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| ORIGINAL ARTICLE |
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| Year : 1995 | Volume
: 43
| Issue : 2 | Page : 69-72 |
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Ocular lesions in AIDS: A report of first two cases in India
Jyotirmay Biswas, HN Madhavan, SS Badrinath
From Sankara Nethralaya, Medical Research Foundation, Madras, India
Correspondence Address:
Jyotirmay Biswas
Vision and Medical Research Foundation, Sankara Nethralaya, 18 College Road, Madras 600 006
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 8818313 
Although 444 cases of AIDS have been officially registered till July 1993 from various parts of India, ocular lesions in these cases have not been reported. Till May 1994, ELISA test for HIV 1 and HIV 2 had been done in 12 cases of suspicious ocular lesions which include viral retinitis, endogenous endophthalmitis and active chorioretinitis. Two patients had seropositivity for HIV 1. Ocular lesions include subretinal yellow mass in the first case and cytomegalovirus retinitis and cotton-wool spots in the second case. These two patients also had several systemic infections which include tuberculosis in both and nocardia in one. To the best of our knowledge, these two cases are the first report of ocular lesions in AIDS from India. Keywords: AIDS - Ocular involvement.
How to cite this article:
Biswas J, Madhavan H N, Badrinath S S. Ocular lesions in AIDS: A report of first two cases in India. Indian J Ophthalmol 1995;43:69-72 |
Eye is one of the organs commonly affected by the primary or secondary pathologic processes in the multisystem involvement of acquired immunodeficiency syndrome (AIDS). Ocular lesions can occur in 75% of cases of AIDS. Ocular lesions are varied and affect almost all the structures of the eye.[1][2][3] The first case of AIDS in India was reported in May 1986,[4],[5] the source of infection being blood transfusion. Since then, the number of AIDS cases has risen steadily (444 registered cases, July 1993) and has shown an epidemic spread. Out of 18,13,870 cases that were screened, about 12, 519 cases were found to be seropositive, amounting to a seropositivity rate of 6.90 per thousand of the cases examined.[6] AIDS patients can often present with ophthalmic complaints in the early stages of the disease while in good general condition without any clinical evidence of systemic opportunistic infection. Early recognition of the ophthalmic manifestations of the disease is often the basis of identification of primary HIV infection and other opportunistic infections.
| Materials and methods | |  |
This communication is the first report of two cases of ocular lesions in AIDS, in India.
| Case 1 | | |
A 21-year-old male presented with a history of sudden dimness of vision along with pain and redness in the left eye since 8 days following an episode of fever and cough. He was treated with injection of streptopenicillin for his systemic ailment. He was seen by a local ophthalmologist and was diagnosed as endophthalmitis and was treated with flubiprofen, atropine and subconjunctival injection of dexamethasone. The patient gave a history of sexual exposure to prostitutes and a 6-month history of penile sore. He denied any history of homosexual contact.
On examination, his visual acuity was found to be 6/6; N6 in the right eye and counting fingers at 1 foot in the left eye. Slit-lamp examination of the right eye revealed no abnormalities. In the left eye, however, multiple fine keratic precipitates, 2+ aqueous flare, 2+ aqueous cells and 2+ vitreous cells were observed. The intraocular pressure was 14 mm Hg in the right eye and 4 mm Hg in the left eye. Fundus examination revealed no abnormality in the right eye. In the left eye there was vitreous haze, secondary retinal detachment and subretinal yellowish masses inferiorly [Figure - 1]. Ultrasound examination revealed partial retinal detachment in the left eye with intraretinal deposits of high reflectivity. The case was diagnosed as endogenous endophthalmitis.
The total WBC count was 7,700/cu mm and differential count demonstrated neutrophils 62%, lymphocytes 33%, monocytes 4%, and atypical lymphocytes 1%. The RBC count was 4.26 million/cu mm, haemoglobin 12.6gm%, and ESR was 95 mm in the 1st hour. Urine examination was normal. To rule out infectious aetiology, anterior chamber tap was done under topical anaesthesia in the out-patient department. It revealed many mononuclear cells, fibrinous material and occasional pus cells, with no evidence of microbial organisms. Culture did not reveal growth of any bacteria, fungus or acid-fast bacilli. Serum analysis for VDRL and TPHA was found to be negative. ELISA test for HIV 1 antibody was positive and anti- HIV2 antibody was not detected. The results of the ELISA test for HIV was confirmed from another centre. Culture for acid- fast bacilli from the gastric aspirate was found to be positive. Sputum subjected for AFB culture showed growth of Nocardia madurae. X-ray chest showed hazy right lower zone indicating evidence of pleural effusion. Examination of the patient by the internist revealed enlarged axillary lymphnodes. The patient was put on antituberculous treatment and was referred to a specialized AIDS care centre for further management.
| Case 2 | | |
A 48- year-old male presented to us in March 1994 with complaints of seeing "black spots" and loss of visual field in the left eye. He was seen by a local ophthalmologist and was suspected to have necrotizing retinitis due to viral aetiology. The patient gave a history of pulmonary tuberculosis in 1991 and had been treated with a full regimen of antituberculous drugs for 1 year.
The patient gave a history of extramarital sexual exposure to prostitutes. The patient also gave a history of blood transfusion in a private hospital about one year ago following a car accident. He was not a known diabetic or hypertensive. He was on oral prednisolone and ranitidine, and was also on antituberculous treatment with isoniazide 450 mg daily and ethambutol 800 mg once daily.
On examination, his visual acuity was found to be 6/6; N6 in the right eye and 6/24 in the left eye. Slit-lamp examination revealed no abnormality in the right eye. In the left eye, there was corneal oedema, multiple fine keratic precipitates, aqueous flare (+) and aqueous cells (+). The intraocular pressure was 12 mm Hg in the right eye and 34 mm Hg in the left eye. Fundus examination revealed multiple cotton-wool spots in the right eye [Figure - 2]. The left fundus showed necrotizing retinitis involving the superior temporal quadrant associated with vasculitis involving all the major vessels [Figure - 3]. The inferior temporal arcade also showed necrotizing retinitis with secondary retinal detachment [Figure - 4]. There were a few cotton-wool spots seen around the macula in the left eye also. Clinical features were suggestive of HIV retinopathy in both eyes with anterior uveitis, secondary glaucoma and cytomegalovirus retinitis in the left eye. Clinically, ocular lesion due to HIV infection was suspected. ELISA for HIV 1 and HIV 2 was done which showed HIV 1 to be positive. Systemic investigations revealed total WBC count to be 3800/cu mm. Differential count showed neutrophils 60%, lymphocytes 24%, eosinophils 14% and monocytes 2%. ESR was 123 mm/1st hour. Blood examination for malarial parasite was negative. Protein electrophoresis showed generalised increase of all globulin fractions particularly alpha 2, beta and gamma. The patient was started on betamethasone eye drops 8 times/day, atropine eye drops 3 times daily and 0.5% timolol for control of intraocular pressure.The patient was sent to a referral AIDS care centre for further management and it was suggested that a course of intravenous ganciclovir sodium 5 mg/kg be given every 12 hours for 14 to 21 days followed by a maintenance therapy of 6 mg/kg, five days a week for an indefinite period.
| Discussion | | |
To the best of our knowledge, the above two cases are the first report of ocular lesions in AIDS from India. In our first case, the suspicion of HIV infection was based on clinical features of endogenous endophthalmitis and a history of sexual exposure. In our second case, a clinical diagnosis of viral retinitis prompted us to order for ELISA test for HIV 1 and HIV 2. As both the patients had systemic infections and required specific treatment for HIV infection, they were referred to an AIDS care centre where such facility is available. In addition, the patients also required treatment for ocular lesions and the same was advised.
Ocular lesions in the first case could be due to any infective organism. Anterior chamber tap did not reveal growth of any organism. Various opportunistic infections can occur in an AIDS patient leading to severe intraocular inflammation. The organisms identified in such cases include Cryptococcus neoformans,[7]Mycobacterium avium-intercellulare,[8]Histoplasma capsulatum,[9] Toxoplasmagondii,[10] and Sporothrixschenckii.[11]Transvitreal fine-needle biopsy has been reported to be helpful in obtaining material from the site of pathology and diagnosing such subretinal abscess by pathological and microbiological study. As the patient required urgent attention for several systemic infections, we could not do the same for aetiological diagnosis.
In the second case, the clinical picture was very typical of cytomegalovirus retinitis due to necrotizing retinitis with dry granular border along with vasculitis and clear vitreous. Hence, treatment with intravenous ganciclovir was advised.
HIV retinopathy is characterized by cotton-wool spots, retinal haemorrhages and microaneurysms, and is seen in about 50 to 70% of cases. Multiple cotton-wool spots seen in our second case also indicated HIV retinopathy. The cotton-wool spots are usually seen along vascular arcades. They indicate focal ischaemia in the nerve fibre layer of the retina. They are non-specific and are seen in several systemic disorders, e.g., diabetes, hypertension, severe anaemia and collagen vascular diseases. However, characteristic retinal changes due to such diseases and abnormal laboratory reports can also aid in differentiating HIV retinopathy from cotton-wool spots due to other systemic disorders. Our patient was non-diabetic and non-hypertensive and also had no evidence of other retinal changes of these disorders.
CMV retinitis is the most common opportunistic infection in patients with AIDS, occurring in 15 to 40% of these patients. Cytomegalovirus retinitis can be the initial manifestation of AIDS as in our second case.[12] The diagnosis of CMV retinitis is usually based on clinical features such as full-thickness granular retinal opacification with hard exudates and haemorrhages. The characteristic fundus appearance enabled us to diagnose CMV retinitis. Serologic diagnosis of CMV retinitis in patients with AIDS can be equivocal and unreliable due to profound immunosuppression.
With the threat of an AIDS epidemic in India, our two cases indicate that more ophthalmologists will encounter an increasing number of such cases. It is therefore important for the ophthalmologist to be aware of all ocular manifestations of AIDS and to enquire from the patient whether he/she has a history of extramarital sexual exposure, blood transfusion and intravenous drug usage, which are the most common modes of transmission of AIDS.
Acknowledgement
We thank Dr. C.R. Kamath, Prof and Head of the Department of Ophthalmology, Kasturba Medical College, Mangalore,for referring the second case.
| References | | |
| 1. | Biswas J, Rao NA. Diagnosis and management of ocular lesions in acquired immune deficiency syndrome. Indian J Ophthalmol 36:15-155,1988.  |
| 2. | Rao NA, Biswas J. Ocular pathology in AIDS. In: Fujikawa L (ed). Ophthalmology Clinics of North America, Vol.1. Philadelphia, Saunders Company, pp. 63-72, 1988. |
| 3. | Holland GN. Acquired immunodeficiency syndrome and ophthalmology-The first decade. Am J Ophthalmol 114:86-95, 1992. |
| 4. | Simoes EAF, Babu PG, John TJ et al. Evidence of HTLV III infection in prostitutes in India. Ind J Med Res 87:335-338, 1987. |
| 5. | John TJ, Babu PG, Jayakumari H, et al. Current prevalence and risk group of HIV infection in Tamilnadu, India. Lancet 1:160-161, 1987. |
| 6. | Pavri MK. Facts and figures about HIV/AIDS, 1993: Surveillance for what, and, at what? Carc Calling 6:23-29, 1993. |
| 7. | Denning DW, Armstrong RW, Fishman M, et al. Endophthalmitis in, a patient with disseminated cryptococcosis and AIDS who was treated intraconazole. Rev Infect Dis 13:1126-1130, 1991. |
| 8. | Cohen JI, Saragas SJ. Endophthalmitis due to mycobacterium avium in a patient with AIDS. Ann Ophthalmol 22:47-51, 1990. |
| 9. | Specht CS, Mitchell KT, Bauman AE, et al. Ocular histoplasmosis with retinitis in a patient with acquired immune deficiency syndrome. Ophthalmology 98:1356-1359, 1991. |
| 10. | Gagliuso DJ, Teich SA, Friedman, et al. Ocular toxoplasmosis in AIDS patients. Trans Am Ophthalmol Soc 88:63-88, 1990. |
| 11. | Kurosawa A, Pollock SC, Collins MP, et al. Sporothrix schenckii endophthalmitis in a patient with human immunodeficiency virus infection. Arch Ophthalmol 106:376-380, 1987. |
| 12. | Henderly DE, Freeman WR, Smith RE, et al. Cytomegalovirus retinitis as the initial manifestation of the acquired immune deficiency syndrome. Am J Ophthalmol 103:316-320, 1987. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
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