Patients with CD4 counts <50 cells/mm3 should be examined by an ophthalmologist every 6 months. (Kuppermann et al., 1993; Whitly et al., 1998)
Patients with visual disturbances or unremitting ocular symptoms, regardless of CD4 cell count, should be evaluated by an ophthalmologist. The severity of signs and symptoms should guide the clinician in choosing whether to request emergency consultation.
Retinal examination in human immunodeficiency virus (HIV)-infected patients should include indirect ophthalmoscopy through a dilated pupil so the entire peripheral fundus can be evaluated.
The primary care clinician and the ophthalmologist should work in conjunction to manage ocular opportunistic infections in HIV-infected patients.
Anterior Segment Complications of HIV
Herpes Zoster Ophthalmicus
The clinician should refer patients with herpes zoster ophthalmicus for evaluation by an ophthalmologist because uveitis, corneal opacities, or secondary glaucoma may develop. The retina should also be examined because the infection can involve the posterior segment as well, which is a medical emergency. See below: Infectious Retinitis and Choroiditis for information on zoster retinitis (progressive outer retinal necrosis).
Treatment
Clinicians should treat HIV-infected patients with herpes zoster ophthalmicus with intravenous acyclovir (10 mg/kg) every 8 hours for 10 to 14 days. It should be administered at a constant rate for 1 hour to prevent renal tubular damage. The course of intravenous acyclovir should be followed by oral therapy with valganciclovir (1 g three times a day [tid]) until lesions have healed.
Neuro-Ophthalmic Complications of HIV
Patients with orbital and central nervous system opportunistic infections and malignancies should undergo neurologic evaluation, neuroimaging studies, and further evaluation by specialists.
Refer to Table 1 in the original guideline document for the list of ocular disturbances associated with orbital and central nervous system opportunistic infections, as well as which guideline to refer to for recommendations concerning diagnosis and treatment.
Retinal and Choroidal Manifestations of HIV Infection
HIV-Related Retinal Microangiopathy
Diagnosis
Patients who are suspected of having retinal microangiopathy but have visual complaints should be re-evaluated serially to exclude an alternative diagnosis.
Infectious Retinitis and Choroiditis
The primary care clinician and the ophthalmologist should work in conjunction to manage infectious retinitis and choroiditis in HIV-infected patients.
Cytomegalovirus (CMV) Retinitis
Treatment of CMV Retinitis
Clinicians should initiate highly active antiretroviral therapy (HAART) in antiretroviral (ARV)-naïve patients who present with CMV retinitis.
When patients who are receiving HAART present with CMV retinitis, clinicians should re-evaluate the ARV regimen in an attempt to maximize the effect of HAART on the immune system. However, CMV retinitis should be treated with both HAART and specific antiviral treatment, which varies depending on the immune status of the patient (refer to Figure 1 in the original guideline document for more information).
Because the ganciclovir implant does not start consistent delivery of medication to the retina until the second week after placement, patients should receive 2 weeks of an anti-CMV agent, such as intravenous ganciclovir or oral valganciclovir, immediately following implant placement.
When systemic therapy alone is indicated:
- A 2- to 3-week induction period with one of the following should be used to stabilize CMV retinitis:
- Typical first-line therapy options:
- Intravenous ganciclovir (5 mg/kg twice daily [bid] for 14 to 21 days, then 5 mg/kg once daily [qd] for 21 days), or
- Oral valganciclovir (900 mg orally [PO] bid for 21 days, then 900 mg PO qd).
- Acceptable first-line therapy options in select cases (e.g., long-standing previous prophylaxis with ganciclovir):
- Foscarnet (60 mg/kg IV every 8 hours or 90 mg/kg intravenously [IV] every 12 hours for 14 to 21 days, then 90 to 120 mg/kg IV every 12 hours), or
- Cidofovir (5 mg/kg IV once weekly for 2 weeks, then 5 mg/kg every 2 weeks; with probenecid, 2 g PO 3 hours before each cidofovir dose, 1 g PO at 2 hours and again at 8 hours post cidofovir dose)
The clinician should base the need for all maintenance regimens on the patient's immune status. If patients have achieved immune reconstitution with a CD4 count >100 cells/mm3 for more than 6 months, discontinuation of maintenance therapy should be considered.
Table
Choosing the Treatment Modality for CMV Retinitis
|
| Consideration |
Effect on Treatment Choice |
| The location and extent of CMV retinitis (i.e., sight threatening or peripheral) and the status of the fellow eye |
If the patient has sight-threatening CMV retinitis or bilateral disease, parenteral therapy should be used. |
| Whether the disease is newly diagnosed or relapsed |
If the patient is experiencing a relapse, combination therapy with two parenteral agents has produced the best results. |
| The immune status of the patient |
The immune status of the patient will determine whether an implant is required (see Figure 1 in the original guideline document). |
| Whether the patient is HAART naïve or whether HAART has failed |
HAART should be initiated in naïve patients, and the regimen should be optimized in patients with failing HAART. |
| The presence of other conditions that can affect medication choice |
For example, for patients actively using drugs, the implant may facilitate treatment. |
| Other medications with overlapping toxicities |
Overlapping toxicities may help decide between ganciclovir versus foscarnet. For example, if a patient has neutropenia that is unlikely to resolve, ganciclovir should be avoided. |
| Adherence to follow-up |
For patients with poor adherence, the implant may facilitate treatment. |
| Patient's preference and quality-of-life concerns |
Quality-of-life issues may sway a patient away from parenteral therapy. |
Reactivation of Progression of CMV Retinitis
During therapy, the ophthalmologist should monitor for progression or reactivation of retinitis by examination and serial retinal photography.
Prophylaxis for CMV Retinitis
Patients receiving oral ganciclovir prophylaxis or therapy for extraocular CMV should be evaluated every 3 months by an ophthalmologist because treatment may mask the development of symptoms of retinitis.
Ocular Toxoplasmosis
Treatment
Clinicians should perform a central nervous system evaluation in patients with ocular toxoplasmosis.
Therapy for ocular toxoplasmosis should be the same as that for central nervous system toxoplasmosis. Atovaquone and/or azithromycin can be considered for patients in whom standard therapy fails or may not be used (e.g., allergies to sulfa or clindamycin).
Clinicians should continue maintenance therapy to prevent relapse of toxoplasmosis lesions.
Pneumocystis carinii Choroidopathy
Treatment
Because ocular Pneumocystis carinii is a manifestation of disseminated pneumocystosis, clinicians should initiate standard anti-pneumocystis therapy.
Syphilis
Diagnosis and Treatment
Clinicians should treat patients with syphilitic uveitis, chorioretinitis, or optic nerve disease for neurosyphilis. The treatment of ocular syphilis optimally will include 2 weeks of intravenous penicillin G.
