Saudi Journal of Medicine and Medical Sciences

IMAGE QUIZ
Year
: 2017  |  Volume : 5  |  Issue : 2  |  Page : 193--196

An HIV patient with a unilateral decrease of vision


Faisal M. K. Malik 
 Department of Ophthalmology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

Correspondence Address:
Faisal M. K. Malik
Department of Ophthalmology, King Fahd Hospital of the University, P.O. Box 30319, Al-Khobar 31952
Saudi Arabia




How to cite this article:
Malik FM. An HIV patient with a unilateral decrease of vision.Saudi J Med Med Sci 2017;5:193-196


How to cite this URL:
Malik FM. An HIV patient with a unilateral decrease of vision. Saudi J Med Med Sci [serial online] 2017 [cited 2021 Apr 17 ];5:193-196
Available from: https://www.sjmms.net/text.asp?2017/5/2/193/204865


Full Text

A 38-year-old man was diagnosed with HIV infection 1 year ago. Three months after the diagnosis, he complained of blurring vision in the left eye with floaters. The patient's vision was 6/9, and the fundoscopy image is shown in [Figure 1]. Further, the patient had no other AIDS-defining illnesses.{Figure 1}

 Questions



What are the findings? What is the diagnosis?

Answers

See the answer in page 196.

 Answers



A large irregular patch of retinal necrosis appearing as a white, fluffy lesion with overlying retinal hemorrhages, following the superior retinal vessel arcade and soft exudate with a flame-shaped hemorrhage infranasal to the optic nerve. Cytomegalovirus retinitis.

 Discussion



Cytomegalovirus retinitis (CMVR) remains one of the most common opportunistic ocular infections in patients with AIDS. This disease occurs in HIV-positive patients with profound immunosuppression, i.e., patients with a CD4 T-lymphocyte count of ≤50 cells/mm 3.[1],[2],[3] Although advances in antiretroviral therapy (ART) such as highly active ART (HAART) have significantly reduced the incidence of this disease, active CMVR in patients with higher T-cell counts can occur through the deletion of CMV-specific CD4 memory cells or blunted T-cell response.[1],[2],[3],[4]

HAART is a combination of two nucleoside reverse transcriptase inhibitors and at least one protease inhibitor or nonnucleoside reverse transcriptase inhibitor. The combination has proven to significantly reduce the number of plasma HIV messenger RNA copies and to increase the number of CD4+ T lymphocytes. Since the introduction of HAART, the incidence of CMVR has declined by 50–80%.[4],[5] The strongest predictor for CMVR in the pre-HAART era was the absolute CD4 count, and the risk was directly correlated with lower CD4 counts.[1],[2],[3],[4]

Most of the cases start as an unilateral retinal necrosis, and later, if left untreated, the second eye can be involved.

Many patients with CMVR experience no symptoms. However, some of the following signs that may be indicative of CMVR:

Floaters in the eye Flashes in the eye Blind spots or blurred vision Loss of peripheral vision.

Diagnosis

The most common clinical presentation is typical retinal necrosis with retinal hemorrhage progressing along the major retinal vessels emerging from the optic nerve. Further, the hemorrhages are more prominent than necrosis, CMVR can be differentiated from other retinal necrosis-causing diseases such as herpes retinitis.

During the early stages, the disease can start as multiple soft retinal exudate (cotton wool spots) with retinal hemorrhage and with minimal ocular symptoms.

In atypical cases, virtuous fluid is needed for polymerase chain reaction to reconfirm the diagnosis.[4],[5]

Treatment

There are several antiviral medications that minimize the effects of CMVR such as ganciclovir, valganciclovir, foscarnet and cidofovir. The sooner the treatment is started, the better is the chance of improving the vision. In addition, if only one eye is infected, receiving proper systemic treatment early may protect the other eye.

Oral, intraocular (intravitreal) or intravenous medication are used to slow the progression of the disease, and the dose should be evaluated on a weekly basis.[4],[5]

References

1Fekrat S, Dunn JP, Lee D, Miller T, Jabs DA. Cytomegalovirus retinitis in HIV-infected patients with elevated CD4 counts. Arch Ophthalmol 1995;113:18.
2Jabs DA, Green WR, Fox R, Polk BF, Bartlett JG. Ocular manifestations of acquired immune deficiency syndrome. Ophthalmology 1989;96:1092-9.
3Freeman WR, Lerner CW, Mines JA, Lash RS, Nadel AJ, Starr MB, et al. A prospective study of the ophthalmologic findings in the acquired immune deficiency syndrome. Am J Ophthalmol 1984;97:133-42.
4Freeman WR, Gross JG. Management of ocular disease in AIDS patients. Ophthalmol Clin North Am 1988;1:91-100.
5Palella FJ Jr., Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N Engl J Med 1998;338:853-60.