This presentation is about the brief introduction of AIDS and its ocular manifestations

1. AIDS , PATHOPHYSIOLOGY
SIGN SYMPTOMS
DIAGNOSIS AND OCULAR
MANIFESTATIONS
1
Presenter :
Pabita Dhungel
B.optometry

2. Presentation layout
• Introduction
• Global prevalence
• Mode of transmission
• Pathophysiology
• Symptoms
• Sign
• Ocular manifestation
• Summary
2

3. introduction
• AIDS – caused by retrovirus ( HIV- virus)
• Eye involvement – 90% Autopsy cases
• Ocular complication in 75% of pts with AIDS
• Visual morbidity & blindness – leading cause
of suicide in pt. with AIDS
• Maybe the first sign of HIV infection – imp.
Role of Eye consultant to make a sight saving
& life sustaining Diagnosis
3

4. Classification of HIV
• Two serological types
• HIV – 1 (world wide)
• HIV – 2 (West Africa & Portugal)
• HIV – 1 • HIV – 2
1.Type M 1. Type A, B,C,D and E
2. Type O
4

5. Global prevalence
• In 2009, WHO estimated 33.4 million people
worldwide living with HIV/AIDS, with 2.7
million new cases of HIV infection per year
and 2.0 million deaths due to AIDS
• In 2007, UNAIDS estimated 33.2 million
people worldwide had AIDS that year,2.1
million deaths that year including 3,30,000
children
5

6. Contd…
• According to UNAIDS 2009 report, 60 million
people have been infected since the start of
pandemic , with 25 million deaths, and 14
million orphaned children in southern Africa
alone
6

7. Global picture
7

8. AIDS prevalence in Nepal
National centre for Aids &Std Control ,Teku 2009/12/1
• Cumulative no.of reported HIV infections(17th
OCT 09)
=14,787( M=9701 +F=5086)
Enrolled in HIV care=13,005
Enrolled in ART = 3,423
Total Deaths =450
People living with HIV as of 31 Dec 2006 (Nepal)
Total -8893
Adults- 5999
Women -2510
Children under 15 years- 364
Newly infected with HIV in 2006- 2681
AIDS deaths in 2006 - 81 8

9. History
• 1st
reported on June 5, 1981 when the U.S
Centers for Disease Control recorded a cluster
of Pneumocystis cariniipneumonia (now still
classified as PCP but known to be caused by
Pneumocystis jirovecii) in five homosexual
men in Los Angeles
• Its cause HIV,identified in the early 1980s
9

10. Mode of transmission
• Sexual contact – 70% of cases
• IV drug use – 27%
• Blood transfusion – 2-3%
• Perinatal transmission – 1%
• HIV has been isolated from all body fluids
including tears, semen, vaginal fluids,
preseminal fluids, and breast milk from
infected person
10

11. Pathophysiology
• HIV attaches to T-cells & monocytes /macrophage that
display a membrane Ag-complex known as CD4.
• The target cells of HIV show different cytopathic effects
• CD4 + helper T-cells – decrease in number – immunodef. –
opportunistic infections
• Macrophage – decreased migration response to
chemoattractants
-defective intracellular killing of mircroorg. (eg.
Toxo. , Candida.)
- impaired Ag presentation
-excessive production of TNF-alpha –leads to
dementia , wasting , unexplained fever.
11

12. Flowchart
Binding to CD4 Internalization Uncoating
Reverse transcriptase
Integrated proviral DNA
Productive infection Latent infection
Mature HIV production
Cell lysis
12

13. Sign and Symptoms
• Symptoms are usually
result of decrease in
Immunity, opportunistic
infections are common
affecting nearly every
organ system
• High chance of
developing cancers like
Kaposi sarcoma,
cervical cancer and
lymphomas
13

14. System related Symptoms
• Pulmonary
• Pneumocystis pneumonia is common in HIV infected
individuals
• 1st
indication of AIDS in untested individuals
• Doesn’t occur unless the CD4 count is less than 200
cells/µL of blood
• TB with HIV co-infection is major world health
problem
14

15. Pulmonary contd…
• In early HIV(CD4 count >300 cells/µL) TB
typically present as pulmonary disease
• In advanced cases of HIV it occurs as
extrapulmonary affecting bone marrow, bone,
urinary and gastrointestinal tracts , liver,
regional lymph nodes and the CNS
15

16. Gastrointestinal
• Esophagitis is common due to fungal
(candidiasis) or viral (herpes simplex-1 or
CMV) infections, rarely Mycobacterium
• Unexplained chronic diarrhoea due to
bacterial (Salmonella, Shigella, Listeria or
Campylobacter) and parasitic and
opportunistic infections like cryptosporidiosis,
microsporidiosis and viruses viz astrovirus,
adenovirus, rotavirus , CMV etc
16

17. Neurological and psychiatric
• Toxoplasmosis caused by Toxoplasma gonadii
infects the brain causing toxoplasma
encephalitis affecting eyes and lungs
• Cryptococcal meningi caused by Cryptococcus
neoforman causing fevers, headache, fatigue,
vomiting and also seizures and confusion
17

18. Contd…
• Progressive multifocal leukoencephalopathy
(PML) is a demylinating disease with gradual
destruction of myelin sheath impairing
transmission of nerve impulses
• Caused by virus called JC virus which occurs in
70% of population in latent form, causing
disease only when immune system has been
weakened as in the case of AIDS patients
18

19. Contd…
• AIDS dementia complex (ADC) is a metabolic
encephalopathy induced by HIV infection and
fueled by immune activation of HIV infected
brain macrophages and microglia
• Prevalence is 10-20% in Western countries
19

20. Tumors
• High incidence due to co-infection with
oncogenic DNA virus, especially Epstein – Barr
virus (EBV), Kaposi’s Sarcoma- Associated
Herpesvirus (KSHV) and Human Papillomavirus
(HPV)
• Kaposi’s sarcoma is the most common tumor
in HIV infected patients
20

21. • Lymphomas often arises in extranodal sites
such as gastrointestinal tracts
• AIDS patients are at increased risk of certain
tumors like Hodgkin’s disease , rectal
carcinomas, hepatocellular carcinomas, head
and neck cancers and lungs cancer
21

22. Other infections
• Includes opportunistic infections causing low
grade fevers and weight loss
• Opportunistic inf. with Mycobacterium avium
intracellulare and CMV causes colitis, CMV
retinitis leading to blindness
• Penicilliosis due to Penicillium marneffei is 3rd
most common opportunistic infection (after
extrapulmonary TB and cryptococcosis)
22

23. Diagnosis
• Lab. Inv. – depends on :
• Demonstration of virus sp. Ab by ELISA and
Western Blot
• Viral Ag by EIA( Enzyme immunoassay)
• Detection of HIV Nucleic acid by PCR
• Viral P24 Ag detection
23

24. WHO staging diagnosis
• Given by WHO in September 2005
• Stage I: asymptomatic and not catagorized as
AIDS
• Stage II: minor mucocutaneous and recurrent
URTI(upper respiratory tract infection)
• Stage III: chronic diarrhoea, pulmonary TB
• Stage IV: toxoplasmosis of brain, candiasis of
oesophagus, trachea, lungs, Kaposi’s sarcoma
24

25. HIV Staging with CD4 counts
• CD4 counts Normal- 600- 1500 cells/cumm
• 250-500/cumm– oral candidiasis , disseminated TB
• 150-200/cumm- Kaposi sarcoma, Lymphoma,
Cryptosporidiosis
• 75-125/cumm – pneumocystis carinii, mycobact.
avium, HS, toxo, cryptococcosis, esophageal candida
• <50 cell/cumm- CMV retinitis
25

26. Ophthalmic Manifestations of HIV
Infection
26

27. CMV Retinitis
• Most common ocular infection in pts. with
AIDS, & maybe the initial manifestation
• Prior to HAART (Highly Active Antiretroviral
Therapy)- 15-40% of AIDS pts.
• Untreated CMV – is a progressive and
destructive infection- leads to blindness
• CMV – double stranded DNA virus,
herpetoviridae
27

28. Clinical Features
28

29. • Brush Fire- leading active border due to
spread by direct extension
• optic nerve involvement
• RD
29

30. Diagnosis
• Blood C/S
• Urine C/S
• PCR( sensitive & specific – 46 days – 6 months)
to dev. CMV retinitis
• Fundus exam. Is essential – pt. with CMV +
blood ,urine c/s or extraocular CMV disease
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31. MANAGEMENT
• Drugs Used: ( Virostatic)
1.Gancyclovir
2.Foscarnet
3.Cidofovir
4.Formivirsen
31

32. Toxoplasma Retinochoroiditis
32

33. • Decreased vision
• Moderate granulomatous uveitis ( AC+Vit-
cells)
• Retina :
Focal areas of necrotizing retinitis
Abs of pre existing scars (pr 4-6%)
• ~ 25% pts. –intracranial involvement( Imp. to
do intracranial imaging study in all AIDS pts.
With ocular toxpl.)
33

34. • D/D-
CMV retinitis , PORN
• T/T:
Pyrimethamine(50mg/dailly)+ sulfanamide(4-
6gm/daily)+clindamycin(300mg x QID) –folinic
acid
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35. HIV Retinopathy
• Most common ocular finding in
AIDS pts(50-70%)
• Features: cotton wool spots, retinal
hmg, miroaneurysms
• Infection capillary
endothelium & retinal tissue
• Deposition of immunocomplex
• Disseminated intravascular
microangiopathy
• Increased RBC aggregation
• Increased blood viscosity
• Capillary closure Ischemia
Cotton wool spots( along
vascular arcade, focal area of NFL
ischemia)
35

36. Progressive Outer Retinal Necrosis
(PORN)
• Caused by Herpes Zoster (HZ)
• Rapid destruction of retina
• Disease starts in one eye – fellow eye usu.
Involves subsequently
36

37. • Deep outer retinal lesions in a circumferential
pattern in the peripheral retina
• lesion coalesce ,progress to full thickness
retinal necrosis in a matter of days
• Rapid diminution of vision
( sparing of the perivascular retina)
37

38. 38

39. PORN - Diagnosis
• H/o HZ inf. In the skin or elsewhere
• Rapid progressive & sparing of the retinal
vessels and the adj. area
• CD4 < 50 cells/mm3
D/D
• CMV retinitis /toxoplasmosis.
Retinochoroiditis
T/T
• I.V. gangciclovir /foscarnet with acyclovir
• Oral sorivudine
39

40. Acute Retinal Necrosis (ARN)
• Caused by: HZ & HS
• Clinical features:
• Decreased vision with pain
• Photophobia
• Floaters
• Granulomatous uveitis
• Marked vitritis
• Multiple white opaque patches of
thickened retina (periphery)
enlarges gradually & coalaesce
• RD
• 1/3 B/L involvement
40

41. Other Forms Of Retinitis
• Protozoa : Pneumocystis carinii choroiditis
• Fungal : Cryptococcosis
• Candidiasis
• Bacterial : Tubercular retinitis
• Spirochaete : Treponema Pallidum
Syphilitic retinitis
41

42. Herpes Zoster ophthalmicus
• If young pts have HZ of the face or eyelids
Suspect HIV infection
• Corneal involvement:
persistent, chr. Epithelial keratitis
• T/T: Systemic acyclovir : I.V 10mg/kg/8hrly
oral 600-800mg 5x daily
conjunctivitis, keratitis, uveitis –t/t accordingly
• Regular FU
42

43. Herpes Simplex infection
Keratitis:
• Prolonged course
• Multiple recurrence
• Involve the limbus
Bacterial & Fungal Keratitis
– More aggressive & likely to cause perforation
– Difficult or non responsive to t/t
– Microsporidia
– Punctate epithelial keratopathy
– Mild conjunctivitis
43

44. Molluscum Contagiosum (MC)
• Causative agent:
• DNA Virus ( Poxvirus)
• Eyelids:
• Umbilicated skin papule
• Multiple >10 B/L
• Size: large >5mm
• Resistant to therapy
• Follicular conjunctivitis
• T/T:
• Surgical excision
• cautery, cryotherapy to the
base
44

45. conjunctival Squamous cell
carcinoma
• third most common neoplasm associated to HIV infection.
• occurs due to Papilloma Virus infection.
• appears as a pink, gelatinous growth, usually in the
interpalpebral area. Often an engorgedblood vessel feeding
the tumour is seen.
• It may extend onto the cornea, but deep invasion and
metastasis are rare.
• •The treatment of choice is local excision and cryotherapy
• but the presence of orbital invasion is an indication of
exenteration
45

46. Conjuctival SCC
46

47. Trichomegaly
• Trichomegaly or
hypertrichosis is an
exaggerated growth of
the eye lashes found in
the later stages of the
disease
• The cause is not known
• When symptomatic or
for cosmetic reasons
the eyelashes can be
trimmed 47

48. Dry Eye
• • Sicca syndrome is
frequent among patients
with HIV infection
• •Patients complain of
burning uncomfortable red
• eyes.
• causes of dry eye in HIV
infection from blepharitis,
due to destruction of the
• lacrimal glands.
• •T/T with tear supplements
48

49. Anterior uveitis
• HIV related anterioruveitis can be:
• – Direct manifestation of the human
immunodeficiency virus infection
• – autoimmnune in origin
• – drug induced ie: rifabutin, secondary to direct toxic
effect upon the non-pigmented epithelium of the
ciliary body
• –Any of the different infections
• associated with AIDS, ie: Herpes Zoster Virus, Herpes
Simplex Virus,Cytomegalovirus, Toxoplasma gondii,
Syphilis 49

50. • Candida albicans endophthalmitis
• •Infection with candida albicansis rare.
• Candida albicans is the commonest cause of fungal
endophthalmitis
• •Affected patients usually have a history of drug
abuse
• •In the initial stages, floaters are the main symptom.
As the condition progresses, whitish “puff-balls”and
vitreous strands develop. Later, similar infiltrates
appear in the choroid and retina
50

51. • •The treatment depends on the severity of
the ocular involvement and systemic disease.
The original foci should be removed. The
drugs of choice are Amphotericine BBand
Fluconazol
51

52. Non Infectious Ocular Manifestation
Kaposi’s Sarcoma
• 30% of the pts/ with AIDS
• Multifocal malignant
sarcoma
Ocular
• Eyelid
• Conjunctiva inf. Fornix
• Orbit
Proptosis
Ptosis
Ocular nerve palsy
52

53. Other Non infective Ocular
Manifestation
• Keratoconjunctivitis sicca: 10-15%
• Thrombocytopenia – Subconjunctival
Hemorrhage
• Peripheral corneal ulceration
• CN palsy
• Papilloedema
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