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Factors associated with changes in posterior corneal surface following photorefractive keratectomy. Graefes Arch Clin Exp Ophthalmol 2021; 259:3477-3483. [PMID: 34097113 DOI: 10.1007/s00417-021-05237-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To identify factors associated with changes in the posterior cornea curvature following laser refractive surgery. MATERIALS AND METHODS This retrospective study included myopic astigmatic eyes that underwent PRK between January 2013 and December 2013 at Care-Vision Laser Centers, Tel-Aviv, Israel. The average posterior K was measured with the Sirius device at a radius of 3 mm from the center. The correlations between the surgical induced change in average posterior k and preoperative parameters such as central corneal thickness (CCT), refraction, Baiocchi Calossi Versaci index (BCV), ablation depth, percent tissue altered (PTA), and residual stroma bed (RSB) were analyzed. RESULTS A total of 280 eyes with a mean age of 24.9 ± 6.1 years (range, 18-47 years were included in this study. The mean PTA was 14.8 ± 6.0%. A greater change in posterior K was found in females (p = 0.01), smaller treatment zones of 6.0 mm (p = 0.02) and PTA > 20% (p < 0.001). A lower CCT (r = - 0.24, p < 0.001), higher myopia (r = - 0.34, p < 0.001), higher astigmatism (r = - 0.17, p < 0.001), higher total BCV (r = 0.13, p = 0.03), lower back BCV (r = - 0.12, p = 0.05), higher front BCV (r = 0.16, p = 0.01), higher posterior I-S ratio (r = 0.16, p = 0.01), and a lower RSB (r = - 0.42, p < 0.001) were all significantly correlated with percentage of change in mean posterior K. In ranked stepwise multiple regression analysis, 26.2% of the variance of change in posterior K could be explained by the examined factors. The factors that remained significant were PTA (p < 0.001), CCT (p = 0.001), and posterior I-S ratio (p = 0.001). PTA alone accounted for 15% of the variance in posterior K changes in multivariate analysis. CONCLUSIONS Understanding of factors affecting a change in posterior cornea after refractive surgery may have an important practical value for the prevention of iatrogenic keratectasia. Preoperative CCT, posterior I-S ratio, and PTA were significantly associated with changes in posterior K after PRK. PTA was the strongest predictor of posterior corneal changes (p < 0.001).
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Sharma K, Menia N, Bajgai P, Sharma M, Sharma A, Katoch D, Singh R. Nontubercular Mycobacteria Associated Uveitis in HIV Positive Patients. Ocul Immunol Inflamm 2020; 30:21-28. [PMID: 32813606 DOI: 10.1080/09273948.2020.1788610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To report clinical features and outcomes of nontuberculous mycobacteria (NTM) presenting as uveitis in HIV positive patients. MATERIALS AND METHODS Retrospective study of HIV positive patients who were diagnosed as uveitis due to NTM. RESULTS Six eyes of four HIV positive patients with NTM were studied. Average age at presentation was 35.5 years (range 30-38). With specific PCR primers, Mycobacterium avium was detected in three patients (75%) and Mycobacterium fortuitum in one patient (25%). Culture was positive in two cases. Two eyes (33.33%) each had endophthalmitis and necrotizing retinitis like picture, one eye (16.66%) each had chorioretinitis and frosted branch angitis like. Visual acuity improved in two eyes (33.33%), worsened in three eyes (50%), and remained unchanged in one eye (16.6%). CONCLUSIONS NTM infection is a unique entity in immunosuppressed with poor visual outcome. PCR forms a useful tool for rapid diagnosis and timely initiation of specific anti-tuberculosis therapy.
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Affiliation(s)
- Kusum Sharma
- Department of Microbiology, Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Nitin Menia
- Advanced Eye Centre, Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Priya Bajgai
- Department of Ophthalmology, Vitreoretina and Uveitis Services, Nepal Eye Hospital, Kathmandu, Nepal
| | - Megha Sharma
- Department of Microbiology, Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Deeksha Katoch
- Advanced Eye Centre, Post Graduate Institute Medical Education and Research, Chandigarh, India
| | - Ramandeep Singh
- Advanced Eye Centre, Post Graduate Institute Medical Education and Research, Chandigarh, India
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MULTIMODAL IMAGING OF CHOROIDAL LESIONS IN DISSEMINATED MYCOBACTERIUM CHIMAERA INFECTION AFTER CARDIOTHORACIC SURGERY. Retina 2020; 39:452-464. [PMID: 29206759 DOI: 10.1097/iae.0000000000001991] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To explore morphologic characteristics of choroidal lesions in patients with disseminated Mycobacterium chimaera infection subsequent to open-heart surgery. METHODS Nine patients (18 eyes) with systemic M. chimaera infection were reviewed. Activity of choroidal lesions were evaluated using biomicroscopy, fundus autofluorescence, enhanced depth imaging optical coherence tomography, fluorescein angiography/indocyanine green angiography, and optical coherence tomography angiography. Relationships of choroidal findings to systemic disease activity were sought. RESULTS All 9 male patients, aged between 49 and 66 years, were diagnosed with endocarditis and/or aortic graft infection. Mean follow-up was 17.6 months. Four patients had only inactive lesions (mild disease). In all five patients (10 eyes) with progressive ocular disease, indocyanine green angiography was superior to other tests for revealing new lesions and active lesions correlated with hyporeflective choroidal areas on enhanced depth imaging optical coherence tomography. One eye with a large choroidal granuloma developed choroidal neovascularization. Optical coherence tomography angiography showed areas with reduced perfusion at the inner choroid. All 5 patients with progressive ocular disease had evidence of systemic disease activity within ±6 weeks' duration. CONCLUSION Choroidal manifestation of disseminated M. chimaera infection indicates systemic disease activity. Multimodal imaging is suitable to recognize progressive ocular disease. We propose ophthalmologic screening examinations for patients with M. chimaera infection.
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Ganesh SK, Abraham S, Sudharshan S. Paradoxical reactions in ocular tuberculosis. J Ophthalmic Inflamm Infect 2019; 9:19. [PMID: 31493128 PMCID: PMC6730739 DOI: 10.1186/s12348-019-0183-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 08/09/2019] [Indexed: 12/18/2022] Open
Abstract
Paradoxical reactions following initiation of anti-tubercular therapy have been documented most often in extrapulmonary tuberculosis. A combination of factors such as delayed hypersensitivity, decreased suppressor mechanisms, and an increased response to mycobacterial antigens mediated by the host’s immune system have been implicated in the development of these reactions. Similar worsening in patients with ocular tuberculosis while on treatment has been described. It is therefore important for the clinician to be aware of this occurrence, as prompt recognition and timely institution of corticosteroids and immunosuppressants can lead to restoration of vision. In these patients, an alteration or discontinuation of anti-tubercular therapy may not be indicated.
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Affiliation(s)
- Sudha K Ganesh
- Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006, India.
| | - Sharanya Abraham
- Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006, India
| | - Sridharan Sudharshan
- Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006, India
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Dalvin LA, Smith WM. Intraocular manifestations of mycobacterium tuberculosis: A review of the literature. J Clin Tuberc Other Mycobact Dis 2017; 7:13-21. [PMID: 31723696 PMCID: PMC6850243 DOI: 10.1016/j.jctube.2017.01.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 01/04/2017] [Accepted: 01/31/2017] [Indexed: 11/18/2022] Open
Abstract
Mycobacterium tuberculosis: is most commonly associated with pulmonary infection. However, tuberculosis (TB) can also affect the eye. TB can affect nearly any tissue in the eye, and a high index of suspicion is required for accurate diagnosis, as many of the intraocular manifestations of TB can mimic other, more common diseases. Correct diagnosis is critical because systemic anti-tuberculosis treatment may be required, and vision loss or even loss of the affected eye can occur without proper treatment. Thus, it is important for ophthalmologists and infectious disease specialists to work together to accurately diagnose and treat intraocular TB. This article reports the various known presentations of intraocular TB and reviews important elements of diagnosis and treatment.
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Affiliation(s)
| | - Wendy M. Smith
- Department of Ophthalmology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
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Bell LCK, Breen R, Miller RF, Noursadeghi M, Lipman M. Paradoxical reactions and immune reconstitution inflammatory syndrome in tuberculosis. Int J Infect Dis 2016; 32:39-45. [PMID: 25809754 DOI: 10.1016/j.ijid.2014.12.030] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/15/2014] [Accepted: 12/16/2014] [Indexed: 12/01/2022] Open
Abstract
The coalescence of the HIV-1 and tuberculosis (TB) epidemics in Sub-Saharan Africa has had a significant and negative impact on global health. The availability of effective antimicrobial treatment for both HIV-1 (in the form of highly active antiretroviral therapy (HAART)) and TB (with antimycobacterial agents) has the potential to mitigate the associated morbidity and mortality. However, the use of both HAART and antimycobacterial therapy is associated with the development of inflammatory paradoxical syndromes after commencement of therapy. These include paradoxical reactions (PR) and immune reconstitution inflammatory syndromes (IRIS), conditions that complicate mycobacterial disease in HIV seronegative and seropositive individuals. Here, we discuss case definitions for PR and IRIS, and explore how advances in identifying the risk factors and immunopathogenesis of these conditions informs our understanding of their shared underlying pathogenesis. We propose that both PR and IRIS are characterized by the triggering of exaggerated inflammation in a setting of immunocompromise and antigen loading, via the reversal of immunosuppression by HAART and/or antimycobacterials. Further understanding of the molecular basis of this pathogenesis may pave the way for effective immunotherapies for the treatment of PR and IRIS.
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Affiliation(s)
- Lucy C K Bell
- Division of Infection and Immunity, Cruciform Building, University College London, Gower Street, London WC1E 6BT, UK.
| | - Ronan Breen
- Department of Respiratory Medicine, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Robert F Miller
- Research Department of Infection and Population Health, Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, Cruciform Building, University College London, Gower Street, London WC1E 6BT, UK
| | - Marc Lipman
- Centre for Respiratory Medicine, Royal Free London NHS Foundation Trust, University College London, London, UK
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Ikeda H, Nakamura K, Ikenori M, Saito T, Nagamine K, Inoue M, Sakagami T, Suzuki H, Usui M, Kanemitsu K, Matsumoto A, Shinbo T. Severe Disseminated Mycobacterium avium Infection in a Patient with a Positive Serum Autoantibody to Interferon-γ. Intern Med 2016; 55:3053-3058. [PMID: 27746449 PMCID: PMC5109579 DOI: 10.2169/internalmedicine.55.6896] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report a case of disseminated Mycobacterium avium infection that involved both optic nerves, the conjunctiva, the right lower lung, and multiple skin lesions, including a thoracic nodule. The patient was a 65-year-old man without any significant medical history. The pathogen was detected in the patient's eye discharge, sputum, bronchial lavage fluid, and thoracic nodule. Anti-mycobacterial chemotherapy, including clarithromycin, rifampicin, and ethambutol, was administered, and the thoracic nodule was resected. An autoantibody to interferon-γ was detected in the patient's serum. Bilateral swelling of his optic nerves and facial dermatitis improved after initiating anti-mycobacterial chemotherapy.
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Affiliation(s)
- Hiroshi Ikeda
- Department of Internal Medicine, Ohta-Nishinouchi Hospital, Japan
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Nontuberculous Mycobacterial Ocular Infections: A Systematic Review of the Literature. BIOMED RESEARCH INTERNATIONAL 2015; 2015:164989. [PMID: 26106601 PMCID: PMC4461732 DOI: 10.1155/2015/164989] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 02/20/2015] [Accepted: 02/20/2015] [Indexed: 11/01/2022]
Abstract
Nontuberculous or atypical mycobacterial ocular infections have been increasing in prevalence over the past few decades. They are known to cause periocular, adnexal, ocular surface and intraocular infections and are often recalcitrant to medical therapy. These infections can potentially cause detrimental outcomes, in part due to a delay in diagnosis. We review 174 case reports and series on nontuberculous mycobacterial (NTM) ocular infections and discuss etiology, microbiology, risk factors, diagnosis, clinical presentation, and treatment of these infections. History of interventions, trauma, foreign bodies, implants, contact lenses, and steroids are linked to NTM ocular infections. Steroid use may prolong the duration of the infection and cause poorer visual outcomes. Early diagnosis and initiation of treatment with multiple antibiotics are necessary to achieve the best visual outcome.
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Schaftenaar E, van Gorp ECM, Meenken C, Osterhaus ADME, Remeijer L, Struthers HE, McIntyre JA, Baarsma GS, Verjans GMGM, Peters RPH. Ocular infections in sub-Saharan Africa in the context of high HIV prevalence. Trop Med Int Health 2014; 19:1003-14. [PMID: 25039335 DOI: 10.1111/tmi.12350] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Healthy eyes and good vision are important determinants of populations' health across the globe. Sub-Saharan Africa is affected by simultaneous epidemics of ocular infections and human immunodeficiency virus (HIV). Ocular infection and its complications, along with cataract and ocular trauma, are common conditions in this region with great impact on daily life. In this review, we discuss the epidemiology, clinical manifestations and microbial aetiology of the most important infectious ocular conditions in sub-Saharan Africa: conjunctivitis, keratitis and uveitis. We focus specifically on the potential association of these infections with HIV infection, including immune recovery uveitis. Finally, challenges and opportunities for clinical management are discussed, and recommendations made to improve care in this neglected but very important clinical field.
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Affiliation(s)
- Erik Schaftenaar
- Department of Viroscience, Erasmus MC, Rotterdam, the Netherlands; Anova Health Institute, Johannesburg, Tzaneen, South Africa; Rotterdam Eye Hospital, Rotterdam, The Netherlands
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Rose-Nussbaumer J, Goldstein DA, Thorne JE, Arantes TE, Acharya NR, Shakoor A, Jeng BH, Yeh S, Rahman H, Vemulakonda GA, Flaxel CJ, West SK, Holland GN, Smith JR. Uveitis in human immunodeficiency virus-infected persons with CD4+ T-lymphocyte count over 200 cells/mL. Clin Exp Ophthalmol 2013; 42:118-25. [PMID: 23777456 DOI: 10.1111/ceo.12141] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 05/19/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Introduction of highly active antiretroviral therapy has altered the course of disease for persons infected with human immunodeficiency virus by elevating CD4+ T-lymphocyte levels. Changes in the spectrum of systemic diseases encountered in human immunodeficiency virus-positive individuals are reported in the general medical literature. DESIGN Retrospective case series. PARTICIPANTS Sixty-one individuals infected with human immunodeficiency virus, who presented with uveitis when the peripheral CD4+ T-lymphocyte count was over 200 cells/μL. METHODS Standardized data collection at seven tertiary-referral inflammatory eye disease clinics. MAIN OUTCOME MEASURES Standardization of Uveitis Nomenclature anatomic classification and descriptors, cause of uveitis, and visual acuity RESULTS Peripheral CD4+ T cell counts varied between 207 and 1777 (median = 421) cells/μL at the time of diagnosis of uveitis. Uveitis was classified anatomically as anterior (47.5%), intermediate (6.6%), anterior/intermediate (16.4%), posterior (14.8%) and pan (14.8%). Specific causes of uveitis included infections (34.4%), with syphilis responsible for 16.4% of all cases, and defined immunological disorders (27.0%); no cause for the inflammation was identified in 34.4% of persons. Visual acuity was better than 6/15 in 66.7% and 6/60 or worse in 11.8% of 93 eyes at presentation, and better than 6/15 in 82.4% and 6/60 or worse in 8.8% of 34 eyes at 1 year of follow-up. CONCLUSIONS Both infectious and non-infectious forms of uveitis occur in individuals who are infected with human immunodeficiency virus and have preserved or restored peripheral CD4+ T cell levels. Individuals who are human immunodeficiency virus-positive and present with uveitis should be evaluated in the same way all patients with uveitis are assessed.
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Affiliation(s)
- Jennifer Rose-Nussbaumer
- Casey Eye Institute and Department of Ophthalmology, Oregon Health Sciences University, Portland, Oregon, USA
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Mycobacterium avium complex infection-related immune reconstitution inflammatory syndrome of the central nervous system in an HIV-infected patient: Case report and review. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 46:68-72. [DOI: 10.1016/j.jmii.2011.12.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 11/30/2011] [Accepted: 12/12/2011] [Indexed: 11/19/2022]
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Moorthy RS, Valluri S, Rao NA. Nontuberculous mycobacterial ocular and adnexal infections. Surv Ophthalmol 2012; 57:202-35. [PMID: 22516536 DOI: 10.1016/j.survophthal.2011.10.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 10/01/2011] [Accepted: 10/04/2011] [Indexed: 10/28/2022]
Abstract
The nontuberculous (also called "atypical") mycobacteria have become increasingly important causes of systemic as well as ocular morbidity in recent decades. All ocular tissues can become infected with these organisms, particularly in patients who are predisposed following ocular trauma, surgery, use of corticosteroids, or are immunocompromised. Because of their relative resistance to available antibiotics, multidrug parenteral therapy continues to be the mainstay of treatment of more serious ocular and adnexal infections caused by nontuberculous mycobacteria (NTM). Periocular cutaneous, adnexal, and orbital NTM infections remain rare and require surgical debridement and long-term parenteral antibiotic therapy. NTM scleritis may occur after trauma or scleral buckling and can cause chronic disease that responds only to appropriate antibiotic therapy and, in some cases, surgical debridement and explant removal. NTM infectious keratitis following trauma or refractive surgical procedures is commonly confused with other infections such as Herpes simplex keratitis and requires aggressive topical therapy and possible surgical debridement, particularly in those cases occuring after laser in situ keratomileusis. Only 18 cases of endophthalmitis due to NTM have been reported. Systemic and intraocular antibiotic therapy and multiple vitrectomies may be needed in NTM endophthalmitis; the prognosis remains poor, however. Disseminated NTM choroiditis in acquired immune deficiency syndrome patients with immune reconstitution during highly active anti-retroviral therapy is a rare infection that can present as a necrotizing chorioretinitis with dense vitritis, mimicking many other entities and needs to be recognized so that timely, life-saving treatment can be administered. Regardless of which ocular tissue is infected, all NTM ocular infections present similar challenges of recognition and of therapeutic intervention. We clarify diagnosis and delineate modern, effective therapy for these conditions.
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Affiliation(s)
- Ramana S Moorthy
- Indiana University Medical Center, Department of Ophthalmology, Vincent Hospital, Indianapolis, IN 46260, USA.
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Lamzaf L, Ammouri W, Berbich O, Tazi Mezalek Z, Adnaoui M, Aouni M, Harmouche H. [Ocular complications of HIV infection: experience of the Northern Excellence Pole of Morocco]. J Fr Ophtalmol 2011; 34:75-82. [PMID: 21276636 DOI: 10.1016/j.jfo.2010.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 09/29/2010] [Accepted: 10/24/2010] [Indexed: 11/26/2022]
Abstract
INTRODUCTION HIV infection is associated with a wide variety of ophthalmic manifestations. The objective of this study was to identify the ocular complications of HIV/AIDS in Morocco. MATERIAL AND METHODS A retrospective study conducted in the internal medicine department of the Rabat Teaching Hospital between 1998 and 2008. All HIV-positive patients were retained for the study. Each patient had an exhaustive ocular examination. RESULTS Of 115 ophthalmologic examinations, 28 were abnormal. Twenty-seven patients had stage C HIV infection and one patient was in stage A. The ocular manifestations were: 21 cases of ocular HIV-related anomalies (microangiopathies), four cases of cytomegalovirus (CMV) retinitis, one case of toxoplasmosis chorioretinitis, one case of CMV retinitis associated with toxoplasmosis chorioretinitis, two cases of Cryptococcus neoformans infection, two cases of varicella-zoster virus (VZV) retinitis, and one case of conjunctival Kaposi sarcoma. The CD4 count average was of 86±91/mm(3). Twenty-six patients had a CD4 count lower than 200/mm(3). Progression was favorable in 85 % of the cases, with three cases of blindness: bilateral in a case of VZV retinitis and unilateral in two cases of CMV retinitis and toxoplasmosis chorioretinitis. CONCLUSION CMV infection is the main ocular opportunistic infection in our series. However, Highly Active Antiretroviral Treatment (HAART) may be the cause for the decline in the prevalence of ocular diseases and visual impairment in HIV/AIDS.
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Affiliation(s)
- L Lamzaf
- Rabat Institut, service de médecine interne, CHU Ibn Sina Rabat, rue Lamfadel-Cherkaoui, BP 6527, Rabat, Maroc.
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Ala-Kauhaluoma M, Aho I, Ristola M, Karma A. Involvement of intraocular structures in disseminated histoplasmosis. Acta Ophthalmol 2010; 88:493-6. [PMID: 19141146 DOI: 10.1111/j.1755-3768.2008.01454.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe ocular involvement and response to treatment in a patient with human immunodeficiency virus (HIV) infection with severe progressive disseminated histoplasmosis (PDH). METHODS We report a 35-year-old HIV-infected patient seen in our clinics over a period of 4 years. During antiretroviral treatment (ART), the HIV load became undetectable at 3 months; however, CD4 T-cell count increased slowly and rose to 100 cells/microl. Histoplasma capsulatum was cultured from skin pustules, cerebrospinal fluid (CF) and aqueous humour. RESULTS The patient developed central nervous system (CNS) involvement 2 months and panuveitis in both eyes 4 months after the initiation of ART. With intravenous liposomal amphotericin B followed by oral voricanozole, the chorioretinal lesions of the right eye (RE) became inactivated and magnetic resonance imaging (MRI) lesions of CNS disappeared. Relapse of the inflammation in the anterior segment of the left eye (LE) resulted in a total closure of the chamber angle and severe glaucoma. Despite medical therapy, two cyclophotocoagulations, total vitrectomy and repeated intravitreal amphotericin B injections, LE became blind. Histoplasma capsulatum was cultured from the aqueous humour after antifungal therapy of 16 months' duration. CONCLUSION PDH with intraocular and CNS manifestations was probably manifested by an enhanced immune response against a previous subclinical disseminated infection. It seems difficult to eradicate H. capsulatum from the anterior segment of the eye in an immunocompromised patient.
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Abstract
PURPOSE OF REVIEW The aim of this article is to review the current literature concerning immune reconstitution inflammatory syndrome in relation to the eye. The definition, epidemiology, pathophysiology, risk factors, clinical features, diagnosis and treatment are discussed. RECENT FINDINGS Immune reconstitution inflammatory syndrome affecting the eye has been documented in association with cytomegalovirus retinitis following the introduction of highly active antiretroviral therapy in a large number of patients. This syndrome is referred to as immune recovery uveitis, which is presumed to be mediated by recovery of immune responses specific to residual cytomegalovirus antigen located in the eye. In addition to improved immunity itself, risk factors include a low CD4 T count at the time of initiation of highly active antiretroviral therapy and involvement of a larger proportion of retina. Immune recovery uveitis is a major cause of visual loss and morbidity among patients with AIDS who are receiving highly active antiretroviral therapy. SUMMARY Immune recovery uveitis is the most common form of immune reconstitution inflammatory syndrome in HIV-infected patients with cytomegalovirus retinitis who are receiving highly active antiretroviral therapy. Clear clinical definitions are required for ocular immune reconstitution inflammatory syndromes to avoid misclassification of other inflammatory conditions. A multidisciplinary approach is important in the diagnosis and management of immune recovery uveitis.
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Khurana RN, Javaheri M, Rao N. Ophthalmic manifestations of immune reconstitution inflammatory syndrome associated with Cryptococcus neoformans. Ocul Immunol Inflamm 2008; 16:185-90. [PMID: 18716955 DOI: 10.1080/09273940802204550] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To describe the ophthalmic manifestations of immune reconstitution inflammatory syndrome (IRIS) associated with Cryptococcus neoformans. METHODS Four HIV-positive patients on highly active anti-retroviral therapy (HAART) presented with marked optic disk swelling. RESULTS Three months after the episode of IRIS, 2 of the patients maintained 20/20 visual acuity whose elevated intracranial pressure (ICP) was successfully managed, while 2 patients visual acuities were worse than 20/400 whose ICP was persistently elevated. CONCLUSION Cryptococcus is another opportunistic infectious organism associated with IRIS with ophthalmic manifestations. Ophthalmologists have the opportunity to play a key role in the early diagnosis and management to prevent serious visual loss.
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Affiliation(s)
- Rahul N Khurana
- Uveitis & Ocular Pathology, Dohney Eye Institute, Los Angeles, California 90033, USA
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19
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Jeng BH, Holland GN, Lowder CY, Deegan WF, Raizman MB, Meisler DM. Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease. Surv Ophthalmol 2007; 52:329-68. [PMID: 17574062 DOI: 10.1016/j.survophthal.2007.04.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.
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Affiliation(s)
- Bennie H Jeng
- The Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Babu RB, Sudharshan S, Kumarasamy N, Therese L, Biswas J. Ocular tuberculosis in acquired immunodeficiency syndrome. Am J Ophthalmol 2006; 142:413-8. [PMID: 16935585 DOI: 10.1016/j.ajo.2006.03.062] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Revised: 03/27/2006] [Accepted: 03/27/2006] [Indexed: 11/17/2022]
Abstract
PURPOSE To present the clinical, histopathological, and molecular biologic findings in fifteen cases of ocular tuberculosis (TB) in patients with acquired immune deficiency syndrome (AIDS). DESIGN Retrospective, observational, noncomparative case series of HIV-infected patients with ophthalmic complaints and/or with advanced disease (CD4+ cell count < 200), seen between the years 1993 to 2005 at tertiary care ophthalmic and AIDS care hospitals. METHODS Each patient underwent a complete ophthalmic examination and relevant laboratory and radiologic investigations and was treated accordingly. The study was carried out in this cohort to describe the ocular manifestations of TB. The main outcome measures were to describe the clinical course histopathologic and molecular biologic features of ocular lesions attributable to tuberculosis in AIDS patients in our center. RESULTS Ocular TB was seen in 15 (1.95%) out of 766 consecutive cases of HIV/AIDS. Nineteen eyes of 15 patients were affected. Four cases (26.66%) had bilateral presentation. Presentations of ocular TB included choroidal granulomas in 10 eyes (52.63%), subretinal abscess in seven eyes (36.84%), worsening to panophthalmitis in three eyes, conjunctival tuberculosis, and panophthalmitis each in one eye (5.26%). All cases had evidence of pulmonary tuberculosis. Coexistent central nervous system (CNS) tuberculosis was seen in two cases and one case had abdominal tuberculosis. CD4+ cell counts were done in 14 patients; the count ranged from 14 to 560 cells/microl--mean 160.85 cells/microl. CONCLUSIONS Ocular TB in AIDS is relatively rare and can occur even at CD4+ cell counts greater than 200 cells/microl. It can have varied presentations with severe sight-threatening complications.
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Affiliation(s)
- Rajesh B Babu
- Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, India
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Ustianowski AP, Lawn SD, Lockwood DNJ. Interactions between HIV infection and leprosy: a paradox. THE LANCET. INFECTIOUS DISEASES 2006; 6:350-60. [PMID: 16728321 DOI: 10.1016/s1473-3099(06)70493-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Early in the HIV epidemic it was feared that the disease would undermine leprosy control, as has occurred with tuberculosis. It was predicted that patients with leprosy and HIV coinfection would have an increased risk of lepromatous disease and a faster clinical evolution, and that the leprosy would be more difficult to treat. None of these concerns have materialised and the interaction between HIV and Mycobacterium leprae seems to be far more subtle than that between HIV and tuberculosis. We review the epidemiological, clinical, and pathological data relating to leprosy/HIV coinfection. The published epidemiological data are limited in quality but show neither an increased HIV prevalence among leprosy cases nor an alteration in clinical spectrum of leprosy among coinfected patients. Some data suggest that immune-mediated reactions that complicate leprosy occur at a higher frequency in coinfected patients. Leprosy has now been reported presenting as immune reconstitution disease among patients commencing highly active antiretroviral treatment. Histopathological observations reveal a normal spectrum of appearances in biopsies of leprosy lesions from coinfected patients, even among those with advanced immunodeficiency. These observations suggest that cell-mediated immune responses to M leprae are preserved at the site of disease despite evidence that these responses are abrogated systemically, by contrast with tuberculosis, in which the host granulomatous response is impaired by HIV coinfection. We speculate that this paradox may relate to differences between the activation state and rates of cell turnover within leprosy and tuberculosis granulomas that differentially affect the susceptibility of the granulomas to HIV. The interactions between leprosy and HIV have been little studied and further research on the clinical, pathological, and management aspects of this coinfection is warranted.
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Modorati G, Miserocchi E, Brancato R. Immune recovery uveitis and human leukocyte antigen typing: a report on four patients. Eur J Ophthalmol 2005; 15:607-9. [PMID: 16167291 DOI: 10.1177/112067210501500511] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To report the typing of human leukocyte antigen (HLA) in four human immunodeficiency virus-positive (HIV) patients with immune recovery uveitis (IRU). METHODS The medical history of four consecutive patients who presented at the Ocular Immunology and Uveitis Service (University Hospital San Raffaele, Milan, Italy) with definite diagnosis of IRU is reported. The HLA typing was tested in all patients. RESULTS All patients presented the clinical and ophthalmological characteristics of IRU. The HLA typing analysis showed the presence of HLA B 8-18 in all patients. CONCLUSIONS The data obtained from these patients indicate the presence of the same HLA typing (B 8-18). The clinical relevance of such association needs to be further evaluated.
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Affiliation(s)
- G Modorati
- Department of Ophthalmology and Visual Sciences, Immunology and Uveitis Service, University Hospital San Raffaele, Milano, Italy.
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Lawn SD, Bekker LG, Miller RF. Immune reconstitution disease associated with mycobacterial infections in HIV-infected individuals receiving antiretrovirals. THE LANCET. INFECTIOUS DISEASES 2005; 5:361-73. [PMID: 15919622 DOI: 10.1016/s1473-3099(05)70140-7] [Citation(s) in RCA: 382] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Immune reconstitution disease (IRD) in HIV-infected patients is an adverse consequence of the restoration of pathogen-specific immune responses during the initial months of highly active antiretroviral treatment (HAART). Previously subclinical infections are "unmasked" or pre-existing opportunistic infections clinically deteriorate as host immunopathological inflammatory responses are "switched on". IRD is most frequently associated with mycobacterial infections. Our literature search identified 166 published cases of IRD associated with mycobacterial infections. We review the underlying immunological mechanisms, difficulties surrounding case definition and diagnosis, the wide diversity of clinical manifestations, and treatment. The importance of screening patients for mycobacterial disease before starting HAART and the critical impact of the timing of commencement of HAART in patients receiving treatment for tuberculosis are highlighted. We also discuss the problem of IRD associated with mycobacterial diseases in developing countries where tuberculosis prevalence is high and access to HAART is currently expanding.
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Affiliation(s)
- Stephen D Lawn
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Ng WT, Versace P. Ocular association of HIV infection in the era of highly active antiretroviral therapy and the global perspective. Clin Exp Ophthalmol 2005; 33:317-29. [PMID: 15932540 DOI: 10.1111/j.1442-9071.2005.01001.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Ocular involvement is a common complication of HIV infection. Since the late 1990s, widespread use of highly active antiretroviral therapy (HAART) has altered the spectrum, and reduced the incidence of ocular involvement in developed countries. The incidence of the most common ocular opportunistic infection, cytomegalovirus retinitis, has decreased tremendously. However, immune recovery uveitis secondary to HAART has emerged as a frequent visually threatening condition. Early diagnosis and treatment with periocular steroids is helpful in minimizing visual loss. Clinicians should also be aware that certain antimicrobial agents used to treat opportunistic infections in HIV-positive patients are associated with potentially serious ocular side effects. In developing countries, where most of the world's 40 million HIV-positive patients live, the spectrum and incidence of ocular involvement differ from those in developed countries. The lack of HAART availability is among the many causes of these differences, which may include nutritional factors, basic medical care availability and the levels of exposure to different infectious agents. These factors add to the already challenging task of treating ocular complications and preventing blindness in HIV-positive patients in developing countries.
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Affiliation(s)
- Weng T Ng
- Department of Ophthalmology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
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Kuo IC, Kempen JH, Dunn JP, Vogelsang G, Jabs DA. Clinical characteristics and outcomes of cytomegalovirus retinitis in persons without human immunodeficiency virus infection. Am J Ophthalmol 2004; 138:338-46. [PMID: 15364214 DOI: 10.1016/j.ajo.2004.04.015] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2004] [Accepted: 04/12/2004] [Indexed: 11/23/2022]
Abstract
PURPOSE To describe the characteristics and outcomes of patients with cytomegalovirus (CMV) retinitis in the absence of human immunodeficiency virus (HIV) infection. DESIGN Retrospective cohort study. METHODS Consecutive patients with CMV retinitis in the absence of HIV infection were identified at a university hospital. Demographic and clinical characteristics were noted at the time of CMV retinitis. Outcomes were determined retrospectively. Main outcome measures were rates of second eye involvement, vision loss, rhegmatogenous retinal detachment (RD), immune recovery uveitis, progression of retinitis, and mortality. RESULTS The clinical characteristics of CMV retinitis in 18 patients (30 eyes) without HIV infection diagnosed between January 1, 1984, and April 13, 2003, were similar to those of patients with HIV infection. The incidences of visual loss to the levels of 20/50 or worse and of 20/200 or worse were 17% per eye-year and 14% per eye-year, respectively. The observed incidence of RD was 3.7% per eye-year, and the mortality rate was 23% per person-year. Following reduction of immunosuppression, 10 patients (56%) who discontinued anti-CMV therapy remained free of retinitis progression. The incidence of immune recovery uveitis was 13% per person-year. CONCLUSIONS In our series, CMV retinitis in patients without HIV infection had a clinical course similar to that in patients with AIDS treated with highly active antiretroviral therapy (HAART), except the incidence of RD was lower for patients without AIDS. A substantial number of patients no longer required long-term anti-CMV therapy after adjustment of immunomodulatory therapy.
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Affiliation(s)
- Irene C Kuo
- Department of Ophthalmology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
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Rathinam SR, Rao NA. Tuberculous intraocular infection presenting with pigmented hypopyon: a clinicopathological case report. Br J Ophthalmol 2004; 88:721-2. [PMID: 15090435 PMCID: PMC1772127 DOI: 10.1136/bjo.2003.029124] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2003] [Indexed: 11/04/2022]
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