OCULAR MANIFESTATIONS OF HIV/AIDS AT MOI
A dissertation submitted in part fulfilment for the degree of masters of Medicine
(Ophthalmology) at the
DR. NGONA BANGA LISTO
This dissertation is my original work and has not been presented for a degree at any other university.
Dr. Listo Ngona Banga
This dissertation has been submitted in part fulfilment of the degree of masters of medicine in ophthalmology with our approval as university supervisors.
Dr. K.H.M. Kollmann (FEACO)
(Goettingen), MD (Goettingen), DTMMP (
Lecturer, Department of Ophthalmology,
Dr. K. Kimani
(U.O.N), M.Med.Opthalmol. (U.O.N), MSC CEH (UCL,
Department of Ophthalmology,
Dr. C. Owino
MBChB (U.O.N), M.Med. Opthalmol. (U.O.N)
Department of Ophthalmology,
This dissertation is dedicated to my darling Mami Grace, our beloved daughters Benita, Atali, Abigail and Eunice.
I am grateful to my supervisors, Dr. KHM Kollmann and Dr. K Kimani, and Dr. C Owino, for their invaluable assistance and healthy critique, without which this study would not be what it is.
Many thanks to the administrations of Moi Teaching Referral Hospital, AMPATH clinic, for allowing this study to be carried out in their institutions and for giving all the necessary assistance.
Special thanks to all my lecturers in the department of ophthalmology for their invaluable support towards my study in ophthalmology. I also thank the consultants at KNH, all support staff at the department and KNH and my colleagues. I also wish to thank CBM for their support.
LIST OF ABREVIATIONS
AIDS : Acquired Immunodeficiency Syndrome
AMPATH : Academic Module for Prevention and Treatment of HIV/AIDS
ARVT : AntiRetroviral Therapy
CMV : Cytomegalovirus
ETB : Extra-pulmonary tuberculosis
HAART : Highly Active antiretroviral therapy
HIV : Human Immunodeficiency Virus
HZO : Herpes Zoster Ophthalmicus
HZ : Herpes Zoster
NNRTI : Non-nucleoside Reverse Transcriptase inhibitors
NRTI : Nucleoside Reverse-transcriptase Inhibitors
WHO : World Health Organization
OPC : Oropharyngeal Candidiasis
TB : Tuberculosis
KS : Kaposi Sarcoma
PGL : Peripheral Generalized Lymphadenopathy
AIM: The management
of patients with HIV/AIDS has improved in
This was a hospital based cross sectional
RESULTS: A total of 200 HIV/AIDS Patients were examined. The prevalence of ocular findings was 77%. The most common findings were observed in the posterior segment in 53% of the patients, followed by anterior segment in 26.5%. Retinal microvasculopathy (37.5%), chorioretinitis (4.5%), vitreous opacities (4%), macular edema (4%) and CMVretinitis (2.5%) were the main posterior segment findings. Fibrous membrane attached to the iris mostly near the papillary margin (18.5%) and iridocyclitis (5.5%) were the main anterior segment findings. Conjunctival growth (6.5%), Herpes zoster ophthalmicus (6.5%) and Kaposi (5%), conjunctival microvasculopathy (4%) and molluscum contagiosum (2.5%) were the main ocular adnexal findings. Tuberculosis was the main systemic finding (53%).
CONCLUSIONS: The prevalence of ocular finding in HIV/AIDS patients at MTRH was found to be high at 77%. Retinal microvasculopathy was the commonest retinal findings observed. Ocular findings were directly related to the severity of the clinical state of the disease (WHO clinical staging; p value 0.001) and to the severity of immune suppression (CD4+ count; p =0.044).
The earliest known case of HIV was from a blood sample
collected in 1959 from a man in
The etiologic agent of AIDS is a retrovirus designated HIV, (Human Immunodeficiency Virus) (3). The CD4 T Lymphocyte is the primary target for HIV infections because of the affinity of the virus for the CD4 surface marker. The CD4 T Lymphocyte coordinates a number of important immunologic structures and loss of these, result in progressive impairment of the immune response. The CD4 T Lymphocyte counts are used to guide clinical and therapeutic management of HIV infected patients.
Since it was first described in 1981, Acquired Immunodeficiency Syndrome (AIDS) has become a major concern to all doctors, irrespective of their area of study or specialization. Ophthalmologists have not been spared. They are often called upon to make the initial diagnosis of AIDS, most often; however, they are requested to help treat the ocular manifestation of related opportunistic infection. These can have disastrous consequences for sight, especially for patient who are first seen when already markedly debilitated.
Practicing ophthalmologists are faced with the challenges to recognize and treat potentially sight threatening conditions and to identify unusual presentations.
The Human Immuno-deficiency Virus (HIV) infection has spread worldwide with various adverse health economic implications particularly in the developing world.
A global summary of the HIV/AIDS epidemic from December 2003 by joint United Nations Program for HIV/AIDS (UNAIDS) and WHO estimate that there are 40 million people worldwide living with HIV/AIDS (5).
At present about 90% of HIV infected persons live in
developing countries in particular in sub-Sahara Africa and
The eye is affected in 50 -75% of adult patients (6). These observations indicate that regular screening of HIV positive patients is warranted to allow early identification of potential vision and life threatening disease (7) .
There are several ways of making a diagnosis of HIV/AIDS.
The HIV tests available for diagnosis include antibody testing such as Enzyme Immune Assay (home kits, rapid tests, saliva tests, urine tests, and vaginal secretion), Immunofluorescent Assay and Western Blot. The available antigen tests include P24 antigen and peripheral blood monocyte Polymerase Chain Reaction (PBMC DNA PCR).
Plasma viral load can also be measured using the reverse transcriptase polymerase chain reaction method. This involves amplifying proviral DNA in the laboratory so that a diagnosis of infection can be made. It does not depend on antibodies but on the presence of the virus within the monocytes and allows diagnosis of infection in infant who still carry antibody passed from the HIV+ mother.
The viral life cycle is important when considering the drugs to combat HIV. New drugs under development target different parts of the life cycle. Reverse transcriptase is targeted by 3 classes of drugs; the NNRTI ( non nucleoside reverse transcriptase inhibitors), the NRTI ( nucleoside reverse transcriptase inhibitors) and the nucleotide RTI. Viral protease is targeted by protease inhibitors drugs such as ritonavir and Fusion is targeted by fusion inhibitors drugs such as enfuvirtide.
Figure 1: Viral cycle indicating the action points of drugs (3, 5)
The detailed mode of action of the 3 classes of antiretroviral is as follows:
a. Reverse transcriptase (RT) inhibitors (NRTI, NNRTI): inhibit reverse transcriptase (prevent copying of viral RNA to DNA, blocks subsequent steps in viral replication). The nucleoside (NRTI)/nucleotide analogues compete with natural substrate while non nucleoside inhibitors (NNRTI) bind at different site and change activity.
b. Protease inhibitors (PI): inhibit the protease enzyme thereby preventing viral proteins from becoming functional. They mimic peptide bonds i.e. look like proteins to the protease enzyme and they compete with the natural substrate.
c. Fusion inhibitors: prevents fusion of viral envelope with the cell membrane and prevents entry of viral RNA and proteins into cell.
CD4+ count in lymphocyte proved to be a reliable predictor of ocular complications in HIV infection (8). The increased use of highly active antiretroviral therapy has allowed substantial and sustained, albeit incomplete, repopulation of T lymphocytes to occur in many patient. Such observations have raised the question whether reconstituted T lymphocyte population are in fact functional and, more specially, whether the current or the lowest CD4 T lymphocyte count is a better predictor of the risk of HIV- associated disorders.
For years, the CD4+ T-lymphocyte count proved a reliable predictor of the risk of ocular complications of HIV infection (Table 1). Recently, however, the use of highly active antiretroviral therapy (HAART), which consists of a combination of nucleoside reverse transcriptase inhibitors, HIV protease inhibitors and non nucleoside reverse transcriptase inhibitors, has decreased plasma levels of HIV RNA and increased CD4+ T lymphocyte counts, improving the immune function of patients with HIV infection (6). The clinical presentation of HIV related diseases may be modified by HAART, which has dramatically improved the prognosis of HIV infection. Before the introduction of HAART, patients with cytomegalovirus retinitis commonly had CD4+ counts less than 50 cells/µl, usually with minimal ocular inflammation (7). There are reports of spontaneous resolution of cytomegalovirus retinitis in patients with increased CD4+ counts related to such therapy, although the recovery in T lymphocyte may take months (9). Nevertheless, substantial intraocular inflammation in patients with healed cytomegalovirus retinitis receiving HAART has been reported, which is known as immune recovery uveitis (6).
Table 1: CD4 + T -Lymphocyte Count in Patients Presenting with Common HIV-Associated Disorders Involving the Eye (6,8)
Retinal / Conjuctival microvasculopathy
Varicella zoster virus retinitis
Mycobacterium avium complex infection
Progressive multifocal leucoencephalopathy
Teaching and Referral Hospital (MTRH) is located in the Rift Valley Province of
hospital has’ since grown to incorporate the Academic Model for the Prevention
and Treatment of HIV/AIDS (AMPATH) which is a Kenya-USA partnership between Moi
University School of Medicine, MTRH in Eldoret, in collaboration with USA
Medical schools headed by Indiana School of Medicine. AMPATH has 18
comprehensive HIV/AIDS care clinics in urban and rural centres in
The overriding goal of AMPATH is to establish a working model of both urban and rural comprehensive HIV preventive and treatment services, representing the unique attributes of academic institutions. AMPATH has structured its patients care programs to simultaneously provide HIV related teaching and research. The pilot phase of AMPATH began in November 2001. In a bid to mount a meaningful response to the HIV pandemics, AMPATH has set up infrastructure and human resources capable of effectively managing the complex issues surrounding anti retroviral therapy and cost effective systems that ensure sustainable patients care and support. Established in November 2001, with funds born largely by private donations from the US and selected grant support, it has made significant progress and the last few years: established adult and paediatric HIV treatment services at Moi Teaching and Referral Hospital and other satellite hospitals and health centres like Mosoriot, Turbo, Burnst Forest, Amukura, Naitiri, Chulaimbo, Webuye, Kitale, Kapengura, Teso, Mt ELGON, Iten, Kabarnet, Busia and Port Victoria; trained medical staff in the provision of comprehensive multi dispensary care of HIV infected patient; demonstrated cost effective initial workup, treatment strategies and monitoring of HIV infected adults and children; developed a fully computerized medical record and data registry; established a fully functional HIV reference laboratory capable of providing CD4-counts, viral load and PCR DNA testing.
It has been the goal of AMPATH to demonstrate working programs worthy of ongoing support by agencies, foundations and the Government of Kenya. It is at this clinic with it’s large patient turnover that this research was carried out.
Numerous ophthalmic manifestations of HIV infection may involve the anterior or posterior segment of the eye. Since the first report of the ocular manifestations of AIDS by Holland et al. in 1982 (10), subsequent studies have described several AIDS related conditions in the eye and orbit.
2.1.1 Adnexal Manifestations
The ocular adnexal include the eyelids, conjunctiva, and lachrymal drainage system. In a review article by Cunningham et al the most common complications affecting these structures are herpes zoster, Kaposi’s sarcoma, Molluscum contagiosum, conjunctival growth and conjunctival microvasculopathy (8).
In a study
by Giorgis et al in
In a study in
Another Study in
2.1.2 Anterior Segment Manifestations
The anterior segment includes the cornea, anterior chamber and iris. Cunningham et al noted that the most common visually important complications include dry eyes (keratoconjunctivitis sicca), cornea infection (keratitis), and anterior chamber inflammation ( iridocyclitis) (8). Differences in the prevalence have been reported in different parts of the World.
Ndoye et al in
2.1.3 Posterior-Segment Manifestations
The posterior segment includes the retina, choroid, and optic-nerve head. More than half of HIV-positive patients have disorders involving these structures(10). Diagnoses are usually based on characteristic clinical findings observed on dilated fundus examination with the use of either a direct or an indirect ophthalmoscope.
Posterior segment findings as noted by Cunningham in a review article included HIV associated retinopathy and a number of opportunistic infections of the retina (CMV Retinitis, VZV retinitis, Toxoplasmic retinochoroiditis, bacterial and fungal chorio-retinitis ) and infectious choroiditis (8).
Mvogo at al in
In Ethiopia, Giorgis et al in a study in the armed forces found uveitis and CMV
retinitis in 4 out of 65 patients (6.2% each) (12). In Gambia Jaffar et al
found no cases of CMV retinitis but cotton wool spots were noted and their
conclusion was that CMV retinitis is less common in
2.1.4 Neuro-Ophthalmic Manifestations
Cunningham et al in their review noted that
papilloedema from elevated intracranial pressure, cranial nerve palsies, and
ocular motility disorders are significant findings in patients with
HIV/AIDS. Visual field defects have also
been reported (8). Assefa at al conducted a study to describe the ocular manifestations
of HIV/AIDS documented at
Copeland et al noted that neuro-ophthalmological manifestations are not necessarily a marker of the disease severity although some sight threatening eye disease in AIDS patients occur at late stage in the disease when the immunity has been severely compromised ( CD4 cell count<100/mm³ (6).
The pattern of ocular manifestations in HIV/AIDS patients observed in different studies seem to suggest that it is related to the CD4 count (16).
Giorgis et al in a cross sectional study in
Mvogo et al in
Ndoye et al in
et al in
Ah-Fat et al suggested that with the improvement of treatment and patients’ survival, ophthalmic complications are now being seen with increasing frequency in AIDS, occurring in up to 75% of patients during the course of the disease (25).
In the USA in 1998 a study was conducted to determine whether the maintenance therapy can be discontinued in patients with quiescent CMV retinitis and increased CD4 count after active treatment with highly active anti retro therapy (HAART). The results showed that discontinuation of therapy may be considered in patients with HAART induced elevated CD4 count above 100 cells /uL (24).
To determine the prevalence and pattern of ocular manifestations in adolescents and adults with HIV/AIDS at MTRH (AMPATH clinic).
1. To determine the prevalence of ocular manifestation in HIV/AIDS patients attending HIV/AIDS care clinic (AMPATH).
2. To determine the association between ocular manifestations and CD4+ T lymphocyte count in patients with HIV/AIDS.
3. To determine the association between ocular manifestations and systemic diseases in patients with HIV/AIDS.
A cross sectional hospital based study.
Adolescents and adults with HIV/AIDS attending AMPATH clinic.
- Patients diagnosed with HIV/AIDS attending AMPATH clinic. The diagnosis made in AMPATH clinics was based on ELISA test results.
- All patients of aged 15 years and older were recruited into the study. The age of 15 was considered a cut off point for adolescents in this study. This cut off point has been used in most HIV/AIDS studies as it is considered the age at which most subjects are sexually active.
- Patients who gave written informed consent. In patients too young to give consent this was obtained from their parents or guardians.
HIV seronegative patients and those who refused consent.
Sample Size Justification:
The sample size was determined by the following formula:
Where n = required sample size,
P = prevalence of the population set at 0.3,
D = Precision of the Study set at 0.1 (10%) and
Both Zcrit is the cut off points along the x-axis of the standard normal probability distribution that represents probabilities matching the 95% confidence interval (1.96).
Substituting the above in the formulae we get;
n ≈ 121.01
= 121 patients
This formula was chosen because the study design of this study is a cross sectional hospital based study.
The study was carried out in Eldoret at MTRH (AMPATH clinic).
3 weeks from 31 March to 21 April 2008.
The data was recorded on a well structured questionnaire. Care was taken to minimize the risk for missing and erroneous data. Data was then cleaned and entered on a specially designed SPPS data analysis sheet.
Data analysis was done using SPSS version 12.0. A p- value of less than 0.05 was considered statistically significant.
The following material was used:
· A formulated questionnaire.
· Pens and books.
· Torches/spotlights with batteries and spares bulbs.
· Snellen chart literate and illiterate.
· Slit lamp.
· Direct and indirect ophthalmoscope
· Loupes +20, +90 Ds
· Mydriatics: tropicamide, mydriatic cocktail, cyclopentolate.
· Pencils( colored)
· Scheme and sheet for fundus drawing
· Dry gauze
Patients were randomly recruited daily from the AMPATH clinic. On average, about 100 patients were seen every day. Daily, only 20 patients were randomly selected for the study. Upon arrival at the clinic patients were allocated numbers from 1 to 100. The first patient (number 1) was picked, followed by every other 5th patient (i.e. patients number 5, 10, 15, etc). The aims and the procedures of the study were explained and those who consented to participate were examined. The ocular examination had the following format:
- Visual acuity test: Snellen chart
- Color vision test: Ishihara test
- Tonometry: Goldmann applanation
- Anterior segment examination : slit lamp
- Dilated fundus examination with mydriatics: 90 D slit lamp biomicroscopy and 20 D binocular indirect fundoscopy.
The medical records of the patients were used to obtain information on systemic diseases, HIV status, CD4 counts and use of antiretroviral therapy.
Potential bias in measuring predictors: CD4-count is considered a reliable predictor of ocular manifestations. However, the lower limit for CD4 count to predict ocular involvement in HIV/AIDS is difficult as some patient may have ocular manifestations with a normal CD4-count.
Laboratory tests like CD 4 counts, renal function tests and histology for conjunctival tumours had already been done where appropriate. It was therefore difficult to confirm some diagnosis or get the new tests if needed. Some patient had tumours in situ and diagnosis was made based on clinical judgement.
The study period was short and was preceded by post election violence . This could mean that the cases we saw were the very sick ones who needed urgent treatment.
· The Institutional research and ethics committees (IREC) were informed and appropriate approval was obtained.
· Informed consent (both verbal and written) was obtained from all participants. For subjects not capable of giving informed consent, surrogate consent was obtained.
· Anonymity was ensured by using an anonymous case form which was filled by the investigators.
· Results were communicated to the patients and appropriate treatment was instituted where necessary.
· Confidentiality and privacy was maintained throughout the study. Data was stored savely and only made accessible to the researchers.
· There was no gender or racial biases.
Table 2: Baseline Data of the Study Patients (n = 200)
Age (years) - 38.65 (±0.74) 36.0 (32 –44)
15 - 24 9 (4.5)
25 – 34 71 (35.5)
35 – 44 72 (36.0) - - -
45 – 54 30 (15.0)
55 – 64 13 (6.5)
64 + 5 (2.5)
Male 68 (34.0) - - -
Female 132 (66.0)
The mean age of the study participants was 38.65
years with a standard deviation of 0.74. The median was 36.0 yrs and the
interquantile range was 32 – 44 years.
There were more females (66%) recruited as compared to males (34%).
Figure 2: Distribution by Sex (n = 200)
The ration of females to males was 2:1.
Figure 3: Distribution by Level of Education (n=200)
More patients had a primary school level of education.
Figure 4: Distribution by Age (n = 200)
Most of the participants were in the age group
between 25 yrs and 44 years (71.5%).
Figure 5: WHO Visual Acuity Classification in Better Eye (n = 200)
Five percent of the study participants were blind in this study based on the WHO ICD – 10 classifications. All the five patients with CMV retinitis had bilateral involvement and all of them were in WHO category of blindness. Also in this group were patients with bilateral optic atrophy and some with bilateral chorioretinitis. Severe visual impairment and visual impairment were mostly due to a combination of anterior and posterior segment features.
Figure 6: Prevalence of Ocular Manifestation among patients HIV/Aids (n =200)
The overall prevalence of ocular manifestations was 77% in the AMPATH HIV/AIDS patients.
Figure 7: Pattern of Ocular Manifestation (n = 200)
manifestations were noted in the posterior segment (53%). In the anterior
segment, iridocyclitis was predominat in patients with posterior segment
findings such as retinal microangiopathy and chorioretinitis.
Table 3: Ocular Examinations: Summary of Findings (n = 200)
Extra Ocular Motility
Anterior Segment Manifestation
Two cases of papilloedema and 2 cases of papillitis were attributed to cryptococcal meningitis.
Figure 8: Adnexal Findings (n = 52)
The conjunctival growths noted were suspicious lesions. They were not degenerations like pingueculas. Squamous cell carcinoma confirmed by histology was noted in 5.8% of the patients.
Figure 9: Anterior Segment Findings (n = 52)
Cyclitic pupillary membranes were the commonest anterior segment finding (50.7%). The diagnosis of acute simplex keratitis was based on the clinical picture.
Figure 10: Posterior Segment Findings (n = 103)
Signs of retinal microvasculopathy noted included cotton wool spots, retinal dot and flame shaped haemorrhages.
Figure 11: Neurophthalmology Findings (n = 11)
Eleven patients were noted to have neuro – ophthalmologic findings. Two cases of papilloedema and 2 cases of papillitis were attributed to cryptococcal meningitis. No clear cause could be identified in the other cases.
Figure 12: Systemic Manifestation (n = 81)
Tuberculosis was the commonest systemic finding in the study participants. Over half (53.1%) of the patients were on TB treatment.
Figure 13: Level of Current CD4 Count (n = 200)
Twenty seven percent of the participants had a current CD4 count of ≤200 cells/microliter.
Figure 14: HIV/AIDs Staging (WHO Classification; n = 200)
Forty one percent of the participants were in stage III and IV as graded by the AMPATH physicians. By definition, these are patients all eligible for HAART by WHO recommendations.
Table 4: ARV Treatment (n = 200)
Yes 118 59.0
No 82 41.0
· AZT (Zidovudine) 35 29.7
· 3TC (Lamivudine) 104 88.1
· D4T (Stavudine) 53 44.9
· DDZ (Didanosine) 2 1.7
· ABC (Abacavir) 5 4.2
· NVP (Nevirapine) 65 55.1
· EFV (Efavirenz) 34 28.8
· NFV (Nelfinavir) 4 3.4
ARV Dug Combinations:
· Four drugs 6 5.1
· Three drugs 69 58.5
Most of the patients were on a three
drug combination (58.5%).
Table 5: Association between Ocular Manifestation and Current CD4-Count (n = 200)
0 – 100 22 21 (95.5) 5.7 (0.77 – 117.30) 0.044
101 – 200 32 31 (96.9) 9.1 (1.26 – 184.14) 0.021
201 – 300 30 26 (86.7) 1.7 (0.51 – 6.12) 0.500
301 – 400 33 38 (75.7) 0.9 (0.33 – 2.45) 0.975
401 – 500 37 28 (75.7) 0.7 (0.28 – 1.79) 0.975
There was a significant association between current CD4 count of between 0 – 100, 101 – 200 and 500+ and ocular manifestations with a p-value of less than 0.05. Participants with CD4 counts of between 0 – 100 were 5.7 times more likely to have ocular manifestations than participants with CD4 counts of >100.
Table 6: Association between Ocular Manifestation and Systemic Disease (n = 200)
Systemic Disease (n)
TB 43 35 (81.4) 1.1 (0.27 – 4.19) 0.844
OPC 19 19 (84.2) 1.0 (0.22 – 5.38) 0.641
ETB 6 5 (86.7) 1.0 (0.10 – 23.05) 0.593
Enteropathy 4 3 (75.0) 0.7 (0.10 – 19.21) 0.593
Recurrent HZ 3 3 (75.7) - -
PGL 3 3 (75.7) - -
Meningitis 2 2 (100.0) - -
There was no significant association between the systemic disease status and ocular manifestations (p > 0.05). However, patients with TB were 1.1 times more likely to have ocular manifestations.
Table 7: Association between Adnexal Findings and Current CD4 count (n = 52)
0 – 100 2 - 1 - 1 -
101 – 200 12 - 3 3 3 1 2
201 – 300 6 2 2 1 1 - -
301 – 400 9 3 1 3 1 - 1
401 – 500 11 3 3 2 1 1 1
No significant association was observed between current CD4 count and adnexal findings (p = 0.803)
Table 8: Association between Posterior segment Findings and Current CD4 count (n = 106)
0 – 100 (20) 11 5 2 1 - 1
101 – 200 (23) 16 - 3 2 1 1
201 – 300 (15) 11 - 1 1 - 2
301 – 400 (16) 12 - 2 2 - -
401 – 500 (18) 12 - 1 1 - 4
* Ret.M. Retinal Microvasculopathy
** Cho. Choroidopathy
*** PV Perivascular Sheathing
There was a significant association between current CD4 count and posterior segment findings (p=0.040). CMV retinitis was noted only in patients with a CD4 count of less than 100 while retinal microvasculopathy was seen in patients with higher CD4 counts.
Table 9: Association between Ocular Manifestation WHO staging and ARV Treatment (n = 200)
On ARV (n)
Yes (118) 106 (68.8) 6.3 (3.0 – 13.1) <0.001
There was a significant association between ocular manifestation, patients on ARV and WHO staging with p< 0.001. Patients who were on ARV were 6.3 times likely to have ocular manifestations.
Table 10: Factors associated with Presence of Ocular Manifestations (n = 200)
Age 0.068 0.024 0.004
AZT use -2.99 1.36 0.028
On logistic regression only age (p=0.004), AZT (p=0.028) and ARV (p=0.029) usage were significant as shown in the table above.
In this series at AMPATH clinic in
All participants were out patients in fair general condition. They were on follow up and on management for HIV/AIDS in the AMPATH clinic.
The age range was 16 years to 74years with a mean age of
38.65 (±0.74) years. More than 70 % of
the patients fell in the 25-44 years age group (Table 1) considered the high
risk group for HIV infection. This age distribution could be explained by the
mode of spread of HIV in
In terms of level of education 20.5 % of the patients
had not attended school at all, 49 % had achieved primary level of education, 28
% had secondary education and only 5 % had any form of tertiary education (Table
1). It is important to point out that education not
only affects changes in sexual behaviour, but also predicts level of knowledge
about the disease. A study based on data from the 1998–1999 National Family
Health Survey (NFHS) of
Visual acuity was normal in 65 % of the patients, 20 %
had visual impairment, 10 % severe visual impairment and 5 % were blind by WHO
standards (Figure 3). The significant causes of blindness were bilateral
fulminant CMV retinitis involving the macula and optic nerve atrophy. In
It was noted that 77 % of the patients had some form
of ocular manifestations. These findings are close to the results noted in
In a review article by Al- Fat et al they noted that ocular manifestations may occur in about 75% of HIV/AIDS patients in the course of their disease (25) and suggested that with improvement of treatment and patients survival, ophthalmic complications are now being seen with increasing frequency in AIDS, occurring in up to 75% of patients during the course of the disease.
Ocular findings in this study were more common in the
posterior segment (53%), followed by the anterior segment (26.5%). Adnexal
manifestations were noted in 26.5 % of the patients and neuro ophthalmic
manifestations in 11 % (Figure 5). This is consistent with Jabs et al
observations in the
This study found CMV retinitis in 2.5% of the cases.
Findings in other studies range from <1% to 20%. Asseffa et al, in
Retinal microvasculopathy was the most common posterior
segment finding seen in 37.5% of the patients. Only 2.5% of the patients had
presumed CMV retinitis with poor vision and 4.5% had other forms of
chorioretinitis apparently not related to CMV. Some of chorioretinal lesions
may have been ocular TB as they occurred all in patients on TB treatment. However
there were no classical choroidal granulomas (Figure 8). CMV retinitis was
noted only in patients with a CD4 count of less than 100 while the HIV
microangiopathy was also noted in CD4 counts of greater than 500. Nwosu et al
at the Guinness Eye centre in
Anterior segment manifestations were seen in 36.5 % of
patients, the most notable being a greyish fibrous membrane attached to the
iris mostly near the pupillary margin (18.5% ), followed by active iridocyclitis (5.5%). Similarly Nwosu
et al in
Mvogo et al in
Adnexal manifestations were present in 26% of our patients and the main findings were squamous cell carcinoma (6.5 %), HZO (6 %), Kaposi Sarcoma (5%), conjunctival microvasculopathy (4.5%), molluscum contagiosum (2.5 %) and suspicious conjunctival growth (1.5%). The lower prevalence of microvasculopathy noted in this study could be due to the fact that most of the patients were on HAART for a longer duration and the consequent decrease in the viral load may lead to a decline in the vasculopathy.
The prevalence of squamous cell carcinoma in this study was comparable to findings in Chisi et al study. They noted a prevalence of proven conjunctiva SCC of 7.8 % in HIV patients (14). Ten of the SCC were diagnosed clinically while three had histological confirmation. Guech, Ongey et al in the USA found a significantly increased risk for squamous cell carcinoma in patients with HIV/AIDS (28).
Neurophthalmic findings were seen in 11 patients and included optic atrophy (3 patients), papilloedema (4 patients) and papilitis (4 patients). Assefa Y et al found neuro-ophthalmologic disorders in 9.6% in their HIV/AIDS patients which is similar to this study (29). Two cases of papilloedema and two cases of papillitis were attributed to cryptococcal meningitis based on the clinical appearance and context. However, no other specific causes for neuro-ophthalmologic findings could be established. This is similar to other studies from comparable settings where limited diagnostic capacities often prevent establishing exact causes. These infections are due to the immunosuppression of HIV.
Systemic manifestations of HIV/AIDS were seen in 81
patients with TB (53.1 %) and oro-pharyngeal candidiasis (23.5%) being the
In this study most patients were in HIV/AIDS stage I (36 %), followed by stage III (9.5 %), stage II (23 %) and stage IV (11.5%) (Figure 8). Patients in stage IV had the highest prevalence of ocular manifestations (95.7%) followed by patients in stage III (91.5%). The least prevalence was noted in stage I (66.7%). This relation was statistically significant and suggests that the magnitude of the ocular involvement increases with severity of the HIV/AIDS disease (Table 5). The higher magnitude of ocular manifestations in stage I demonstrates that ocular manifestations may occur at any CD4 count. Most of the manifestations in this stage were non-blinding. Assefa et al in their study from Ethiopia reported 90% of the patients in clinical stage III and IV. Of these, 60% had at least one ocular manifestation (29).
CD4 T lymphocyte counts have previously been said to be a reliable predictor of ocular complications of HIV infections (5). This study found that patients with CD4 count less than 100 cells/ml had higher rate (95.5%) of ocular manifestations (p=0.04).
However the study showed no linear association between ocular adnexal findings, ocular anterior segment findings and neuro-ophthalmic findings with the level of CD4 count, but demonstrated a positive association between posterior segments findings (p=0.04).
1. The prevalence of ocular manifestations in HIV/AIDS patients as seen at AMPATH clinic was 77%. The most prevalent manifestations were noted in the posterior segment (53.9%). The prevalence of anterior segment manifestations was 26.5% and that of adnexal manifestations was also 26.5%.
2. The most common posterior segment findings were retinal microvasculopathy and chorioretinitis while fibrous membrane on the iris and active iridocyclitis were the most common findings in the anterior segment. Though CMV retinitis was noted in only 2.5% of the patients, it was one of the main causes of binocular blindness.
3. The commonest systemic finding was pulmonary TB. However, there was no statistically significant relation with ocular manifestations of HIV/AIDS in this study.
4. Ocular manifestations of HIV/AIDS are related to both the severity of clinical disease staging (e.g. WHO stages III and IV) and severity of immune suppression (CD4+ count).
5. Fifty-nine percent of HIV/AIDS patients were on ARV and among these 93.2% had ocular manifestations.
1. There is need for routine referral for ophthalmic evaluation of HIV positive patient in WHO stages III and IV and / or severe immune suppression (CD4+ count levels less than 200 cells/ml).
2. There is need for early and appropriate management of immune recovery related eye disease as evidenced by the high rate of old and active cyclitis in our patients from presumed immune recovery uveitis.
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A) DEMOGRAPHIC DATA.
B) EYE EXAMINATION
13- Posterior segment manifestation:
14-Neuro ophthalmology manifestation:
C) SYSTEMIC MANIFESTATIONS (OI’s);
17-Current WHO stage:
18. Is the patient currently taking, or has the patient ever taken, any of the following antiretroviral medications?
19. If yes fill the box next to each medication:
20.When did you start ARV’S……..
21. Any relevant past medical history………………………………………
Of ______________________________p.o box______________________________
Hereby acknowledge that the aims and purpose; procedures, benefits, and risks of this study have been explained to me.
I confirm that I have voluntarily agreed to participate in the study being carried out on ocular manifestation in HIV/AIDS.
A. WHO classification
¨ Stage1: -asymptomatic HIV infection
-persistent generalized lymphadenopathy
¨ Stage 2: - herpes zoster (within the last 5 years)
-minor micocutaneous manifestation
-recurrent upper respiratory tract infection
-weight loss<10% of body weight
¨ Stage 3: -severe bacteria infection( pneumonia)
-oral candidacies ( thrush)
-unexplained chronic diarrhea (>1month)
-oral hairy leukoplakie
-unexplained prolonged fever intermittent constant (>1month)
-tuberculosis, pulmonary (within previous years)
-weight loss>10% of body weight
¨ Stage 4: -candidacies( esophageal, bronchi, tracheal)
-cryptosporiosis with diarrhea
-CMV virus disease
-HIV wasting syndrome
B. CDC classification scheme for HIV disease.
3 Categories based on the CD4+Tlymphocyte percentage (count per microliter of blood)
Categories 1: >500 cells/mm3 (orcd4%.24%)
Categories 2: 200-499cells/mm3(or cd4 %<14%-28%)
Categories 3:<200 cells/mm3(or cd4%<14%)
Consist of one or more of the condition listed below in adolescent or adult >13 years with documentation HIV infection:
-asymptomatic HIV infection
-persistent generalyzed lymphadenopathy
-acute primary HIV infection with accompagning illness or history of acute HIV infection
Consistent of symptomatic conditions in HIV infected adolescent or adult that are not included among condition listed in clinical category C and that meet at least one of the following criteria:
A.The condition is attributed to HIV infection or is indicated of a defect in cell mediated immunity.
B.The condition is considered by the physicians to have a clinical course or to require management that is complicated by HIV infection.
•Examples of condition in clinical category B include:
-Candidiasis, oropharyngeal( THRUSH)
-Candidiasis, vulvovaginal, persistent, frequent or poorly responsible to therapy.
-Cervical dysplasia, cervical carcinoma in situ.
-constitutional symptoms, such as fever (38.5) or diarrhea lasting longer than 1 month.
-hairy leukoplakia, oral
-herpes zestier involving at least 2 distinct episodes .
-idiopathic thrombocytopenic purpura
-Pelvic inflammatory disease
•Includes the clinical condition listed in the 1993 AIDS surveillance case definition.
•Once a category c condition ocurred the person remain in category C