Abstract
BackgroundThe ocular manifestations of HIV may lead to visual impairment or blindness. In India, patients typically initiate antiretroviral treatment (ART) with low CD4 cell counts when the risk of ocular complications may be high. The objective of this study was to determine the prevalence and types of HIV-associated ocular conditions in patients referred for ART in India.MethodsThis cross-sectional study was undertaken at a large public sector ART centre in Mumbai, India. Data collection including a standardised symptom screen, and an ophthalmic examination were performed on all consecutive patients satisfying the criteria for enrolment into the ART clinic irrespective of the presence or absence of ophthalmic/visual symptoms.ResultsEnrolled patients (n = 149) had a median CD4 cell count of 180 cell/μL (inter-quartile range [IQR], 106-253 cells/μL). The prevalence of HIV-associated ocular disease was 17.5% (95% CI, 11.2-23.6%) in all participants and 23.8% (95% CI: 14.5-33.1) in those with CD4 cell counts <200 cells/μL (n = 84). Only 7.7% of patients with HIV-associated ocular disease reported any eye symptoms in the standardised symptom screen. Objective visual impairment was detected in 20% of those with HIV-associated ocular disease compared to 6% in those without ocular manifestations (p = 0.02). Vitreoretinal disease was the most common manifestation, of which cytomegalovirus retinitis (CMVR) was the most frequent retinal infection (overall prevalence 8.7%, 95% CI: 4.1-13.3%). In a multivariable analysis, HIV-associated ocular disease was independently associated with a CD4 count <100 cells/μL (odds ratio [OR], 6.3, 95% CI: 1.5-25.9) and WHO clinical stages 3 and 4 (OR 9.4, 95% CI: 2.4-37.2). However, symptoms were not independently predictive of ocular disease. Sensitivity of ocular symptom screening was 7.7%, with a positive predictive value of 18% in this population.ConclusionOver a fifth of unselected patients who are eligible for ART in this setting have HIV-related ocular disease of which CMVR is the most common form. Such patients may be at risk of developing ocular immune reconstitution phenomena during ART. Screening for ocular symptoms is not a reliable method to identify those with ocular morbidity and this highlights the need for routine ophthalmic screening prior to commencement of ART.
Highlights
The ocular manifestations of HIV may lead to visual impairment or blindness
The very low prevalence of cytomegalovirus retinitis (CMVR) seen in sub-Saharan Africa may not be a direct reflection of lower incidence, but possibly reflect that these patients die from systemic opportunistic infections before their CD4 counts fall low enough to allow the development of HIV-related eye disease [2,3,5]
All participants were of Indian origin, and 93.2% were resident in Mumbai
Summary
The ocular manifestations of HIV may lead to visual impairment or blindness. In India, patients typically initiate antiretroviral treatment (ART) with low CD4 cell counts when the risk of ocular complications may be high. HIV-related eye disease may affect 50-75% of HIVinfected people worldwide at some point during the course of their illness [1]. This generally takes the form of opportunistic infections that can affect any of the ocular tissues, from the eyelids to the retina. Those conditions affecting the retina may lead to chronic visual impairment or blindness. The number of patients affected by HIV has greatly increased, and the patient demographic is likely to have changed
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