What are the posterior segment ocular manifestations in HIV infection?

Updated: Jul 21, 2021
  • Author: Luca Rosignoli, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Complications of CMV retinitis include papillitis, seen in about 5% of these patients, and retinitis. Cystoid macular edema, retinal vascular occlusion, and rhegmatogenous retinal detachment (RRD) may result from CMV retinitis. [20]  The incidence of RRDs tends to increase with time in patients with CMV retinitis, with a cumulative probability of 26-61% in different studies.

Immune recovery uveitis (IRU) is a HAART-dependent inflammatory response that may occur in up to 63% of patients with regressed CMV retinitis and elevated CD4+ counts. IRU is thought to be secondary to a response to CMV antigens. IRU is generally recognized in its most severe form by an increase in intraocular inflammatory reactions within weeks after starting HAART, or it may manifest later by the presence of inflammation and may be associated with vision loss from epiretinal membrane, cataract, neovascularization of the retina or optic disc, and cystoid macular edema.

Patients with large areas of CMV retinitis and a history of cidofovir use have an increased risk for IRU. To reduce the risk of developing IRU, induction of CMV therapy before initiation of HAART should be considered.

Acute retinal necrosis (ARN) frequently presents with anterior uveitis, retinal and choroidal vasculitis, vitritis, and papillitis. Episcleritis, scleritis, or optic neuropathy may also be present. During the initial phase of the infection, the severity of the retinitis can lead to exudative retinal detachment. After the resolution of the retinitis, however, traction between the posterior hyaloid  and the resulting gliotic scar of the necrotic retina may occur, leading to retinal tears at the interface between the normal and necrotic retina with subsequent RRD. In as many as 75% of cases, ARN may be complicated by RRD 2-3 months after onset. [21]

Complications of progressive outer retinal necrosis (PORN) may include macular retinitis, optic nerve disease, acute vitreous hemorrhage, and/or retinal detachment. Up to 66% of patients diagnosed with PORN become blind within 6 weeks of diagnosis despite aggressive treatment.

Posterior segment complications of syphilitic infection may include posterior placoid chorioretinitis, neuroretinitis, vitritis, pigmentary chorioretinopathy, choroiditis, papillitis, choroidal neovascular membranes, and retinal vasculitis. Posterior segment complications of tuberculosis include scleritis, disseminated chorioretinitis, panophthalmitis, and papillitis. These ocular manifestations tend to occur in patients with other extrapulmonary disease.

Pneumocystis jirovecii choroidopathy usually results in minimal vitritis. The major cause of morbidity and/or mortality in patients with P jirovecii infection results from the debilitating pneumonia.

Chorioretinal scarring secondary to posterior segment pathology can result in the formation of choroidal neovascular membranes. Intraocular inflammation can lead to the development of epiretinal membranes. Cases of choroidal neovascularization after Toxoplasma chorioretinitis have been described. [22]  

Disseminated histoplasmosis has a high mortality rate in patients with AIDS. This disease tends to have a fulminant course, usually complicated by disseminated intravascular coagulation. Ocular complications of disseminated histoplasmosis include retinitis, choroiditis, optic neuritis, or uveitis. Secondary choroidal neovascularization also may develop.

The most frequent intraocular sequela of cryptococcal infection is chorioretinitis. With inadequate treatment, endophthalmitis may result. Other reported ocular complications of cryptococcal infection include disc edema, optic atrophy, and ophthalmoplegia.

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