Indian Journal of Ophthalmology

: 1997  |  Volume : 45  |  Issue : 4  |  Page : 233--234

Blepharitis and lid ulcer as initial ocular manifestation in acquired immunodeficiency syndome patients

J Biswas, HN Madhavan, N Kumarasamy, S Solomon 
 Vision Research Foundation, Chennai, India

Correspondence Address:
J Biswas
Vision Research Foundation, Chennai

How to cite this article:
Biswas J, Madhavan H N, Kumarasamy N, Solomon S. Blepharitis and lid ulcer as initial ocular manifestation in acquired immunodeficiency syndome patients.Indian J Ophthalmol 1997;45:233-234

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Biswas J, Madhavan H N, Kumarasamy N, Solomon S. Blepharitis and lid ulcer as initial ocular manifestation in acquired immunodeficiency syndome patients. Indian J Ophthalmol [serial online] 1997 [cited 2023 Jun 1 ];45:233-234
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Ocular lesions can occur in as high as 70% of patients with acquired immunodeficiency syndrome (AIDS). Majority of the ocular lesions occur in the retina and choroid.[1] Infections of the eyelid and conjunctiva are rare in patients with AIDS. Holland and coworkers[2] reported a self-limiting conjunctivitis or keratoconjunctivitis in 10% of their patients with AIDS. Grasbon and coworkers[3] found both coagulate negative and positive staphylococci in the uninfected and infected conjunctivae of patients who tested positive for the human immunodeficiency virus (HIV). Blepharitis or lid ulceration as the initial ocular manifestation of AIDS has not been reported. We report two cases of staphylococcal lid infection in patients with AIDS. In both cases lid infection had a protracted course but responded to topical and systemic antibiotics. The first patient in addition developed cotton wool spots and cytomegalovirus retinitis.

 Case 1

A 26 year old male was referred to us by the internist of an AIDS care centre. He gave a history of an ulcerated lid lesion in the right eye which persisted for 2.5 months. Patient gave history of multiple unprotected sexual contact with commercial sex workers. He was detected positive for HIV-1 by enzyme linked immunosorbent assay (ELISA) and this was confirmed by the western blot test. A systemic examination by the internist revealed oral candidiasis, pulmonary tuberculosis, and pneumocystis carinii pneumonia. He was referred here by the internist for ocular complaints. On examination, visual acuity was 6/6 in both eyes. In the lateral one third of the right upper eyelid, an ulcerated lesion with irregular margins and granulation tissue was observed [Figure:1]. Fundus examination did not reveal any abnormality. Scraping of the mass lesion showed necrotic material with dense infiltration of polymorphonuclear leukocytes. Gram stain showed clumps of gram positive cocci. Culture showed growth of Staphylococcus aureus. Topical ciprofloxacin eye ointment was given along with oral doxycycline 100 mg daily for 2 weeks. Scarring occurred after 6 weeks. Two months later the patient developed cotton wool spots in the left eye, and four months later developed cytomegalovirus retinitis in the right eye. Retinitis regressed with intravenous ganciclovir therapy. However, the patient died after a year due to multiple systemic infections.

 Case 2

A 32 year old male was referred to us by an AIDS care centre. He complained of itching, irritation, and swelling in both eye lids. The patient gave history of multiple unprotected sexual contact with commercial sex workers and was found to be positive for the HIV-1 antibody by ELISA and this was confirmed by western blot test. He was seen by an internist and was found to have oropharyngeal candidiasis and pulmonary tuberculosis. On examination, his visual acuity was 6/6 in both eyes. Slitlamp biomicroscopy revealed extensive blepharitis with multiple pus points on the upper eyelids in both eyes [Figure:2]. Fundus examination revealed no abnormality. Scraping of the lid margin showed degenerated cellular material, plenty of polymorphonuclear leukocytes, and several gram positive cocci. Culture revealed Staphylococcus aureus. The patient was treated with ciprofloxacin eye ointment twice daily and doxycycline capsule 100 mg daily, and advised regarding lid hygiene. There was slow regression of blepharitis after two weeks and complete resolution after one month.


Inflammatory lesions in the eyelid in AIDS patients are rare. Molluscum contagiosum, a viral infection of the eyelid is known to cause numerous and larger lesions in the eyelid and is more resistant to standard therapy in patients with AIDS.[4] In our patients the initial ocular presentation was lid ulcer and severe blepharitis. It is unlikely that such a presentation can be incidental, as in both cases lid infection was more severe and had a more protracted course than in a healthy individual. Subsequent development of cytomegalovirus retinitis in Case 1 also indicates the progressive immunodeficiency leading to opportunistic infections.

Staphylococcus aureus has been found to cause increased mucocutaneus infections as well as deep soft tissue infections and sepsis in patients with AIDS.[5] However, lid ulcer and blepharitis have not been found as common feature of AIDS. In countries with warm climates, the prevalence of Staphylococcus aureus is as high as 95% in lid cultures,[6] and subclinical and mild lid infections are quite common. In our patients, due to immunodeficiency the infection was more severe and led to lid ulceration and extensive blepharitis with multiple pus points. Such unusual lid infections should arouse suspicion of immunocompromised or immunodeficient status of the patient. As the number of AIDS patients are increasing, it is likely that many patients with AIDS will present to ophthalmologists with such atypical external infections. It is important for the ophthalmologist to rule out HIV infection if not detected earlier by ordering appropriate tests like ELISA. These open lesions also pose a risk of transmission of HIV during the ophthalmic examination of such patients.


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