Delhi Journal of Ophthalmology

Central Retinal Artery Occlusion and Simultaneous Third Nerve Palsy in HIV Patient

Raghnandan Kothari, Priyanka Dhaytadak, Pratik Gogri
Rural Medical College, Loni, Maharashtra, India

Corresponding Author:

Dr. Pratik Gogri
E-mail : pratikgogri@yahoo.com

Published Online: 25-SEP-2013

DOI:http://dx.doi.org/10.7869/djo.2012.71

Abstract
Ocular manifestations can occur in approximately 70% of human immunodeficiency virus acquired immune deficiency syndrome patients and posterior segment involvement seen in about 50% cases is the most common presentation. We report a case of 39 years old HIV positive male who presented with unilateral central retinal artery occlusion with simultaneous third nerve palsy. Magnetic resonance Imaging brain revealed acute infarct in thalamo-capsular region on right side and old lacunar infarct involving pons on left side. We report this case for its rare presentation of CRAO and simultaneous third nerve palsy in HIV infection.

Keywords :

Microvasculopathy is one of the most common ocular manifestation, seen in about 40% to 60% of human immunodeficiency virus (HIV) positive patients.[1,2] Large retinal vessel occlusion is relatively uncommon and occurs in less than 1 % of patients and appears to be more common in severely immunosuppressed patients. Retinal veins are affected more often than retinal arteries.

Neuro-ophthalmic manifestations occur in 3-8% of HIV positive patients.[3] Most common findings include optic nerve head edema, nonspecific optic atrophy, cranial nerve palsies, especially of sixth nerve. We report a case of HIV positive patient who presented with sudden, unilateral loss of vision due to central retinal artery occlusion (CRAO) and simultaneous 3rd nerve palsy.



Case report

A 39 year old male patient presented with sudden, painless loss of vision in right eye of 15 days duration. Following this two days later, he also developed drooping of upper eyelid and outward deviation of the same eye. Six months back he had a febrile episode and was found to be HIV positive, however no anti-retroviral therapy was initiated. He was not a known case of hypertension, diabetes mellitus or any other systemic disease. He was also not on any medication. He was non-smoker and consumed alcohol occasionally. He did not had any significant past history. On ocular examination, visual acuity in right eye was perception of light and left eye was 20/20. Right eye had mild ptosis, exotropia of 15 degrees, with complete restriction of adduction and mild restriction of depression and elevation (Figure-1a,b). Left eye ocular movements were normal. Anterior segment was within normal limit in both eyes, except for relative afferent pupillary defect in right eye. Intraocular pressure was normal in both eyes. Ophthalmoscopic examination, right eye showed diffuse retinal pallor with faint cherry-red spot and marked generalized attenuation of the retinal arteries, sheathing of vessels and few empty vessels near optic disc. Few atrophic patches were seen just inferior to disc (Figure 2). Left eye fundus was normal. Systemic examination did not reveal any abnormality. Hemogram, blood sugar and lipid profile were within normal limits. Erythrocyte sedimentation rate (ESR) was 74 mm/hr. Rheumatoid factor (RA) & C-reactive protein (CRP) were negative. Serum enzyme linked immune sorbant assay (ELISA) for HIV was positive. The CD4 count was 350 cells/mm3. Cerebrospinal fluid (CSF) examination showed slight increase in proteins (51mg/dl) and CSF culture was sterile. Magnetic resonance Imaging (MRI) brain (plain & contrast) showed acute infarct in thalamo-capsular region on right side and old lacunar infarct involving pons on left side. On the basis of clinical examination & investigations case was diagnosed as Central retinal artery occlusion with 3rd nerve palsy right side and referred to department of medicine for further management.





Discussion

Thromboembolic phenomenon associated with HIV infection is relatively less common as compared to opportunistic infections and malignancies. Cases have been reported of isolated cranial nerve palsy and vascular occlusions, arterial occlusions being very uncommon.[4,5] Dunn JP et al have reported 1.3% risk of non-infectious retinal vascular occlusion in patients infected with HIV, 48.5% involving central retinal vein whereas central retinal artery occlusion was noted in only about 3% cases.[6] The specific etiology of the vasculopathy has not been elucidated completely. However, increased plasma viscosity, immune-complex deposition, and a direct cytopathic effect of the virus on the retinal vascular endothelium are believed to play a role.[7,8] Isolated retinal vasculitis has also been associated with HIV infection. Increased erythrocyte aggregation and increased leukocyte rigidity in HIV infected patients have also been attributed to reduced microvascular blood flow in the posterior retina.[9] HIV infection has been recognized as a prothrombotic condition and there is two to ten fold increased risk of venous thromboembolism with HIV infection.[10] It is associated with elevated levels of cytokines, tumour necrosis factor-alpha (TNF-alpha), which decreases the fibrinolytic potential leading to vaso-occlusive events. Low CD4 count is one of the risk foctors. In our case CD4 count was 350, however there are reports of thrombosis occurring with CD4 count as high as 800cells/m3.[11] Recently, Venkatesh et al, reported presence of retinal arterial plaques in AIDS patient, resembling fibrin emboli probably leading to branch or central retinal artery occlusion.[12] However, no such plaques were seen in our patient. Neuro-ophthalmological disturbances have been widely described in both asymptomatic HIV positive subjects and in those with full blown AIDS. In addition, it has been shown that asymptomatic HIV infected subjects, even in early stages of the infection, exhibit ocular electrophysiological and psychophysical abnormalities. The prevalence of neuro-ophthalmic manifestations in patients with HIV cases regardless of the presence of neurological symptoms, has been reported to range between 3% and 8%.[3,13] In the series reported by Helweg-Larsen et al only 17 of 589 patients with neurological manifestations (3%) had ocular nerve palsy.[14]

Cranial neuropathies in patients with HIV always prompt a search for opportunistic infections or lymphoma. In our case presence of acute infarcts on MRI and simultaneous occlusion of central retinal artery are suggestive of thromboembolic phenomenon / microvascular abnormality. The cerebral microvascularisation is frequently altered in HIV-infected patients and disturbed vasoreactivity contributes to microinfarcts. Ischaemic oculomotor mononeuropathies are common in older patients and are attributed to microvascular atherosclerotic injury exacerbated principally by hypertension, diabetes mellitus or hypercholesterolaemia.[15] Our patient was young and had no relevant vascular risk factors, however due to lack of facilities at our set up, we could not estimate antithrombin III, protein S and C levels. Premature atherosclerosis is frequent in HIV-infected patients though the exact mechanism is not known.[16] HIV itself also has been identified as an etiologic agent of Ocular Motor Nerve Palsy (OMNP) either by its direct effect on the nerves or by indirect immune mechanisms. Jean-Claude Mwanza et al repoted 3 HIV-positive patients of OMNP in absence of any obvious cause.[17]

In summary, though non-infectious CRAO and 3 rd nerve palsy is seen in HIV patients, simultaneous involvement of central retinal artery and third nerve palsy, in our case is a rare presentation in HIV infection.

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Kothari R, Dhaytadak P, Gogri PCentral Retinal Artery Occlusion and Simultaneous Third Nerve Palsy in HIV Patient.DJO 2013;23:207-209

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Kothari R, Dhaytadak P, Gogri PCentral Retinal Artery Occlusion and Simultaneous Third Nerve Palsy in HIV Patient.DJO [serial online] 2013[cited 2019 Sep 18];23:207-209. Available from: http://www.djo.org.in/articles/23/3/central-retinal-artery-occlusion.html