Optic neuropathy as the presenting feature of HIV infection: recovery of vision with highly active antiretroviral therapy

Infectious optic neuropathy (ION), how to recognise it and manage it

Optic neuropathy can be of infectious or non-infectious/idiopathic aetiology. Many infectious organisms can cause optic neuropathy that can be of varied presentation including papillitis, retrobulbar optic neuritis, neuroretinitis, and optic perineuritis. Detailed history, ocular, systemic/neurologic examination along with appropriate laboratory evaluation can help clinicians to identify the infectious agent causing optic neuropathy. In spite of recent advanced techniques in serological testing and molecular diagnostics like polymerase chain reaction (PCR), the identification of these pathogens is still a diagnostic challenge. It is ideal to have an infectious disease (ID) consultant in the management team, as most of these infections are multisystem involving diseases. Most infectious agents can be effectively treated with specific antibiotics, with or without corticosteroid therapy, but visual recovery is highly variable and depends entirely on early diagnosis of the causative agent. This review article will provide an overview of common pathogens involved in ION and will describe their management paradigms.

Acute Management of Optic Neuritis: An Evolving Paradigm

The current management of acute optic neuritis (ON) is focused on expediting visual recovery through the use of high-dose intravenous corticosteroids. The recent identification of specific autoantibodies associated with central nervous system inflammatory disorders has provided novel insights into immune targets and mechanisms that impact the prognosis, treatment, and recurrence of ON. Therefore, neurologists and ophthalmologists need to be aware of clinical, laboratory, and imaging findings that may provide important clues to the etiology of ON and the potential need for aggressive management. Moving forward, rapid and accurate diagnosis of inflammatory ON will likely be critical for implementing clinical care that optimizes short-term and long-term therapeutic outcomes.

Neuro-Ophthalmic Manifestations of HIV Infection

Purpose: To review the broad spectrum of clinical neuro-ophthalmic presentations associated with human immunodeficiency virus (HIV) infection. Methods: Critical review of the literature regarding neuro-ophthalmic consequences of HIV infection and its sequelae. Results: Neuro-ophthalmological diseases are common in both asymptomatic HIV-positive patients and those who profound immunosuppression with acquired immune deficiency syndrome (AIDS). Neuro-ophthalmic manifestations of HIV infection can involve the afferent or efferent visual pathway. Common clinical presentations include headache, papilledema, chorioretinitis, optic nerve involvement, meningitis, and cranial nerve palsies. Other neuro-ophthalmic manifestations include involvement of the visual pathway in the brain producing visual field defects such as occur in progressive multifocal encephalopathy. Pupil abnormalities have also been reported. Discussion: Neuro-ophthalmic consequences of HIV are important to recognize as it is critical to identify underlying neoplastic or infectious diseases which could be amenable to treatment.

Pattern- and motion-related visual evoked potentials in HIV-infected adults

PURPOSE

The goal of the current study was to explore visual function in virally suppressed HIV patients undergoing combined antiretroviral therapy (cART) by using pattern-reversal and motion-onset visual evoked potentials (VEPs).

METHODS

The pattern-reversal and motion-onset VEPs were recorded in 20 adult HIV+ patients with a mean age of 38 years and CD4 cell counts ≥230 × 10⁶ cells/L of blood.

RESULTS

Nine out of 20 patients displayed VEP abnormalities. Pattern-reversal VEPs pathology was observed in 20% of subjects, and 45% HIV patients had impaired motion-onset VEPs. Five out of 16 neurologically asymptomatic HIV patients had prolonged motion-onset VEP latencies in both eyes. Four neurologically symptomatic patients displayed simultaneously abnormal motion-onset and pattern-reversal VEP latencies: monocular involvement was observed in two patients with Lyme and cytomegalovirus unilateral optic neuritis. Binocular involvement was noted in two patients with cognitive deficits. Correlation analysis between disease duration, CD4 cell count, HIV copies in plasma, MoCA and electrophysiological parameters did not show any significant relationships.

CONCLUSIONS

The functional changes of the visual system in neurologically asymptomatic virally suppressed HIV patients displayed higher motion-onset VEP sensitivity than in standard pattern-reversal VEP examinations. This promising marker, however, has no significant association with clinical conditions. Further exploration is warranted.

Optic Nerve

Optic nerve diseases arise from many different etiologies including inflammatory, neoplastic, genetic, infectious, ischemic, and idiopathic. Understanding some of the characteristics of the most common optic neuropathies along with therapeutic approaches to these diseases is helpful in designing recommendations for individual patients. Although many optic neuropathies have no specific treatment, some do, and it is those potentially treatable or preventable conditions which need to be recognized in order to help patients regain their sight or develop a better understanding of their own prognosis. In this chapter several diseases are discussed including idiopathic intracranial hypertension, optic neuritis, ischemic optic neuropathies, hereditary optic neuropathies, trauma, and primary tumors of the optic nerve. For each condition there is a presentation of the signs and symptoms of the disease, in some conditions the evaluation and diagnostic criteria are highlighted, and where possible, current therapy or past trials are discussed.

Infectious optic neuropathies: a clinical update

Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.

[Recurrent unilateral optic neuropathy associated with human immunodeficiency virus (HIV)]

HIV-related optic neuropathy is rare compared to optic neuropathies secondary to opportunistic infections in seropositive patients. We report the case of a 39-year-old HIV-positive woman referred for unilateral visual loss leading to the diagnosis of recurrent, unilateral, inflammatory optic neuropathy directly associated with HIV. Despite initial recovery after steroid treatment, she relapsed twice. Absence of any opportunist infections or toxic causes and presence of a very high viral load due to non-compliance with treatment led to the diagnosis of HIV-related optic neuropathy. Steroids and effective anti-retroviral treatment resulted in definitive and complete recovery. Inflammatory, degenerative and/or vascular mechanisms have been hypothesized to explain the occurrence of these rare HIV-related optic neuropathies. This diagnosis remains a diagnosis of exclusion to be considered in the work-up of seropositive patients with optic neuropathies.

Human immunodeficiency virus and its effects on the visual system

During the first 15 years of the AIDS epidemic patients experienced a high incidence of blindness due to cytomegalovirus (CMV) retinitis and other severe ocular opportunistic infections. Highly active anti-retroviral therapy, introduced in 1996, dramatically decreased the incidence of CMV retinitis. Though CMV retinitis still causes 40% of vision loss in AIDS patients, other conditions such as immune reconstitution uveitis, cataracts, and a significant othercategory -which most investigators believe is directly due to HIV - comprise the majority of cases. HIV causes vascular abnormalities of the conjunctiva and retina in the majority of AIDS patients, as well as retinitis, anterior and posterior uveitis and vasculitis. HIV frequently causes an optic neuropathy and is responsible for the majority of eye movement disorders among HIV patients. Physicians need to be aware that these problems may be the initial manifestation of HIV infections or a sign of highly active anti-retroviral therapy (HAART) failure. Therefore, patients with identifiable risk factors for AIDS who present with ophthalmologic conditions of unknown etiology should be considered for HIV testing. Finally, anti-retroviral therapy has been reported to cause asymptomatic deposits as well as degenerative conditions of both the anterior and posterior segments of the eye.

AIDS and optic neuritis in a rhesus monkey infected with the R5 clade C SHIV-1157ipd3N4

A Chinese rhesus macaque infected with the pathogenic CCR5-tropic clade C simian-human immunodeficiency virus, SHIV-1157ipd3N4, had persistent viremia, depletion of CD4(+) T cells to <200 cells/μl, opportunistic infections, coagulopathy, and gradual development of bilateral blindness. MRI revealed marked thickening of both optic nerves. Histopathological evaluation showed diffuse cellular infiltration at necropsy and a focus of SHIV-infected cells. This is the first report of CNS pathology following chronic infection with an obligate R5 SHIV.

Optic nerve axonal pathology is related to abnormal visual evoked responses in AIDS

Electrophysiological studies in subjects with HIV/AIDS demonstrate subtle changes in the visual pathway even in the absence of visual symptoms. But the pathological correlate of the electrophysiological abnormalities is largely unknown. This study attempts to correlate pathological changes in the retina and intraorbital portion of optic nerve in four drug naïve patients of AIDS caused by HIV-1 clade C, who had abnormalities in the visual evoked potentials recorded antemortem. Three had no visual complaints and one patient had sudden loss of vision in the right eye. In all four patients, the visual evoked potentials disclosed variable prolongation of P100 latencies. Histologically axonal cytoskeletal breakdown and depletion in the optic nerves was the cardinal finding with variable myelin loss, even in the absence of overt visual dysfunction, or infective retinitis. The axonal loss was maximal in the symptomatic case. Retinal ganglion cell depletion was seen in only two patients. Sectoral infiltration of the optic nerve by cryptococci and Cryptococcal choroiditis was the only opportunistic infection to involve the eye. Axonal pathology in the optic nerve appears to be related to the abnormalities recorded in visual evoked potentials even in the absence of overt clinical symptoms. Opportunistic infections could be contributing to the axonal pathology in the optic nerve in patients with AIDS.

Neuropathie optique bilatérale révélant une infection par le virus de l’immunodéficience humaine

We report the case of a 57-year-old man who presented bilateral subacute and painless optic neuropathy after meningopolyradiculitis revealing a primary human immunodeficiency virus infection. Both antiretroviral and steroid treatments were ineffective. Clinical symptoms and evolutive pattern were consistent with a mechanism of microvascular ischaemia of the optic nerve head. Optic neuropathies related to HIV infection are rare compared to those resulting from opportunistic infections. There are several pathophysiological mechanisms involved.

Neuro-ophthalmological disorders in HIV infected subjects with neurological manifestations

AIMS

To determine the frequency and features of neuro-ophthalmological manifestations in neurologically symptomatic HIV infected patients and to assess whether or not the visual evoked potential (VEP) features in these patients differ from those of neurologically asymptomatic HIV infected patients.

METHODS

Neuro-ophthalmological evaluation was performed in 166 neurologically symptomatic confirmed HIV positive patients, of whom 75 with normal ophthalmological examination were further studied by means of VEPs. The VEPs values were compared to those obtained from 53 other confirmed HIV positive subjects with neither ophthalmological nor neurological manifestations, who served as a comparison group and to the references values of our laboratory.

RESULTS

An abnormal neuro-ophthalmological examination was noted in 99/166 patients (60%). Eye movement disorders were present in 99 patients (51%). Visual field defects were detected in 39% of the patients. Optic neuropathy was noted in 31%, papilloedema in 27% and ocular motor nerve palsies in 26% of the patients. Toxoplasmosis and cryptococcosis were the most frequent associated pathologies, though in some patients the HIV itself was the presumed cause. VEPs were abnormal in 57% and 42% of patients with and without neurological manifestations, respectively. Compared to asymptomatic patients, symptomatic patients had a significantly increased mean latency; however, both groups had significant increase in mean latency compared to reference values.

CONCLUSION

Neuro-ophthalmological manifestations are common in neurologically symptomatic HIV infected patients. Subclinical dysfunction in the visual pathways is a common phenomenon in both HIV infected patients with and without neurological symptoms, but neurologically symptomatic patients seem to have more damage in their visual pathways.

Optic neuropathy in a patient with AIDS

We present a patient with acquired immunodeficiency syndrome (AIDS) with bilateral sequential optic neuropathies attributed to the 14484 mutation of Leber hereditary optic neuropathy (LHON). We discuss the potential interaction of the mitochondrial mutation with antiretroviral therapy and review the literature.