Association between abnormal contrast sensitivity and mortality among people with acquired immunodeficiency syndrome

Vision Problems As a Contributor to Lower Engagement in Care Among Aging Men Living with HIV

PURPOSE

To investigate vision impairment as a barrier to engagement in medical care among aging persons living with HIV (PLWH) who experience multimorbidity and complex care needs.

SETTING

Multicenter AIDS Cohort Study (MACS), a prospective observational cohort of aging PLWH men.

METHODS

We examined relationships of self-reported vision difficulty with indicators of care engagement: 1) adherence to HIV antiretroviral therapy (ART; defined as taking ≥95% of medications); 2) self-reported avoidance of medical care; 3) self-reported tendency to ask a doctor questions about care (>2 questions at a medical visit), as well as with quality of life. A modified version of the National Eye Institute Vision Function Questionnaire was administered at three semi-annual visits (from October 2017 to March 2019) to assess difficulty performing vision-dependent tasks.

RESULTS

We included 1063 PLWH (median age 57 years, 31% Black). Data on care engagement outcomes were analyzed using repeated measures logistic regression with generalized estimating equations adjusted for race, and at visit values for age, education level, depressive symptoms, alcohol use, and smoking status. Compared to no vision difficulty, those reporting moderate to extreme vision difficulty on at least one task had 2.2 times higher odds (95% CI: 1.4, 3.4) of having less than optimal ART adherence, 1.9 times higher odds (95% CI: 1.1, 3.4) of avoiding necessary medical care and median quality of life scores 8 points lower.

CONCLUSION

These findings suggest vision impairment decreases medical care engagement including HIV care and quality of life among aging PLWH.

Sociodemographic predictors associated with the spectrum of non-opportunist neuroretinal disease of non-infectious etiology in patients with HIV/AIDS: A scoping review

BACKGROUND

Non-infectious retinal disease, even in the HAART era, continues to be one of the most common diagnoses in patients with HIV, with prevalences of up to 27% of cases. This study aims to characterize the association between demographic variables and their role. As a risk factor for the development of non-opportunistic non-infectious retinal disease in patients with HIV/AIDS.

METHODS

An integrative review of the literature was carried out according to Arksey O'Malley's approach, based on the PICO methodology and following the PRISMA recommendations; An exhaustive search was carried out in databases of articles that were filtered using established criteria, with their extraction and analysis carried out qualitatively.

RESULTS

Ocular manifestations from any cause develop from 35 years of age in patients with HIV/AIDS, with the highest risk for age-related macular degeneration over the fourth decade of life and for the development of neuroretinal disorder on the fifth decade of life; some studies report a slight tendency to diagnose macular degeneration in women and those who acquired AIDS through sexual contact; data contrasted with increased risk for diagnosing neuroretinal disorder in homosexual men who also use intravenous drugs, possibly due to oversampling in studies; non-Hispanic whites and African Americans were the races most commonly affected by neuroretinal disease; the means between the 11.3-14.5 years elapsed since the HIV diagnosis were more frequently associated with cognitive impairment and both in those with high or low CD4 counts, and in patients with high or low viral loads, neuroretinal disease without Statistically significant differences. Adherence and early initiation of HAART had a modest impact on the development of neuroretinal disease.

DISCUSSION

Even in the HAART era, non-infectious neuroretinal disease and cytomegalovirus retinitis remain the most frequent ocular diagnoses, however, different studies argue an increase in age-related non-infectious retinal diseases in patients with HIV, theories that are may explain by the increase in life expectancy, the metabolic effects of HAART itself or the generalized pro-inflammatory state in this group of patients, it is essential to recognize this new diagnostic challenge in order to direct preventive efforts through the use of cost-effective sociodemographic risk predictors towards that technological tools for diagnosis and treatment can be targeted.

CONCLUSIONS

HIV/AIDS patients who present at the ophthalmological consultation with the suggested sociodemographic predictors have a high risk of visual impairment due to non-infectious retinopathy, therefore prevention, diagnosis and treatment efforts directed at these diseases should be increased.

Sociodemographic predictors associated with the spectrum of non-opportunist neuroretinal disease of non-infectious etiology in patients with HIV/AIDS: a scoping review

BACKGROUND

Non-infectious retinal disease, even in the HAART era, continues to be one of the most common diagnoses in patients with HIV, with prevalences of up to 27% of cases. This study aims to characterize the association between demographic variables and their role. as a risk factor for the development of non-opportunistic non-infectious retinal disease in patients with HIV/AIDS METHODS: An integrative review of the literature was carried out according to Arksey O'Malley's approach, based on the PICO methodology and following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) recommendations; An exhaustive search was carried out in databases of articles that were filtered using established criteria, with their extraction and analysis carried out qualitatively.

RESULTS

Ocular manifestations from any cause develop from 35 years of age in patients with HIV/AIDS, with the highest risk for age-related macular degeneration over the fourth decade of life and for the development of neuroretinal disorder on the fifth decade of life; some studies report a slight tendency to diagnose macular degeneration in women and those who acquired AIDS through sexual contact; data contrasted with increased risk for diagnosing neuroretinal disorder in homosexual men who also use intravenous drugs, possibly due to oversampling in studies; non-Hispanic whites and African Americans were the races most commonly affected by neuroretinal disease; the means between the 11.3 to 14.5 years elapsed since the HIV diagnosis were more frequently associated with cognitive impairment and both in those with high or low CD4 counts, and in patients with high or low viral loads, neuroretinal disease without Statistically significant differences. Adherence and early initiation of HAART had a modest impact on the development of neuroretinal disease.

DISCUSSION

Even in the HAART era, non-infectious neuroretinal disease and cytomegalovirus retinitis remain the most frequent ocular diagnoses, however, different studies argue an increase in age-related non-infectious retinal diseases in patients with HIV, theories that are may explain by the increase in life expectancy, the metabolic effects of HAART itself or the generalized pro-inflammatory state in this group of patients, it is essential to recognize this new diagnostic challenge in order to direct preventive efforts through the use of cost-effective sociodemographic risk predictors towards that technological tools for diagnosis and treatment can be targeted.

CONCLUSIONS

HIV/AIDS patients who present at the ophthalmological consultation with the suggested sociodemographic predictors have a high risk of visual impairment due to non-infectious retinopathy, therefore prevention, diagnosis and treatment efforts directed at these diseases should be increased.

Prevalence and Consequences of Perceived Vision Difficulty in Aging Adults with HIV Infection

PURPOSE

Despite well-known ocular complications of HIV-related immune suppression, few studies have examined the prevalence and consequences of visual impairment among aging long-term survivors of HIV.

DESIGN

Retrospective cohort study.

METHODS

Aging HIV-infected (HIV+) men who have sex with men (MSM) and HIV-uninfected (HIV-) MSM controls reported their difficulty performing 6 vision-dependent tasks (difficulty defined as: no, a little, moderate, and extreme difficulty). Relationships were examined using logistic regression, regressing each outcome separately on categorical visual function responses, with missing data multiply imputed.

RESULTS

There were 634 age-matched pairs for a total sample of 1,268 MSM of 1,700 MSM with available data. The median age was 60 years old (interquartile range [IQR], 54, 66), and 23% were African American. Among HIV+ men, 95% were virally suppressed (viral load <400 copies/mL). HIV+ men were more likely to report moderate or extreme difficulty performing at least 1 task (21% for HIV+ compared to 13% for HIV-; P < .01). Participants reporting extreme vision-related difficulty performing at least 1 task had 11.2 times the odds of frailty (95% confidence interval [CI], 5.2-23.9), 2.6 times the odds of a slow gait speed (95% CI, 1.4-4.8), and 3.2 times the odds of impaired instrumental activities of daily living (95% CI: 1.6-6.3) compared to those reporting no vision-related difficulty on any task.

CONCLUSIONS

Perceived vision difficulty was more common among older HIV+ MSM than age-matched HIV- MSM controls and was associated with higher risk of depression and physical function loss among MSM.

Measurement of Contrast Sensitivity in Patients with Behçet's Disease without Ocular Involvement

Purpose

To evaluate contrast sensitivity in patients with Behçet's disease (BD) without ocular involvement.

Methods

The study group was composed of 47 BD patients (20 to 50 years of age) who did not have ocular involvement. The control group was composed of 47 normal volunteers who were similar to the study group in terms of age and gender. No participants in this study had any ocular or systemic pathologies except for BD. The contrast sensitivity measurements were performed using the Functional Acuity Contrast Test under photopic conditions, and the results were compared between the two groups.

Results

The mean age of the BD patients and control subjects was 34.5 ± 9.7 and 33.2 ± 7.6 years, respectively. The mean disease duration of the BD patients was 5.5 ± 6.4 years. There was a statistically significant decrease at five spatial frequencies (A, 1.5; B, 3; C, 6; D, 2; and E, 18 cycles per degree) in patients with BD compared with control subjects (p < 0.001, p = 0.004, p = 0.002, p < 0.001, and p = 0.001, respectively).

Conclusions

The contrast sensitivity of BD patients without ocular involvement was lower than that of the control group. Further studies seem mandatory to confirm our results.

Neuroretinal Degeneration in HIV Patients Without Opportunistic Ocular Infections in the cART Era

Subtle structural and functional retinal abnormalities, termed 'HIV-associated Neuroretinal Disorder (HIV-NRD)', have been reported in HIV patients receiving combination antiretroviral therapy (cART), without infectious retinitis or any apparent fundus abnormalities otherwise. In this review, we provide an overview of studies investigating HIV-NRD in HIV patients without opportunistic ocular infections in the cART era, and try to elucidate underlying mechanisms and associated risk factors. Most studies focused on patients with severe immune-deficiency and demonstrated that patients with nadir CD4 counts<100 cells/μL are most at risk for neuroretinal damage, with a thinner retinal nerve fiber layer, subtle loss of color vision and/or contrast sensitivity, visual field deficits, and subnormal electrophysiological responses. In contrast, alterations in retinal vascular calibers and retinal blood flow were not associated with nadir CD4 counts, but instead with detectable viremia, suggesting a role for (chronic) inflammation in microvascular damage. Although the alterations in visual function are subtle, they can lead to difficulties in activities, such as reading or driving, thereby affecting quality of life. Since HIV has become a chronic disease, its long-term effects with respect to visual function loss become more important, as is recently emphasized by a longitudinal study, reporting that AIDS patients with HIV-NRD have higher risks of developing bilateral visual impairment and even blindness than patients without HIV-NRD. The question remains whether patients with high (>350 cells/μL) nadir CD4 counts and well-suppressed HIV infection on cART remain at risk for HIV-NRD, as this group constitutes a growing part of the aging HIV-infected population.

Relationship between Human Immunodeficiency Virus Neuroretinal Disorder and Vision-Specific Quality of Life among People with AIDS

PURPOSE

Some human immunodeficiency virus (HIV)-infected individuals have evidence of optic nerve or retinal dysfunction that manifests as decreased contrast sensitivity, even with good best-corrected visual acuity (BCVA). This condition, termed HIV-related neuroretinal disorder (HIV-NRD), is a risk factor for vision impairment (BCVA <20/40), blindness (BCVA ≤20/200), and increased mortality. We investigated the effect of HIV-NRD on vision-specific quality of life (QOL).

DESIGN

Cross-sectional analysis of data from a prospective, observational study.

PARTICIPANTS

Individuals from the Longitudinal Study of the Ocular Complications of AIDS cohort who completed the National Eye Institute 25-item Visual Function Questionnaire (VFQ-25), had BCVA of 20/40 or better, and had no evidence of ocular opportunistic infection or cataract.

METHODS

We compared QOL by HIV-NRD status, adjusting for potential confounding variables, using multiple linear regression. Among those with HIV-NRD, we assessed the relationship between VFQ-25 and the logarithm of contrast sensitivity (logCS), using Spearman correlation. We defined a minimum clinically important difference (MCID) as 1 standard error of measurement from a well-characterized, historical population of individuals with a variety of ophthalmic disorders.

MAIN OUTCOME MEASURES

Subscales and composite VFQ-25 scores (0 = worst, 100 = best).

RESULTS

A total of 813 individuals met study criteria. Those with HIV-NRD (n = 39 [4.8%]) had a lower mean composite score than those without HIV-NRD (81 vs. 89; P = 0.0002) and lower mean scores in the following subscales: near activities (77 vs. 86; P = 0.004), distance activities (85 vs. 91; P = 0.01), social functioning (89 vs. 96; P = 0.0005), mental health (75 vs. 87; P = 0.0001), dependency (81 vs. 94; P < 0.0001), driving (75 vs. 85; P = 0.02), color vision (90 vs. 97; P < 0.0001), and peripheral vision (85 vs. 91; P = 0.0496). Score differences for each of these subscales met criteria for MCID. Among those with HIV-NRD, there was a positive correlation between logCS and composite score (r = 0.36; 95% confidence interval, 0.04-0.60).

CONCLUSIONS

HIV-NRD has a statistically significant and clinically meaningful association with decreased vision-specific QOL among people with AIDS and good BCVA.

Incidence and long-term outcomes of the human immunodefıciency virus neuroretinal disorder in patients with AIDS

PURPOSE

Patients with AIDS have an abnormality of retina/optic nerve function, manifested as decreased contrast sensitivity (in the absence of ocular opportunistic infections or media opacity), abnormalities on automated perimetry, and loss of retinal nerve fiber layer, even among those with good visual acuity, termed the "human immunodeficiency virus (HIV) neuroretinal disorder." The objectives of this study were to determine the prevalence, incidence, risk factors, and outcomes of HIV neuroretinal disorder.

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 1822 patients with AIDS without ocular infections or media opacities.

METHODS

Patients with HIV neuroretinal disorder were identified by a contrast sensitivity <1.50 log units in either eye in the absence of ocular opportunistic infections or media opacity.

MAIN OUTCOME MEASURES

Incidence of HIV neuroretinal disorder, mortality, visual impairment (visual acuity ≤20/50), and blindness (≤20/200) on logarithmic visual acuity charts.

RESULTS

Sixteen percent of participants had HIV neuroretinal disorder at enrollment. The estimated cumulative incidence by 20 years after AIDS diagnosis was 51% (95% confidence interval [CI], 46-55). Human immunodeficiency virus neuroretinal disorder was more common in women and African Americans. Risk factors for HIV neuroretinal disorder included hepatitis C infection, low CD4+ T cells, and detectable HIV RNA in the blood. Patients with HIV neuroretinal disorder had a 70% excess mortality versus those without it, even after adjusting for CD4+ T cells and HIV load (hazard ratio [HR], 1.7; 95% CI, 1.3-2.1; P < 0.0001). Patients with HIV neuroretinal disorder had increased risks of bilateral visual impairment (HR, 6.5; 95% CI, 2.6-10.6; P < 0.0001) and blindness (HR, 5.9; 95% CI, 2.8-13.7; P = 0.01) versus those without HIV neuroretinal disorder.

CONCLUSIONS

Human immunodeficiency virus neuroretinal disorder is a common finding among patients with AIDS, and it is associated with an increased mortality and an increased risk of visual impairment. Successful antiretroviral therapy decreases but does not eliminate the risk of HIV neuroretinal disorder.

Visual function assessment in simulated real-life situations in HIV-infected subjects

Visual function abnormalities are common in people living with HIV disease (PLWH) without retinitis, even after improvement in immune status. Abnormalities such as reduced contrast sensitivity, altered color vision, peripheral visual field loss, and electrophysiological changes are related to a combination of retinal dysfunctions, involving inner and outer retinal structures. The standard protocol for testing vision performance in clinical practice is the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. However, this method poorly correlates with activities of daily living that require patients to assess visual stimuli in multiple light/contrast conditions, and with limited time. We utilized a novel interactive computer program (Central Vision Analyzer) to analyze vision performance in PLWH under a variety of light/contrast conditions that simulate stressful and real-world environments. The program tests vision in a time-dependent way that we believe better correlates with daily living activities than the non-timed ETDRS chart. We also aimed to correlate visual scores with retinal neuro-fiber layer thickness on optical coherence tomography. Here we show that visual acuity is more affected in PLWH in comparison to HIV-seronegative controls in varying contrast and luminance, especially if the nadir CD4+ T-cell count was lower than 100 cells/mm³. Visual impairment reflects the loss of retinal nerve fiber layer thickness especially of the temporal-inferior sector. In PLWH the ETDRS chart test led to better visual acuity compared to the Central Vision Analyzer equivalent test, likely because patients had indefinite time to guess the letters. This study confirms and strengthens the finding that visual function is affected in PLWH even in absence of retinitis, since we found that the HIV serostatus is the best predictor of visual loss. The Central Vision Analyzer may be useful in the diagnosis of subclinical HIV-associated visual loss in multiple light/contrast conditions, and may offer better understanding of this entity called “neuroretinal disorder”.

Retinal nerve fibre layer thickness and contrast sensitivity in HIV-infected individuals in South Africa: a case-control study

Background

Antiretroviral treatment (ART) has altered the spectrum of HIV-related eye disease, resulting in a lower prevalence of retinal opportunistic infections (OIs). However, abnormalities in visual function have been reported in HIV-infected individuals despite effective viral suppression and the absence of retinal OIs. These changes may be mediated by an HIV-associated ‘neuroretinal disorder’, characterized by changes in the retinal nerve fibre layer (RNFL). HIV infection may also be associated with accelerated biological aging. The aim of this study was to investigate the relationships between contrast sensitivity, RNFL thickness, HIV infection and frailty in South African adults.

Methods

Case-control study of 225 HIV-infected individuals without retinal OIs and 203 gender/age-matched HIV-seronegative individuals. Peri-papillary RNFL thickness was determined with spectral domain optical coherence tomography in four quadrants. CS was measured using a Pelli-Robson chart. Frailty was assessed using standard criteria. Multivariable linear and logistic regression were used to assess associations between HIV status and RNFL/CS and frailty.

Results

The median age of both groups was similar (41.2 vs. 41.9 years, p = 0.37). 88% of HIV-infected individuals were receiving ART and their median CD4 count was 468 cells/μl. Adjusted CS score was lower in HIV-infected participants compared to HIV-seronegative individuals (1.76 vs. 1.82, p = 0.002). Independent predictors of poor CS in the HIV-infected group were positive frailty status and current HIV viral load >2 log copies/ml. Lower CS score was also associated with thin temporal RNFL in HIV-infected individuals (p = 0.04). Superior quadrant RNFL thickness was greatest in ART-naïve participants relative to the HIV-uninfected group (p-trend = 0.04). Longer ART duration was associated with thinning of inferior and nasal RNFL quadrants (p-trend = 0.03 and 0.04, respectively).

Conclusions

Contrast sensitivity is reduced in HIV-infected individuals and functionally associated with frailty and unsuppressed viraemia. This may reflect structural changes in the RNFL that are evident despite the absence of OIs.

A quantitative structure-activity relationship study of anti-HIV activity of substituted HEPT using nonlinear models

We performed studies on extended series of 79 HEPT ligands (1-[(2-hydroxyethoxy)methyl]-6-(phenylthio)thymine), inhibitors of HIV reverse-transcriptase with anti-HIV biological activity, using quantitative structure–activity relationship (QSAR) methods that imply analysis of correlations and representation of models. A suitable set of molecular descriptors was calculated, and the genetic algorithm was employed to select those descriptors which resulted in the best-fit models. The kernel partial least square and Levenberg–Marquardt artificial neural network were utilized to construct the nonlinear QSAR models. The proposed methods will be of great significance in this research, and would be expected to apply to other similar research fields.

Optic nerve head morphology and visual field function in patients with AIDS and without infectious retinitis

PURPOSE

To evaluate morphology of the optic nerve head and visual field in AIDS patients without retinitis.

METHODS

One randomly selected eye from 246 patients with AIDS without retinitis was evaluated from prospective multicenter Longitudinal Studies of Ocular Complications of AIDS. Stereo fundus photographs of OHN and serial VF data over 5-years were analyzed. Main outcomes included vertical cup-to-disc ratio (CDR), mean deviation, and pattern standard deviation scores on VF testing.

RESULTS

The median CDR was 0.39 at enrollment and 0.40 at 5-year follow-up. An unadjusted linear regression model revealed a mean change in CDR of 0.004 after 5-years (P = 0.04). After adjustment for practice effect, there were no statistically significant changes in VF performance observed during the 5 years of follow-up.

CONCLUSIONS

We detected clinically minimal, but statistically significant changes in ONH morphology and no change in VF performance among eyes of patients with AIDS and without retinitis.

Association between retinal nerve fiber layer thickness and abnormalities of vision in people with human immunodeficiency virus infection

PURPOSE

To investigate relationships between contrast sensitivity (CS), color vision, and retinal nerve fiber layer (RNFL) among people with human immunodeficiency virus (HIV) infection; to evaluate the effect of time since diagnosis of HIV infection on RNFL thickness.

DESIGN

Noninterventional cross-sectional study.

METHODS

We evaluated 102 eyes of 57 HIV-infected individuals without ocular opportunistic infections. Peripapillary RNFL thickness was determined with spectral-domain optical coherence tomography in 4 quadrants. CS was measured with the Pelli-Robson technique (expressed as logCS); color vision was measured with the Lanthony desaturated 15-hue technique (expressed as color confusion index [C-index], with higher scores indicating worse color vision). Correlations between values were assessed using Spearman correlation coefficients.

RESULTS

Median RNFL thickness (average of 4 quadrants) was 102.9 μm (range, 75.0-134.7 μm). Median logCS was 1.90 (range, 1.25-1.95). Median C-index was 1.58 (range, 0.96-4.07). Temporal RNFL thickness was correlated with logCS (r=0.295, P=.003) and C-index (r=-0.338, P=.0005). Time since diagnosis of HIV infection was shorter for those with thick average RNFL than for those with thin average RNFL (P=.18).

CONCLUSIONS

Both worse CS and worse color vision are correlated with thinning of the temporal RNFL, with possible threshold effects. Increased prevalences of abnormal CS and abnormal color vision in this population are therefore likely attributable to neuroretinal compromise. This pattern of structural and functional losses may reflect preferential damage to small-caliber axons in the maculopapillary bundle, possibly associated with mitochondrial dysfunction, providing a potential disease mechanism for HIV-associated "neuroretinal disorder."

Retinal vessel caliber among people with acquired immunodeficiency syndrome: relationships with disease-associated factors and mortality

PURPOSE

To evaluate relationships between retinal vessel caliber, AIDS-related factors, and mortality.

DESIGN

Longitudinal, observational cohort study.

METHODS

We evaluated data for participants without ocular opportunistic infections at initial examination (baseline) in the Longitudinal Studies of the Ocular Complications of AIDS (1998-2008). Semi-automated evaluation of fundus photographs (1 eye/participant) determined central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), and arteriole-to-venule ratio (AVR) at baseline. Multiple linear regression models, using forward selection, identified independent relationships between indices and various host- and disease-related variables.

RESULTS

Included were 1250 participants. Mean follow-up for determination of mortality was 6.1 years. Smaller CRAE was related to increased age (P < .001) and hypertension (P < .001); larger CRAE was related to lower hematocrit (P = .002). Larger CRAE and CRVE were associated with black race (P < .001). Larger CRVE was related to smoking (P = .004); smaller CRVE was related to age (P < .001) and higher mean corpuscular volume (P = .001). We observed the following relationships with AIDS-associated factors: smaller CRAE and larger CRVE with history of highly active antiretroviral therapy (HAART; P < .001); and larger CRAE with lower CD4+ T lymphocyte count (P = .04). We did not identify independent relationships with human immunodeficiency virus RNA blood levels. There was a 12% (95% CI, 2%-21%) increase in mortality risk per quartile of decreasing AVR (P = .02).

CONCLUSIONS

Variations in retinal vascular caliber are associated with AIDS-specific factors and are markers for increased mortality risk. Relationships are consistent with the hypothesis that the vasculature is altered by known atherogenic effects of chronic HAART or the prolonged inflammatory state associated with AIDS.

Retinal vessel caliber among people with acquired immunodeficiency syndrome: relationships with visual function

PURPOSE

To evaluate relationships between retinal vessel caliber and tests of visual function among people with AIDS.

DESIGN

Longitudinal, observational cohort study.

METHODS

We evaluated data for participants without ocular opportunistic infections at initial examination (baseline) in the Longitudinal Studies of the Ocular Complications of AIDS (1998-2008). Visual function was evaluated with best-corrected visual acuity, Goldmann perimetry, automated perimetry (Humphrey Field Analyzer), and contrast sensitivity (CS) testing. Semi-automated grading of fundus photographs (1 eye/participant) determined central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), and arteriole-to-venule ratio (AVR) at baseline. Multiple linear regression models, using forward selection, sought independent relationships between indices and visual function variables.

RESULTS

Included were 1250 participants. Smaller AVR was associated with reduced visual field by Goldmann perimetry (P = .003) and worse mean deviation (P = .02) on automated perimetry and possibly with worse pattern standard deviation (PSD) on automated perimetry (P = .06). There was a weak association between smaller AVR and worse CS (P = .07). Relationships were independent of antiretroviral therapy and level of immunodeficiency (CD4+ T lymphocyte count, human immunodeficiency virus [HIV] RNA blood level). On longitudinal analysis, retinal vascular indices at baseline did not predict changes in visual function.

CONCLUSIONS

Variation in retinal vascular indices is associated with abnormal visual function in people with AIDS, manifested by visual field loss and possibly by reduced CS. Relationships are consistent with the hypothesis that HIV-related retinal vasculopathy is a contributing factor to vision dysfunction among HIV-infected individuals. Longitudinal studies are needed to determine whether changes in indices predict change in visual function.

Ocular safety of sildenafil citrate when administered chronically for pulmonary arterial hypertension: results from phase III, randomised, double masked, placebo controlled trial and open label extension

OBJECTIVE

To assess the ocular effects and safety profile of chronic sildenafil oral dosing in patients with pulmonary arterial hypertension.

DESIGN

12 week, double masked, randomised, placebo controlled, phase III trial with open label extension.

SETTING

53 institutions worldwide.

PARTICIPANTS

277 adults with idiopathic pulmonary arterial hypertension or pulmonary arterial hypertension associated with connective tissue disease or after congenital heart disease repair (mean pulmonary artery pressure ≥25 mm Hg; pulmonary capillary wedge pressure ≤15 mm Hg at rest).

INTERVENTIONS

During the double masked study, oral sildenafil 20 mg, 40 mg, or 80 mg or placebo (1:1:1:1) three times daily for 12 weeks was added to baseline drug treatment. In the extension study, the placebo, 20 mg and 40 mg groups received 40 mg three times daily titrated to 80 mg three times daily at week 6. After unmasking, the dose was titrated according to clinical need.

MAIN OUTCOME MEASURE

Ocular safety (ocular examinations, visual function tests, participants' reports of adverse events, and visual disturbance questionnaire completed by investigators) by treatment group at 12 weeks, 24 weeks, 18 months, and yearly.

RESULTS

Findings of the objective assessments-that is, intraocular pressure and visual function tests (visual acuity, colour vision, and visual field)-were similar across groups (20 mg, n=69; 40 mg, n=67; 80 mg, n=71; placebo, n=70). No clinically significant changes occurred between baseline and 12 weeks, except for an efficacy signal in contrast sensitivity for the sildenafil 40 mg three times daily group. In right eyes, changes in intraocular pressure from baseline to week 12 ranged from a mean of -0.5 (95% confidence interval -1.3 to 0.2) mm Hg with placebo, -0.2 (-0.9 to 0.5) mm Hg with sildenafil 40 mg, and -0.1 (-0.7 to 0.5) mm Hg with 80 mg to 0.3 (-0.4 to 0.9) mm Hg with sildenafil 20 mg (the approved dose for pulmonary arterial hypertension). Mean changes from baseline to week 12 in contrast sensitivity in right eyes were -0.02 (SD 0.12) in the sildenafil 20 mg three times daily group compared with -0.05 (0.18) in the placebo group (P=0.044). Percentages of participants with deterioration in visual acuity (Snellen) from baseline to week 12 ranged from 10% (n=7) in the placebo group to 3% (n=2) in the sildenafil 20 mg three times daily group; the same percentages had visual field changes from normal to abnormal during the period in these two groups. The investigators did not deem any findings on colour vision assessment to be clinically significant. Findings of the objective assessments in the 40 mg and 80 mg three times daily sildenafil treatment groups and in left eyes were not substantially different, nor were any measures different throughout the open label extension compared with week 12. However, objective data were limited after month 18, as most participants had missing data or visual parameters were no longer collected by investigators. Incidence of ocular adverse events reported on the case report forms and assessed by the investigator was low with all doses, but a modest, dose related incidence of chromatopsia, cyanopsia, photophobia, and visual disturbance was reported with 80 mg three times daily consistent with the indicated dosing for erectile dysfunction. Retinal haemorrhages, captured on funduscopy, occurred in 2% (4/207) of sildenafil treated participants and none in the placebo group during the double masked study and in 4% (10/259) during the open label extension.

CONCLUSIONS

Sildenafil dosing up to 80 mg three times daily is safe and well tolerated from an ocular perspective in patients with pulmonary arterial hypertension. Daily chronic dosing in this patient population was not associated with visual change and had no detrimental effect on best corrected visual acuity, contrast sensitivity, colour vision, or visual field, or on slit lamp examinations, funduscopy, or intraocular pressure during the duration of this study.

TRIAL REGISTRATION

Clinical trials NCT00644605 and NCT00159887.

Evaluation of the United States public health service guidelines for discontinuation of anticytomegalovirus therapy after immune recovery in patients with cytomegalovirus retinitis

PURPOSE

To evaluate United States Public Health Service (USPHS) guidelines for discontinuing anticytomegalovirus (CMV) therapy in patients with AIDS who have immune recovery and quiescent retinitis after initiating highly active antiretroviral therapy.

DESIGN

Cohort study of patients with CMV retinitis (Longitudinal Study of Ocular Complications of AIDS).

METHODS

Participants had CMV retinitis and CD4+ T-cell counts of 50 cells/μL or fewer enrolled from 1998 through 2009 who demonstrated sustained immune recovery (2 consecutive CD4+ T-cell counts of 100 cells/μL or more at least 6 months apart) and inactive retinitis. Participants were classified into 2 groups according to anti-CMV treatment after immune recover: (1) continued anti-CMV therapy and (2) discontinued therapy. We evaluated survival, visual acuity, and CMV retinitis activity; we used propensity scores to adjust for confounding factors for these analyses.

RESULTS

Of 152 participants reviewed, 71 demonstrated immune recovery, 37 of whom discontinued therapy and 34 of whom continued therapy. At immune recovery, participants continuing therapy tended to be older (44 vs 40 years; P = .09), have bilateral retinitis (53% vs 32%; P = .10), and have lower CD4+ T-cell counts (148 vs 207 cells/μL; P < .001). There were no statistical differences in any of the clinical outcomes (death, retinitis progress, visual acuity, or incidence of bilateral retinitis). Both groups lost visual acuity during follow-up, on average 1.2 letters per year (P < .01).

CONCLUSIONS

Discontinuation of anti-CMV therapy after immune recovery did not increase the risk of poor outcomes. These results support the current guidelines for discontinuation of anti-CMV therapy after achievement of sustained immune recovery.

Contrast sensitivity, ocular blood flow and their potential role in assessing ischaemic retinal disease

PURPOSE

To examine the definition, evaluation methodology, association to ocular blood flow and potential clinical value of contrast sensitivity (CS) testing in clinical and research settings, focusing in patients with ischemic retinal disease.

METHODS

A review of the medical literature focusing on CS and ocular blood flow in ischemic retinal disease.

RESULTS

CS may be more sensitive than other methods at detecting subtle defects or improvements in primarily central retinal ganglion cell function early on in a disease process. CS testing attempts to provide spatial detection differences which are not directly assessed with standard visual acuity chart testing. Analyzing all studies that have assessed both CS change and ocular blood flow, it is apparent that both choroidal circulation and retinal circulation may have an important role in influencing CS.

CONCLUSION

The concept that CS is directly influenced by ocular blood flow is supported by reviewing the studies involving both. Although the studies in the literature have not established a direct cause and effect relationship per se, the literature review makes it logical to assume that changes in retinal and choroidal blood flow influence CS. This raises the possibility that a subjective visual characteristic, specifically CS, may be able to be evaluated more objectively by studying blood flow. It appears appropriate to study the relationship between blood flow and CS more extensively to develop improved ways of measuring various aspects of blood flow to the eye and to best quantify early changes in visual function.