HIV and AIDS

Ocular HIV/AIDS - Immune Meltdown

• HIV infection causes progressive depletion of CD4+ T-helper lymphocytes, leading to systemic immune dysfunction.
• Declining CD4 count is the primary marker of immunosuppression, dictating risk for ocular complications.
  • CD4 < 200 cells/µL: Significant risk for opportunistic infections (OIs).
  • CD4 < 50 cells/µL: Severe risk for sight-threatening OIs (e.g., CMV retinitis).
• Ocular manifestations arise from:
  • Direct HIV effects (HIV retinopathy).
  • Opportunistic infections (viral, fungal, parasitic).
  • Neoplasms (Kaposi sarcoma, lymphoma).
  • Neuro-ophthalmic lesions.
  • Drug toxicities.

⭐ HIV retinopathy (cotton wool spots, hemorrhages) is the most common ocular finding, typically seen when CD4 count drops below 200-500 cells/µL, but is often asymptomatic and non-progressive without direct vision threat.

Ocular HIV/AIDS - Retinal Red Zone

• HIV Retinopathy: Most common ocular finding in AIDS. Non-infectious microvasculopathy.

  • Features: Cotton Wool Spots (CWS), retinal hemorrhages, microaneurysms.
  • Usually asymptomatic; may indicate advanced immunosuppression.

• CMV Retinitis: Most common opportunistic ocular infection. Risk ↑ with CD4 < 50 cells/µL.

  • Appearance: "Cottage cheese & ketchup" or "pizza pie" (hemorrhagic, full-thickness necrosis). Indolent, progressive.
  • Tx: Systemic/intravitreal antivirals (ganciclovir, foscarnet), HAART crucial.

• Necrotizing Herpetic Retinopathies (NHR):

  Feature	CMV Retinitis	PORN (VZV)	ARN (VZV/HSV)
  CD4 (cells/µL)	< 50	< 100 (often < 50)	Variable, often > PORN
  Inflammation	Mild vitritis, minimal AC	Minimal/Absent	Significant (vitritis, vasculitis)
  Onset/Prog.	Indolent, sectoral	Rapid, multifocal outer retinal necrosis	Acute, peripheral, circumferential
  Pain	No	No/Mild	Often present

⭐ CMV retinitis is the leading cause of blindness in AIDS patients if untreated or if HAART fails.

Ocular HIV/AIDS - Anterior Arena Alerts

• Herpes Zoster Ophthalmicus (HZO):
  • Vesicular rash in V1 (ophthalmic division of trigeminal nerve) distribution.
  • Hutchinson's sign (lesion on tip/side/root of nose) indicates ↑ ocular involvement risk (keratitis, uveitis, neuralgia).
  • 
• Molluscum Contagiosum:
  • Multiple, waxy, pearly, umbilicated nodules on eyelids/adnexa.
  • If on lid margin, can shed viral particles causing chronic follicular conjunctivitis.
  • 
• Kaposi Sarcoma:
  • Typically violaceous, reddish-purple, vascular lesion on conjunctiva or eyelids.
  • May be flat or slightly raised; can be mistaken for subconjunctival hemorrhage.
• Other Considerations:
  • Conjunctival Microvasculopathy: Non-specific; telangiectasias, irregular vessels, sludging.
  • Keratoconjunctivitis Sicca (KCS): Common; dry eyes due to lacrimal gland involvement.
  • Infectious Keratitis: Increased susceptibility (bacterial, fungal, viral).

⭐ In HIV-positive individuals, Herpes Zoster Ophthalmicus (HZO) tends to be more severe, may occur at a younger age, has a higher rate of recurrence, and is associated with more complications compared to immunocompetent individuals.

Ocular HIV/AIDS - Neuro & Rebound Risks

• Neuro-ophthalmic Lesions:
  • Cranial Nerve (CN) Palsies: CN III, IV, VI (most common), VII; causing diplopia, ptosis, or facial palsy.
  • Optic Neuropathy: Includes papillitis, neuroretinitis; causes ↓VA, dyschromatopsia, visual field loss.
  • Papilledema: Due to ↑ICP from CNS infections (cryptococcal meningitis, toxoplasmosis) or lymphoma.
  • Others: Nystagmus, complex pupillary defects (e.g., light-near dissociation).
• Immune Reconstitution Inflammatory Syndrome (IRIS):
  • Paradoxical worsening of OIs (esp. CMV retinitis) after HAART initiation.
  • Onset: Weeks-months post-HAART as CD4 count ↑ (e.g., >50 cells/µL rise).
  • Signs: ↑Inflammation (uveitis, vitritis, CME, optic disc edema).
  • Management: Corticosteroids. ⭐ > IRIS can unmask subclinical CMV retinitis post-HAART, presenting as new inflammation with rising CD4. 📌 IRIS: Inflammation Reacting to Infections Suddenly.

High‑Yield Points - ⚡ Biggest Takeaways

• CMV retinitis: Most common opportunistic infection (CD4 < 50), "pizza-pie" hemorrhagic retinitis.
• HIV retinopathy: Most common ocular finding; cotton wool spots, hemorrhages; non-infectious.
• HZO: Increased severity and recurrence in HIV patients.
• Molluscum contagiosum: Multiple, widespread eyelid lesions are common.
• Kaposi's sarcoma: Violaceous eyelid or conjunctival nodules.
• IRU: Uveitis post-HAART, often linked to prior CMV.
• Increased risk of ocular syphilis and tuberculosis co-infections.