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The Official Scientific Journal of Delhi Ophthalmological Society
Evaluation of Fundoscopic Findings in HIV Positive Patients in Relation to HAART and CD4 Count
Ajit Kamalakar Joshi, Natasha Patel, Krishangee Kalita
Department of Ophthalmology, Bharati Vidyapeeth Medical College & Hospital, Sangli, Maharashtra, India
Corresponding Author:
Krishangee Kalita 
MS
Department of Ophthalmology
Bharati Vidyapeeth Medical College & Hospital, Sangli, Maharashtra, India
Email id: drkrishangeekalita@gmail.com
Published Online: 01-NOV-2018
DOI: http://dx.doi.org/10.7869/djo.394
Abstract
Aim: To evaluate the fundus findings in patients with HIV in correlation to highly active antiretroviral therapy (HAART) and CD4 count.
Materials and Methods: It was a hospital based observational study. It was conducted from December 2014 to September 2016 in the Ophthalmology Department, Bharati Hospital, Sangli. A total of 195 registered HIV patients on HAART were selected for the study. Informed  written consent of the subjects to participate in the study was taken. Patients of both sexes of any age group were included. Patients who did not give consent for the study were excluded.
Result: The mean age of study subjects was 40.49 years. 83.6% subjects had a best corrected visual acuity (BCVA) between 6/6 to 6/9 in the right eye, 82.6% had BCVA between 6/6 to 6/9 in the left eye. Visual acuity was below 6/60 in 5.1% subjects. The most common anterior segment pathology was cataract (8.2%), corneal opacity (2.1%), pterygium (2.1%) and pseudophakia. CD4 count above 500 cells/mm3 was seen in 28.7% cases while below 250 cells/mm3 was seen in 29.3% cases. The mean age of study subjects was 40.49 years with 51.8% between 21-40 years. Female predominance was observed in study group with 57.9% females to 42.1% males. The prevalence of ophthalmic manifestations in HIV patients on HAART was observed as 37.9%. Prevalance of posterior segment manifestations was 19.5%. Prevalance of ophthalmic pathology increased as CD4 count decreased (250 cells/mm3).
Conclusion: In the present study, significant posterior segment manifestations were seen in HIV positive patients on HAART. Low CD4 count is a risk as well as predictor for ocular manifestations. Advent of HAART has reduced the prevalence of ocular manifestations. Routine referral system for ocular evaluation from other medical departments is mandatory for timely diagnosis of the vision threatening conditions. It is therefore recommended that eye care should be a part of medical care in the management of patients on HAART.
Keywords : HIV retinopathy, HAART, CMV retinitis, Immune recovery uveitis
Ocular manifestation may be the primary presentation of HIV.1 The eye is an organ with wide spectrum HIV related manifestations. The disease can be presented with adnexal, anterior segment, posterior segment, orbital and neuro-ophthalmic manifestations.2 The prevalence of HIV related ocular manifestations increase as CD4+T cell count decreases. Diseases like cytomegalovirus retinitis, retinal and conjunctival microvasculopathy and keratoconjunctivitis sicca occurs commonly when CD4 cell count decreases below 100 cells/mm3 and Kaposi’s sarcoma occurs when the CD4+T cell count falls below 500 cells/mm.3 HAART has changed the prevalence and pattern of HIV related ocular manifestations.4 There was a 80% decrease in the incidence of CMV retinitis5, Kaposi’s sarcoma declined by 87%6, retinal microvasculopathy and opportunistic retinal infections were reduced.7,8 In the HAART era, clinical entities like immune recovery uveitis have appeared as a cause of concern related to blindness.5,9

Materials and Methods
It was a hospital based observational study. It was conducted in the Department of Ophthalmology, Bharati Medical College and Hospital, Sangli from December 2014 to September 2016. Consecutive type of non-probability sampling was used for selection of study subjects. A total of 195 registered HIV patients on HAART in the hospital’s ART centre were selected after taking informed consent. Patients of both sexes of any age were included. Some patients who did not give consent to take part in the study were excluded. For this study, informed written consent of the subjects to participate was taken. Demographic data and detailed history, latest CD4 count and the ART therapy regimen of the subject was recorded on a pre-determined proforma. Complete ocular examination of all subjects was done: visual acuity using Snellen’s chart, anterior segment evaluation using slit lamp, fundus examination using mydriatic agent by direct ophthalmoscopy and 90D/78D on slit lamp, fundus photography was taken, serological investigations in the hospital were correlated, co-morbid conditions affecting the retina other than HIV manifestations were also documented.
Data were statistically described in terms of mean (±SD), frequencies and percentages. For comparing categorical data, Chi square test was performed. Exact test was used instead when the expected frequency was less than 5. A probability value (p value) less than 0.005 was considered statistically significant. All statistical analysis were done using computer programs Microsoft Excel 2007 and SPSS version 21.

Observations and Results
The mean age of study subjects was 40.49 years with 51.8% between 21-40 years of age (Figure 1). Female predominance was observed in the study group with 57.9 % females to 42.1% males (Figure 2). About 83.6% subjects were having best corrected visual acuity between 6/6 to 6/9 in the right eye (Figure 3). Visual acuity below 6/60 was seen in 5.1% subjects. About 82.6% subjects were having best corrected visual acuity between 6/6 to 6/9 in the left eye (Figure 4). Visual acuity below 6/60 was seen in 6.2% subjects. The prevalence of ophthalmic pathology in HIV patients was observed as 37.9% (Figure 5). The most common posterior segment pathology in the right eye was HIV retinitis (6.7%), followed by CMV retinitis (3.6%) (Figure 6). Patients with anaemic fundus had haemoglobin less than 8 gm%.



The most common posterior segment pathology in the left eye was HIV retinopathy (7.6%), followed by CMV retinitis (3%)(Figure 7). CD4 count above 500/mm3 was seen in 28.7% cases while it was below 250/mm3 in 29.3% cases (Figure 8). The prevalence of ophthalmic pathology increased as CD4 count decreased. The prevalence of posterior segment manifestations increased as CD4 count decreased (p<0.01)(Figure 9). The most common anterior segment pathology was cataract (8.2%) followed by corneal opacity, pterygium and pseudophakia (2.1% each).



Discussion 
The mean age of study subjects was 40.49 years with 51.8% between 21-40 years of age. Bekele et al10 studied 348 patients with mean age of study subjects as 31.9 years. The mean age in the study by Gogri et al11 was 38.75 ± 13.9 years while it was 41.48 years in the study by Tarilah et al12 Female predominance was observed with 57.9% females and 42.1% males. This study showed ocular manifestations in 37.9% HIV positive patients where all patients were on HAART. HIV microvasculopathy and uveitis were the most common manifestations. The other ocular manifestations noted included uveitis, ophthalmic herpes zoster, seborrheic blepharitis and molluscum contagiosum. In a study conducted in Gondar University Hospital13, the prevalence was 60%. This difference in the prevalence rates in studies could be due to the nature of the study at Gondar which was conducted on patients who were admitted to hospital with a medical problem and came to the eye clinic with ocular complains and 90% of patients were in WHO stage of 3 and 4. The fact that the Gondar study was conducted during the pre-HAART era might have contributed to the difference. HAART decreases the prevalence of HIV related ocular disease by decreasing plasma levels of HIV RNA and increasing CD4 counts, improving immune function of patients with HIV infections. 80% subjects were having best corrected visual acuity in the range 6/6 to 6/9 in both eyes. Visual acuity below 6/60 was seen in about 6% subjects. The posterior segment was more commonly involved in HIV related ocular manifestations. The most common posterior segment pathology was HIV retinopathy (Figure 10) followed by CMV retinitis (Figure 11).



Binocular affection of HIV retinopathy was 6.1% and CMV retinitis was 1.5%. Gogri et al11 observed that HIV retinopathy was the most common HIV associated ophthalmic lesion. A parallel study done by Joshi et al14 also showed that HIV retinopathy (23.3%) was the most common HIV associated ophthalmic lesion. In a study by Gharai et al15 the most common ocular manifestation was cytomegalovirus retinitis while HIV vasculopathy was seen in 11% patients. In this study, 1% patients had papilledema (Figure 12). Purushottam and coworkers,14 in a study of 103 HIV positive patients, found 1.9% cases with papilloedema. Khurana and colleagues16 reported a case series of four HIV positive cases who were on HAART and all four showed papilloedema. They concluded that Cryptococcus infections associated with immune recovery inflammatory syndrome in patients on HAART, causes papilledema. The patients were on Zidovudine where anaemic retinopathy was seen. This study showed 0.5% patients affected by toxoplasmic retinochoroiditis. Serological tests (IgG and IgM titre) were done to confirm the diagnosis.



In this study, 2 patients had rhegmatogenous retinal detachment. One patient presented with silicon oil in situ (post retinal detachment surgery). Hence in our study, the prevalence of retinal detachment was 1.5%. A single case with unilateral optic atrophy was noted in this study. Lee and co workers also reported two cases of optic atrophy.17 They postulated that they had primary HIV optic neuropathy.
In the present study, CD4 count above 500 cells/mm3 was seen in 28.7% cases while it was below 250/mm3 in 29.3% cases. Prevalence of ophthalmic pathology increased as CD4 count decreased (p value<0.01).
Gharai et al.15 observed that amongst those who had ophthalmic involvement, 70% patients had CD4 count below 200 cells/micro litre.
Bekele et al10 in their study observed that CD4 count of <200 cells/micro litre is a risk factor for ocular manifestations.
In a study conducted by Kumar et al18 on 125 patients on HAART, 43.9% had ocular manifestations and their CD4 count was less than 200 cells/mm3. They concluded that low CD4 count is strongly related to the increased prevalence of ocular lesions as well as ocular symptoms.
Gogri et al.11 studied patients attending their ART center and observed that posterior segment lesions showed significant association (p<0.05) with low CD4 count of the patient. CMV retinitis, retinal detachment, tubercular chorioretinitis and acute retinal necrosis were seen in all patients with CD4 count less than 100 cells/mm3.

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Ajit Kamalakar Joshi, Natasha Patel, Krishangee KalitaEvaluation of Fundoscopic Findings in HIV Positive Patients in Relation to HAART and CD4 Count.DJO 2018;29:34-38
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Ajit Kamalakar Joshi, Natasha Patel, Krishangee KalitaEvaluation of Fundoscopic Findings in HIV Positive Patients in Relation to HAART and CD4 Count.DJO [serial online] 2018[cited 2018 Dec 13];29:34-38. Available from: http://www.djo.org.in/articles/29/2/Evaluation-of-Fundoscopic-Findings-in-HIV-Positive-Patients-in-Relation-to-HAART-and-CD4-Count.html
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