases as immunity of patient decreases, especially when CD4 + cells count becomes less than 200 cell/mm 3 as reported in earlier studies. [7] Jabs et al[12] and Biswas et al[15] both reported toxoplasmosis in 1% of patients in HIV.

Choroidal tubercles were seen in two (5%) patients who had pulmonary tuberculosis also. Both of these patients had unilateral diseases with severe degree of immunosupression as CD4 + cell count in both these patients was less than 200 cells/mm 3 . Sahu et al[16] reported findings of tubercular chorioditis in two (10%) patients and Biswas et al[17] reported in four (6%) cases.

Acute retinal necrosis was seen in 2 (5%) patients both had CD4 + count less than 200 cells/mm 3 because ARN is usually seen after severe immuno depression. Saho et al[16] reported single case of ARN in their series with concurrent HZO. HZO was more common in African study (23%) [13] as compared to two (5%) in our study. The pattern of other manifestations such as anterior uveitis (10%), corneal opacities (7%) papilledema 2 (5%), optic atrophy, 6 th nerve palsy, infective keratitis, blepharitis, and stye were seen each in 1 (2%) patients. These features were similar in other studies.

There were no case of Kaposi's sarcoma, choroidal pneumocystosis, retinal vessel occlusion, and molluscum contagiosum of the eye in this study. Other ocular lesions such as CMV retinitis, ARN, toxoplasmosis, tubercular choroiditis, anterior uveitis, corneal opacity, keratitis, stye, ulcerative blepharitis, papillodema, optic atrophy, and 6th nerve palsy were seen in few patients, so the correlation with CD4 cell count was not statistically significant.

In the present study, we found that the chances of ocular lesions increased proportionally as the CD4 + cell count fall from group I-IV (>500 to <50). The studies have shown [18],[19] ocular findings such as HIV retinopathy; opportunistic infection of retina such as CMV retinitis, ARN, toxoplasmosis and tubercular choroiditis usually seen in our patients when there was profound depletion of immunity i.e. when CD4 + cell count was less then 200 cells/mm 3 . So, every patient who had CD4 + cell less than 200 cells/mm 3 must undergo complete ophthalmic checkup to rule out ocular lesions.

 
   References Top

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4.National AIDS Control Organization (NACO), Ministry of Health and Family Affairs, Government of India. Surveillance for HIV infections/AIDS cases in India. April 2006.  Back to cited text no. 4
    
5.National AIDS Control Organization (NACO), Ministry of Health and Family Affairs, Government of India. Surveillance for HIV infections/AIDS cases in India. 31 August 2006.   Back to cited text no. 5
    
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14.Khadem M, Kalish SB, Goldsmith J. Ophthalmological findings in AIDS. Arch Ophthalmol 1984;102:201-6.  Back to cited text no. 14
    
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17.Biswas J, Madhavan HN, George AE, Kumarasamy N, Solomon S. Ocular lesions associated with HIV infections in India: A series 100 consecutive patients evaluated at a referral center. Am J Ophthalmol 2000;129:9-15.  Back to cited text no. 17
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Correspondence Address:
Ram Lal Sharma
Department of Ophthalmology, IGMC Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.105136

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