Ocular manifestations of HIV are specific changes in the organ of vision caused by the addition of an opportunistic infection in patients with a history of HIV infection. The clinical picture is determined by the nature of the lesion. Common symptoms for most forms are decreased visual acuity, scotomas, photopsias, color perception disorders, photophobia, increased lacrimation. Diagnosis is based on the use of PCR, ELISA, instrumental diagnostic methods (visometry, ophthalmoscopy, perimetry, tonometry, biomicroscopy, ultrasound, CT of the head). Antiretroviral and symptomatic therapy is used for treatment.
Ocular manifestations occur in 70-80% of patients with HIV infection. Approximately 50% of patients have symmetrical involvement of both eyeballs in the pathological process. The prevalence of cytomegalovirus retinopathy in people infected with the immunodeficiency virus is 30-40%. In 5% of cases, irreversible damage to the optic nerve is observed. 30-35% of people with this pathology have a high risk of irreversible vision loss. In 30-50%, intraorbital manifestations are complicated by damage to the nervous system. Ocular manifestations occur with the same frequency among males and females. Geographical features of distribution are not noted.
The cause of eye damage is infection with the human immunodeficiency virus, which belongs to the retrovirus family, and the addition of an opportunistic infection. The source of the spread is a sick person. The virus is contained in the biological media of the body (blood, semen, breast milk, vaginal secretions, cerebrospinal fluid). The infecting dose is 10,000 viral particles. Ways of transmission of infection: sexual, hematogenic and vertical (from mother to child). The eyes are affected when infected blood enters the open mucous membranes (conjunctiva) or the virus penetrates through the hematophthalmic barrier.
The immunodeficiency virus can be identified in the membranes of the eye and watery moisture, but pathological changes are caused not by the pathogen itself, but by associations of other microorganisms. Activation of an opportunistic infection causes recurrent inflammatory processes of intraocular localization. Infection with cytomegalovirus leads to cell lysis and the development of a granulocytic reaction. Due to the violation of the rheological properties of the blood, ischemic manifestations occur due to occlusive arteritis, periflebitis. The appendages of the eye (eyelids, lacrimal pathways) are most often affected by herpes zoster virus, Kaposi’s sarcoma, less often by contagious mollusk.
The central form of toxoplasmosis leads to focal necrotizing chorioretinitis. Extrapulmonary manifestations of pneumocyst infection provoke damage to the uveal tract. With traumatic eye damage, there is a high probability of aspergillosis. An increase in triglyceride levels entails an increase in cytokine synthesis. This mechanism underlies the development of retinal lipemia. The intake of protease inhibitors aggravates the violation of lipid metabolism. Intensive damage to cells on the surface of which CD4 receptors are located leads to the progression of pathological changes.
At the initial stages of the development of pathology, eye lesions have an asymptomatic course. With the progression of changes in the retina and optic nerve, patients complain of loss of certain areas of the visual field, impaired color perception and contrast sensitivity. The development of cytomegalovirus retinopathy leads to photopsias, the appearance of floating opacities or “shrouds” in front of the eyes, visual dysfunction. Eye damage is often bilateral. A pronounced pain syndrome is noted with the herpetic nature of the disease. At the same time, small bubbles with serous contents appear on the skin of the eyelids and the ocular region, which indicates the development of vesiculobullous dermatitis.
Neurological symptoms are represented by photophobia, double vision, small-scale movements of the eyeballs when trying to fix the gaze. In some cases, blepharospasm occurs caused by paralysis of the cranial nerves. With intrauterine infection of the fetus, there is a high risk of developing visual organ abnormalities (anophthalmos, corneal coloboma). Kaposi’s sarcoma with localization on the eyelids or orbital conjunctiva is characterized by an asymptomatic course for a long time. The growth of the neoplasm complicates the process of closing the eyelids, leads to the development of local inflammatory reactions in the form of hyperemia and swelling of the membranes of the anterior segment of the eyes.
Vitreous hemorrhage can reach the degree of total hemophthalmos. Hypopion, hyphema occurs less often. Prolonged course of aspergillosis leads to the formation of a cataract and multiple erosive defects on the surface of the cornea with the risk of its perforation. There is a high probability of bacterial and infectious lesions of the anterior part of the eyes (conjunctivitis, keratitis). Secondary dacryocystitis may develop. In rare cases, the pathological process extends to the bones of the skull and brain tissue. In 20% of patients, retinal detachment is observed due to necrosis of certain areas of the inner shell of the eyes. Complications from the nervous system are represented by cryptococcal meningitis, lymphoma of the meninges, neurosyphilis.
To diagnose HIV infection, a polymerase chain reaction (PCR) is performed, which makes it possible to identify fragments of RNA or DNA of the virus. Enzyme immunoassay (ELISA) allows you to detect specific antibodies to the virus. In order to assess the severity of immunodeficiency, the content of CD4 lymphocytes is studied. The complex of specific ophthalmological examination includes:
- Ophthalmoscopy. When examining the fundus, an ophthalmologist reveals signs of retinal microangiopathy, vascular aneurysms. On the inner shell of the eye, “cotton-like” spots, hemorrhage zones, signs of optic nerve atrophy are determined. Retinal vessels acquire a milky-white color. With retinochorioiditis of toxoplasmosis genesis, pigmented scars are visualized on the retina.
- Ultrasound of the eyes. Ultrasound examination is indicated when the optical media of the eye are clouded. Pathological changes of the optic nerve are represented by an increase in the depth of its physiological excavation in the presence of areas of edema on the retina.
- CT of the head. It is used to detect tumors of intraorbital localization (Kaposi’s sarcoma, lymphoma).
- Retinal angiography. A violation of regional blood flow caused by the aggregation of shaped elements is determined.
- Biomicroscopy of the eyes. With aspergillosis of the eyes, the affected area on the cornea has a white or yellowish color with a dry surface. The focus is limited by the infiltration shaft.
- Perimetry. There is a concentric narrowing of the visual field. Multiple scotomas are detected.
- Visometry. The degree of decrease in visual acuity depends on the nature of the damage to the retina and optical nerve fibers, varies from minor dysfunction to complete blindness.
- Non-contact tonometry. The presence of volumetric formations of intraocular localization provokes an increase in intraocular pressure.
Etiotropic therapy of HIV infection has not been developed, but the use of antiretroviral drugs can slow the progression of the disease. The effectiveness of symptomatic treatment of visual disorders increases with the use of antiviral drugs that inhibit the persistence of the virus in the body. With the development of infectious keratitis, retinitis or vesiculobullous dermatitis caused by herpes zoster, intravenous administration of acyclovir, famciclovir is indicated. Dry keratoconjunctivitis in combination with xerophthalmia requires the appointment of artificial tear preparations, moisturizing ointments.
Treatment of toxoplasmosis retinochorioiditis is based on the use of pyrimethamine, sulfonamides, clindamycin. Acute course of iridocyclitis in HIV-infected patients requires instillation of glucocorticosteroids in combination with short courses of antibacterial therapy. With cytomegalovirus retinitis, cidofovir, foscarnet, ganciclovir are used. The tactics of treatment of patients with Kaposi’s sarcoma is reduced to the appointment of chemo- or cryotherapy, surgical excision of the neoplasm, intra-tumor administration of cytostatics. With aspergillosis of the structures of the eyeball, antifungal therapy is indicated. The expediency of intravenous use of amphotericin B, itraconazole has been proved.
Prognosis and prevention
The outcome of the disease is determined by the viral load, the features of eye damage and the course of the underlying pathology. According to the statistics collected in ophthalmology, the risk of complete vision loss is 40%. Non-specific preventive measures are reduced to the prevention of infection with the immunodeficiency virus (the use of contraceptives, sterilization of medical instruments, the fight against injecting drug addiction). Patients are recommended to give preference to eyeglass correction of visual acuity over contact lenses. Specific methods of prevention have not been developed, but the use of antiretroviral therapy significantly improves the prognosis.