Lowering the limit: reducing the CD4 T-cell threshold for ophthalmic screening in patients with HIV in an ethnically diverse UK population.

Rupal Morjaria,Vaneeta Sood,Alastair Denniston,Helen Palmer,Kaveh Manavi

doi:10.2147/opth.s67493

Abstract

BackgroundBefore highly active antiretroviral therapy, cytomegalovirus (CMV) retinitis was a major threat to vision in individuals with HIV. We investigate whether ophthalmic screening of asymptomatic HIV patients still has value in the highly active antiretroviral therapy era and consider CD4 thresholds in line with the world literature and UK experience.MethodsA retrospective chart review was conducted of all patients seen by the HIV Ophthalmic Service of a UK university hospital both before (2007–2008) and after (2011–2012) introduction of a threshold of CD4 lower than 100 cells/mm3. Data collected included CMV and HIV RNA load, CD4 cell counts and CD4 percentage, CMV-immunoglobulin G status, ocular symptoms, and evidence of HIV-related ocular disease.ResultsIn total, 54 patients were referred to the HIV ophthalmic service. Three patients failed to attend, resulting in complete data for 51 patients (n=24 for 2007–2008; n=27 for 2011–2012). Seven patients had ophthalmic manifestations of their HIV; these cases had lower CD4 counts than those with normal examinations (median [interquartile range], 9 [7–80] versus 175 [44–394]; P=0.0039; Mann–Whitney test). Six cases had HIV retinopathy without sight loss; one case had sight-threatening CMV retinitis associated with a CD4 count of 6 cells/mm3.ConclusionBefore 2008, our practice was to screen all asymptomatic patients with CD4 counts lower than 200 cells/mm3. Screening asymptomatic patients with CD4 counts below 100 cells/mm3 was not associated with any missed or late-presenting cases of CMV retinitis in our HIV population.

Highlights

Cytomegalovirus (CMV) retinitis is the most common ocular opportunistic infection in patients with AIDS,[1,2] despite widespread availability of highly active antiretroviral therapy (HAART).[3]
Before the advent of HAART, the 4-year cumulative risk of developing CMV retinitis in patients with HIV was around 25%,5,6 whereas more recent estimates suggest it is nearer 7%
We present the screening outcomes of patients referred from the HIV clinic for ophthalmic assessment for two time periods: before and after the reduction of our screening threshold for asymptomatic patients with HIV to fewer than 100 CD4 cells/mm[3]

Summary

Introduction

Cytomegalovirus (CMV) retinitis is the most common ocular opportunistic infection in patients with AIDS,[1,2] despite widespread availability of highly active antiretroviral therapy (HAART).[3]. The pattern and incidence of HIV-related ophthalmic presentations has changed in the post-HAART era, with few studies reporting them.[9] Bekele et al found that 39.7% of patients with a CD4+ cell count lower than 200 cells/mm[3] had ocular manifestations of HIV/AIDS in Jimma, Ethiopia, compared with 20.9% in those with counts higher than 200 cells/mm3.9. Before highly active antiretroviral therapy, cytomegalovirus (CMV) retinitis was a major threat to vision in individuals with HIV. We investigate whether ophthalmic screening of asymptomatic HIV patients still has value in the highly active antiretroviral therapy era and consider CD4 thresholds in line with the world literature and UK experience. Screening asymptomatic patients with CD4 counts below 100 cells/mm[3] was not associated with any missed or late-presenting cases of CMV retinitis in our HIV population.

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