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More than / 00 of adult,ID( patients.ill e1perience an ocular complication at some point of the disease$. Or-ital and adne1al manifestations include tumors of the periocular tissues and e1ternal infections$. Posterior segment findings include a HIV associated retinopathy and a number of opportunistic infections of the retina and choroid$ HIV has also -een related
More than / 00 of adult,ID( patients.ill e1perience an ocular complication at some point of the disease$. Or-ital and adne1al manifestations include tumors of the periocular tissues and e1ternal infections$. Posterior segment findings include a HIV associated retinopathy and a number of opportunistic infections of the retina and choroid$ HIV has also -een related
More than / 00 of adult,ID( patients.ill e1perience an ocular complication at some point of the disease$. Or-ital and adne1al manifestations include tumors of the periocular tissues and e1ternal infections$. Posterior segment findings include a HIV associated retinopathy and a number of opportunistic infections of the retina and choroid$ HIV has also -een related
Printer Friendly reno !ocha "ima# M$D$ % &ni'ersity of Miami (chool of Medicine ) *illiam J$ Harrington Medical +raining Programs ABSTRACT INTRODUCTION DISCUSSION ACKNOWLEDGEMENTS REFERENCES CLINICAL PICTURES ,-stract Objective +his re'ie. is intended to descri-e the most common ophthalmic manifestations of HIV infection$ It is estimated that more than /00 of adult ,ID( patients .ill e1perience an ocular complication at some point of the disease$ Or-ital and adne1al manifestations include tumors of the periocular tissues and e1ternal infections$ ,nterior segment findings consist of 2eratitis# 2eratocon3uncti'itis sicca# iridocyclitis# and other complications$ Posterior segment findings include a HIV associated retinopathy and a num-er of opportunistic infections of the retina and choroid$ HIV has also -een related to neuro) ophthalmic manifestations such as 'isual field defects and papilledema$ Methods +he author performed a search of Medline# using Pu-Med$ (earch .ords included HIV# cytomegalo'irus retinitis# retinal micro'asculopathy# herpes 4oster ophthalmicus# 5aposi6s sarcoma# immune reco'ery u'eitis# or-ital lymphoma# to1oplasmosis# herpes simple1 'irus# pneumocystis carinii# microsporidia# syphilis# molluscum contagiosum# ganciclo'ir and 2eratocon3uncti'itis sicca$ ,rticles .ere selected -ased on clinical importance$ ,dditional references of 2ey articles .ere also included$ ,rticles .ere e1cluded if they had non)7nglish a-stracts$ Ke!o"ds HIV# 8ytomegalo'irus 98MV: retinitis# !etinal micro'asculopathy# Herpes ;oster Ophthalmicus# 5aposi6s (arcoma# Immune !eco'ery &'eitis# +o1oplasmic !etinochoroiditis top Introduction +he human immunodeficiency 'irus 9HIV: infection has spread .orld.ide# .ith 'arious ad'erse health and economic implications# particularly in the de'eloping .orld$9<: , glo-al summary of the HIV=,ID( epidemic from Decem-er 200> -y the Joint &nited ?ations Programee on HIV=,ID( 9&?,ID(: and *orld Health Organi4ation 9*HO: estimates that there are 40 million people .orld.ide li'ing .ith HIV=,ID($ ,ppro1imately @ million people .ere infected .ith HIV and there .ere a-out > million ,ID( deaths in 200>$92: ,t present# around A00 of HIV)infected persons li'e in de'eloping countries# particularly those in su-)(aharan ,frica and (outheast ,sia$92# >: &nless a cure is found or life prolonging therapy can -e made more .idely a'aila-le# the ma3ority of people .ill remain suffering the profound impacts the disease has on their Buality of life$94: ?umerous ophthalmic manifestations of HIV infection may in'ol'e the anterior or posterior segment of the eye$ (ince the first report of the ocular manifestations of ,ID( -y Holland et al$ in <AC2#9@# D: su-seBuent studies ha'e descri-ed se'eral ,ID( related conditions in the eye and or-it$ /0EC00 of adult ,ID( patients .ill e1perience an ocular complication at some point of their illness$9@# /: Or-ital and adne1al findings include tumors of the periocular tissues and e1ternal infections$ ,nterior segment manifestations consist of 2eratitis# 2eratocon3uncti'itis sicca# iridocyclitis# and other complications$ Posterior segment findings include a HIV associated retinopathy and a num-er of opportunistic infections 9OI: of the retina and choroid$ HIV has also -een related to neuro) ophthalmic manifestations# such as 'isual field defects# papilledema# and diplopia$ +he occurrence of ophthalmic complications associated .ith HIV infection is significantly lo.er in the pediatric age group$ ,ll patients .ith HIV disease should undergo routine ophthalmologic e1aminations# since proper diagnosis and treatment may help to maintain 'ision and prolong life$ (ome retinal OI may ha'e a rapid and de'astating course$ 8D4F + "ymphocyte pro'ed to -e a relia-le predictor of ocular complications of HIV infection$9/# C: +he use of highly acti'e antiretro'iral therapy 9H,,!+:# .hich consists of a com-ination of nucleoside re'erse transcriptase inhi-itors# HIV protease inhi-itors and non nucleoside re'erse transcriptase inhi-itors# has decreased plasma le'els of HIV !?, and increased 8D4F + lymphocytes counts# impro'ing the immune function of patients .ith HIV infection$9A# <0# <<: +he clinical presentation of HIV related diseases may -e modified -y H,,!+# .hich has dramatically impro'ed the prognosis of HIV infection$ efore the introduction of H,,!+# patients .ith cytomegalo'irus retinitis commonly had 8D4F counts less than @0 cells=Gl .ith minimal ocular inflammation$9A: +here are some reports of spontaneous resolution of cytomegalo'irus retinitis in patients .ith increased 8D4F counts related to such therapy# although the reco'ery in + lymphocytes may ta2e many months$9<2# <># <4: ?e'ertheless# su-stantial intraocular inflammation in patients .ith healed cytomegalo'irus retinitis recei'ing H,,!+ has -een reported# .hich is 2no.n as immune reco'ery u'eitis$9A#<0@: top Discussion II E Or-ital Manifestations Or-ital manifestations of HIV infection are not seen 'ery often$ Ho.e'er# some cases of or-ital cellulitis and or-ital lymphoma ha'e -een reported$ +he cases of or-ital cellulitis .ere related to ,spergillus infection most times# -eing treated .ith systemic antimicro-ial drugs$ Other organisms reported in the literature that caused or-ital infections in patients .ith HIV include !hi4opus arrhi4us# +o1oplasma gondii# and Pneumocystis carinii$ 8hildren may present .ith recurrent episodes of or-ital=peri)or-ital cellulitis$9<@# <D: Primary non)Hodg2in6s lymphoma 9?H": of the or-it and ocular adne1a is a rare disease$ It accounts for only <0 of all ?H"$ In general# the ris2 of de'eloping ?H" is higher in HIV infected patients$ +he reported cases of lymphoma responded .ell to radiotherapy$ Ho.e'er# high doses may -e correlated to late ocular complications$9</# <C: III E ,dne1al Manifestations +he most common adne1al manifestations in patients .ho ha'e HIV infection are 5aposi6s sarcoma# herpes 4oster ophthalmicus# moluscum contagiosum and con3uncti'al micro'asculopathy$9<A: 8on3uncti'al sBuamous)cell carcinoma is a rare finding$ 5aposi6s (arcoma 5aposi6s sarcoma .as a rare tumor$ ,fter the spread of HIV# the incidence mar2edly increased$ It is a highly 'asculari4ed# painless mesenchymal tumor that affects the s2in and mucous mem-ranes and occurs in up to 2@0 of HIV infected patients$ ,round 200 of these patients ha'e asymptomatic 5aposi6s sarcoma of the eyelids# con3uncti'a and rarely the or-it$9/# 20: Ho.e'er# a study -y is.as et al$# .ho follo.ed <00 HIV positi'e indi'iduals in India# did not o-ser'e a single case of 5aposi6s sarcoma of the eye$ +he lo. pre'alence of this tumor in India may -e attri-uted to the lo.er proportion of cases associated .ith homose1ual -eha'ior in that country$ D?, seBuences of human herpes 'irus C ha'e -een detected in patients .ith 5aposi6s sarcoma either .ith or .ithout HIV infection$ +he lo. incidence of human herpes 'irus C in India may also contri-ute to the lo. occurrence of this tumor in that country$9># 2<: 5aposi6s sarcoma may present as purple papules in the eyelids# .hich may -e either flat or slightly raised$ (ometimes# these lesions are part of a multifocal presentation# .hich may include 'isceral in'ol'ement$9@# 22: 8on3uncti'al 5aposi6s sarcoma may occur in up to <0 of patients .ith HIV infection$ +he classic presentation is a reddish plaBue that may mimic a su-con3uncti'al hemorrhage or chala4ion$ +his lesion is often located in the cul de sac$ 7'en small lesions can cause important cosmetic and functional discomfort# .hich may -e related to mass effect or secondary corneal changes$9@# 2>: 5aposi6s sarcoma does not in'ade the eye$ Most lesions are slo.ly progressi'e and respond to systemic drug therapy 9<0D:$ !adiation therapy may -e effecti'e .hen functional discomfort is reported$ ?e'ertheless# it is e1pensi'e and can cause s2in irritation and con3uncti'itis$ Doses of 20 Hy may -e sufficient to produce shrin2age of the tumor$ 71cision and intralesional chemotherapy .ith 'in-lastine are other treatment options$ If there is systemic in'ol'ement# systemic chemotherapy may -e indicated$9/# 2>: +here are some reports of regression in patients treated .ith H,,!+ containing a protease)inhi-itor$ (aBuina'ir# indina'ir# ritona'ir and nelfina'ir may affect angiogenesis# cell sur'i'al# tumor gro.th and in'asion$924: Herpes ;oster Ophthalmicus !eacti'ation of latent 'aricella 4oster 'irus in the ophthalmic di'ision of the trigeminal ner'e causes herpes 4oster ophthalmicus$ +he ophthalmic di'ision -ranches into the lacrimal# nasociliary and frontal ner'es$ In'ol'ement of the frontal ner'e is common$ *hen the nasociliary ner'e is affected# the patients may present .ith 'esicles at the tip of the nose# 2no.n as Hutchinson6s sign$ (tudies ha'e sho.n ophthalmic in'ol'ement in AA0 of patients .ith this sign$92@: Herpes 4oster occurs in patients .ith HIV infection as .ell as other patients .ith depressed cellular immunity such as lymphoma patients and patients recei'ing immunosuppressi'e therapy$ 8haracteristic prodromal symptoms include headache# generali4ed malaise and fe'er$92D: In younger indi'iduals# it may -e the initial manifestation of HIV infection$92/: ,ny patient younger than @0 years of age .ho presents .ith herpes 4oster ophthalmicus is suspect of ha'ing HIV infection or any other immunosuppressi'e condition$9@# 2C: , study -y Hodge et al$ sho.ed a relati'e incidence ris2 ratio of D$D=< in HIV positi'e patients compared to HIV negati'e patients$92A: !eports suggest that it affects @E<@0 of HIV positi'e patients and may ha'e a high rate of painful and sight threatening complications$9/# 2/: Forty one percent of the patients studied -y "e.allen in Mala.i de'eloped corneal perforation and se'enteen percent of the patients studied -y (ellitti et al$ in Miami de'eloped necroti4ing retinitis$ Ocular complications result from inflammation# ner'e damage and tissue scarring$9>0# ><: Herpes 4oster ophthalmicus presents as 'esico-ullous rash and may -e associated .ith 2eratitis# scleritis# u'eitis# retinitis or encephalitis$92/: +he se'erity of the s2in rash is an important prognostic parameter of su-seBuent ocular in'ol'ement$9>2: (ignificant entropion or trichiasis may result from herpes 4oster# -ecause the 'irus can cause permanent contraction scars of the deep dermal tissues of the eyelids$92@: Patients should -e treated .ith intra'enous acyclo'ir 9<0 mg per 2ilogram of -ody .eight three times a day for se'en days: follo.ed -y an oral maintenance regimen 9C00 mg >E@ times a day:$ Other options are famciclo'ir# .hich reBuires long term maintenance therapy# and 'alaciclo'ir$9/# 2@: Molluscum 8ontagiosum Molluscum contagiosum is caused -y a D?, po1'irus and affects the s2in and mucous mem-ranes as translucent papules .ith a central um-ilication$ In HIV patients it occurs commonly and lesions may -ecome Buite large and are often more numerous and more rapidly gro.ing$ In'ol'ement of the eyelids may occur in up to @0 of HIV infected patients$ +hey are usually multiple# -ilateral# confluent# and tend to recur .ithin D to C .ee2s after remo'al$9>: +reatment options are cryotherapy# incision# curettage and e1cision$ +he use of podophylloto1in cream as an ad3unct to cryotherapy may -e helpful$ "esions may recur particularly .hen 8D4F counts decrease$9>># >4: 8on3uncti'al Micro'asculopathy Patients .ith HIV infection may present .ith asymptomatic micro'ascular changes# .hich is correlated .ith retinal micro'asculopathy$ +he se'erity of the micro'asculopathy has -een correlated to increased 4eta sedimentation ratios and fi-rinogen le'els$9>@: &sually# no treatment is necessary$ +hose patients may ha'e microaneurysms and segmental 'ascular dilatations and narro.ings$9/: +he cause of these 'ascular changes is not clear yet# -ut it is pro-a-ly associated .ith the deposition of immune comple1es related to HIV or the direct infection of HIV in the con3uncti'al 'ascular endothelium$9>D: 8on3uncti'al (Buamous)8ell 8arcinoma , study -y ,ga-a in &ganda sho.ed a correlation -et.een an increase in cases of con3uncti'al sBuamous)cell carcinoma and HIV infection$ +hese tumors ha'e also -een related to e1posure to ultra'iolet light and con3uncti'al papilloma'irus infection and usually arise in the lim-us of the eye$9>/: IV),nterior (egment Disease +he anterior segment of the eyes 9cornea# anterior cham-er and iris: may also suffer changes related to HIV infection$ !eports indicate that more than @00 of HIV infected patients ha'e anterior segment manifestations$9>C: 5eratitis# 2eratocon3uncti'itis sicca and iridocyclitis are among the most common complications in the anterior segment of the eyes$ Ho.e'er# studies ha'e sho.n no difference in the ocular flora -et.een HIV) negati'e patients and patients .ith ,ID($9>A: Herpes (imple1 5eratitis Herpes simple1 2eratitis has -een reported in ,ID( patients# -ut .hether there is an increase ris2 of this disease is still un2no.n$ +he infection has a predilection for the peripheral cornea and may cause corneal ulcerations# -eing usually painful$ In general# the course of the disease is longer in ,ID( patients and the rate of recurrences is also higher$ It is associated .ith corneal scarring and iritis$ +he treatment of choice for epithelial 2eratitis consists of topical trifluridine si1 to eight times a day during the first se'eral days$ Orally administered acyclo'ir is also effecti'e$922# 40: Varicella);oster Virus 5eratitis ,s mentioned -efore# the 'aricella 4oster 'irus may -e associated .ith 2eratitis in ,ID( patients$ +he patients may present .ith ele'ated intraocular pressure$ 8ommonly# the patients ha'e herpes 4oster ophthalmicus as .ell# although the dermatitis may -e mild$ ,s in herpes simple1 2eratitis# the course of the disease tends to -e longer in ,ID( patients$ +he treatment is similar to that of 4oster ophthalmicus$ 92@# 2C# ><: acterial and Fungal 8orneal Infections acterial and fungal infections are generally more se'ere in HIV infected patients$ (pontaneous fungal 2eratitis secondary to 8andida al-icans has -een reported in patients .ith ad'anced HIV disease$94<: 8andida species are particularly common in intra'enous drugs users$ ,lthough uncommon# Microsporidia is associated .ith a -ilateral diffuse punctate epithelial 2eratopathy and con3uncti'itis$ +he treatment consists of oral itracona4ole# oral al-enda4ole or topical fumagillin$942# 4># 44: Posterior Intracorneal Infiltrates Posterior intracorneal infiltrates ha'e -een reported in HIV infected hosts .ith concomitant cytomegalo'irus retinitis and in children .ho ha'e -een treated .ith prophylactic rifa-utin$ +hose infiltrates tend to -e distri-uted primarily in the inferior cornea$ +he cause of those corneal infiltrates is still under in'estigation$ +hey may -e caused -y direct deposition of immune comple1es or 'iral particles# to1icity of medication or e'en the direct effect of opportunistic infections$94@: 5eratocon3ucti'itis (icca More than 200 of patients .ith HIV infection may ha'e 2eratocon3uncti'itis sicca# also called dry eye syndrome# .hich results from deficiency of any of the tear film layers$ ,pparently# it is not related to 8D4F counts or associated .ith the se'erity of HIV$94D: (ymptoms may include foreign -ody sensations# photopho-ia and decreased 'isual acuity$ It is li2ely caused -y -oth the destruction of primary and secondary lacrimal glands and inflammation mediated -y the HIV 'irus$ +he treatment is -ased on the administration of artificial tears# often si1 to eight times a day# and lu-ricating ointments$94/: Iridocyclitis ,n HIV infected patient complaining of photopho-ia and red eye may ha'e iridocyclitis$ +his presentation reBuires a thorough ocular e1amination in order to rule out anterior or posterior segment infection$9@: It may -e associated .ith retinal or choroidal infection .ith multiple opportunistic organisms# such as cytomegalo'irus# herpes simples 'irus# 'aricella 4oster 'irus# 8andida species# 8ryptococcus species# +o1oplasma gondii# +reponema pallidum and Myco-acterium species$94C: In the differential diagnosis of acute iridocyclitis in a patient .ith ,ID(# infection .ith syphilis or to1oplasmosis should al.ays -e considered$ Immunocompromised hosts may ha'e +$ gondii infection -ilaterally and ha'e multiple infectious foci$ 7ncysted +$ gondii organisms ha'e -een found in an iris -iopsy specimen from an ,ID( patient presenting .ith iridocyclitis$94A: P8! of the aBueous humor or 'itreous of those patients may -e used for identification of those organisms$ Vitreous samples ha'e a higher sensiti'ity$94A#<0/#<0C: (ome medications# such as rifa-utin and cidofo'ir# ha'e also -een associated .ith iridocyclitis$9@0# @<:$ !ifa-utin is also related to ocular hypotony# and cidofo'ir may cause an endophthalmitis)li2e manifestation$ Iridocyclitis may also -e associated .ith !eiter6s syndrome# .hich is defined -y the classic triad of arthritis# urethritis# and con3uncti'itis$ +his syndrome appears to -e more common in patients .ith HIV infection$ +he treatment of iridocyclitis depends on the specific infectious agent$ In the cases associated .ith medications# the dose should -e tapered or the drug should -e discontinued$ +opical corticosteroids are usually indicated# -ut must -e used carefully .hene'er a infectious cause is suspected$9/: V E Posterior (egment Disease +he posterior segment of the eye 9retina# choroid and optic ner'e head: is affected in more than @00 of ,ID( patients$ +hose disorders may -e either associated .ith infectious causes or non infectious causes$ Decreased 'isual acuity# 'isual field defects and photopsias are among the most common symptoms$9A/: !etinal Micro'asculopathy +he micro'ascular changes in the retina are the most common retinal manifestations of HIV infection$ ?e'ertheless# they are generally asymptomatic and transient$ +hese changes may occur in up to /00 of ,ID( patients at some point of the disease$ +he patients presenting .ith HIV retinopathy may ha'e cotton).ool spots 98*(: in the retina# intraretinal hemorrhages# and retinal microaneurysms# especially .hen 8D4F + lymphocyte count is -elo. <00 cells=mm>$ Forty fi'e percent of the patients .ith HIV related retinopathy ha'e 8DF cell counts -elo. @0 cells=mm>$ 9@# @2: +he 8*( result from occlusion of precapillary arterioles# normally do no affect 'isual acuity and do not reBuire treatment$ +hey appear as small# .hite# superficial retinal opacities and are mainly locali4ed on the posterior pole$ Pathologically# the 8*( are ner'e fi-er layer infarcts# related to accumulations of a1oplasmic de-ris# su-seBuent to o-struction of a1oplasmic flo.$9@>: +hey may represent an increased ris2 for cytomegalo'irus 98MV: retinitis$ +he appearance of 8*( is sometimes similar to 8MV retinitis$ 8*(# ho.e'er# tend to -e smaller# do not progress# are not characteristically associated .ith retinal hemorrhage and resol'e o'er .ee2s to months$ ,ID( patients .ith 8*( should ha'e close follo. up$9@2: Intraretinal hemorrhages# including !oth6s spots# may -e present in ,ID( patients$ +hey are commonly innocuous in the setting of HIV retinopathy and may occur .ithin different layers of the retina$9@: +he pathogenesis of retinal micro'asculopathy is pro-a-ly similar to that of con3uncti'al micro'asculopathy$9>D: Hypothesis including hemorheologic a-normalities# li2e increased plasma 'iscosity and fi-rinogen le'elsI circulating immune comple1es and infectious damage of the retinal 'asculature ha'e -een postulated$ (chmetterer and colleagues studied the ocular -lood flo. in patients infected .ith HIV$ +hey detected a decreased macular leu2ocyte density in HIV infected persons$ +he study also suggested that a-normal retinal hemodynamics in this group may -e in'ol'ed in the pathogenesis of HIV)related micro'asculopathy$ ?o correlation -et.een antiretro'iral treatment and ocular -lood flo. parameters .as found$9@>: ranch retinal artery and retinal 'ein o-structions ha'e -een seen in HIV infected patients$ 9@4# @@: +here are some reports of ischemic maculopathy associated .ith HIV infection# .hich can -e se'ere# ho.e'er the condition is apparently uncommon$ +he presence of opacification of the superficial retina# resulting in a cherry red spot# or intraretinal hemorrhages near the fo'ea may suggest the diagnosis# although some patients may not present .ith these findings$ ilateral in'ol'ement of the eyes# .ith an a-rupt onset often occurs$ Fluorescein angiography should -e done on HIV infected patients .ith une1plained 'ision loss$9@2: , study -y 8unningham and associates suggested the possi-ility that occult herpetic infection may -e a contri-uting factor to ischemic maculopathy# as .ell as alterations in -lood flo. in the setting of micro'ascular a-normalities$9@2: 8hronic Multifocal !etinal Infiltrates "e'inson and associates descri-ed a distinct syndrome in HIV infected su-3ects that .as characteri4ed -y the presence of sta-le or slo.ly progressi'e multifocal peripheral infiltrates# often in association .ith inflammatory reactions in the 'itreous humor and anterior cham-er and lac2 of retinal necrosis$ +hose infiltrates do not seem to -e related to drug to1icity or to opportunistic infections$ Henerally# they .ere round or irregular in shape# and typically less than 200 Gm in the greatest dimension$ Floaters .ere the most freBuent complaint among the patients studied# follo.ed -y -lurred 'ision$ ,n auto immune phenomenon associated .ith immune response to the presence of HIV in the ocular tissue has -een suspected to cause these inflammatory reactions$ +he long term effect of this syndrome on 'isual function remains un2no.n$9@D: Infectious !etinitis !etinal infections in HIV infected patients may result from different pathogens# .hich may affect the retina at the same time$9@/: (yphilis# candida# 'aricella)4oster# to1oplasmosis# herpes simple1 and cytomegalo'irus retinitis are among the most common ones$ ,lthough these infectious may also occur in immunocompetent hosts# the course tends to -e longer in ,ID( patients# and the rate of recurrences is also higher$ Varicella ;oster Virus and Herpes (imple1 !etinitis Varicella 4oster 'irus has -een associated .ith acute retinal necrosis# .hich affects <E40 of HIV infected patients$ It is characteri4ed -y peripheral retinal .hitening# often accompanied -y intraretinal hemorrhages associated .ith rapidly progressing necrosis o'er se'eral days$ Multifocal lesions are commonly seen$ !etinal detachment .ith proliferati'e 'itreoretinopathy as .ell as the in'ol'ement of the other eye may also occur$ 9@C# @A: 8entral retinal 'ein occlusion as the initial presentation of herpes 4oster ophthalmicus has also -een reported$9D0: ,lthough not freBuently seen# herpes simple1 'irus has also -een related to retinitis in HIV)positi'e patients$ It has -een associated .ith a rapid progressing 'isual loss$ +he treatment for these t.o pathogens is normally long$ Intra'enous acyclo'ir and intraocular ganciclo'ir or foscarnet are commonly reBuired$9@A# D<:# and long)term treatment .ith acyclo'ir pre'ents recurrences and is important in prophyla1is of the fello. eye 9<02#<0>: 8ytomegalo'irus !etinitis Human cytomegalo'irus 9H8MV: is part of the -eta su-group of herpes 'iruses 9Herpes 'iridae: and has strong species specificity$ ,lthough the infection .ith 8MV is usually su-clinical in immunocompetent hosts# there may -e a life long persistence in @0EA00 of the population$ In immunocompromised hosts# such as patients infected .ith HIV# 8MV may lead to se'eral complications$9D2# D>: 8ytomegalo'irus 98MV: retinitis is the most common intraocular infection related to HIV infection# affecting around 2@0 of patients according to reports of the past decade and may cause progressi'e loss of 'ision and -lindness$9@: +he pre'alence of 'isual impairment at the time of 8MV retinitis diagnosis is high and is related to demographic characteristics$9D4: , study performed -y Doan et al$ sho.ed a decrease in the incidence and pre'alence of 8MV retinitis after the ad'ent of H,,!+$ +he relapses of 8MV retinitis .ere less freBuent 9>D0 -efore H,,!+ 's$ </0 after H,,!+: and ne.ly diagnosed 8MV retinitis also decreased 9D$<0 -efore H,,!+ to <$20 after H,,!+:$ !emission durations from recurrent 8MV retinitis ha'e increased in patients recei'ing H,,!+# .hich is associated .ith decreased progression of retinal necrosis# and to lo.er ris2 of retinal detachment$ ?e'ertheless# it does not restore the retina .here such damage has already occurred$9D@# <0<: 5empen et al$ follo.ed up @CA patients to e'aluate the relationship of anti)8MV treatment and immune reconstitution in response to H,,!+ on the mortality ris2 of patients .ith ,ID( and 8MV retinitis$ +he use of H,,!+ reduced the ris2 of mortality -y C<0I it .as AD0 lo.er for those .ho de'eloped immune reco'ery and 4A0 lo.er for those .ho did not$9DD: Vision related Buality of life 9JO": may still -e compromised -y 8MV retinitis e'en .hen general health related JO" has impro'ed in response to H,,!+$ +herefore# pre'ention of 8MV .ith anti)8MV medications may -e .arranted in high ris2 su-3ects$ 9D/: +he study -y Doan et al$ also suggested that a 8D4F cell count a-o'e @0 cells=mm> or a lo. 'iral load does not fully protect from 8MV disease$ Immune response reconstitution may -e only partial after H,,!+# -ecause lac2 of pathogen specific 8D4F + cell response may persist e'en in the presence of a significant rise in the a-solute 8D4F + cell counts$ +herefore# HIV)infected patients still reBuire close ocular follo. up e'en if they are -eing treated .ith H,,!+$ Moreo'er# 'irologic resistance to H,,!+ is -ecoming more freBuent$9D># D@# DC: Occasionally# H,,!+ may cause 'ision loss 'ia the mechanism of immune reco'ery u'eitis$9D/: It may -e characteri4ed -y 'itritis and optic disc and macular edema$ Ocular neo'asculari4ation at the optic disc and the retinal periphery may also occur$ 8linically important complications of immune)reco'ery u'eitis may include cataract# epiretinal mem-rane formation# and cystoid macular edema$ +he mechanism of this condition remains unclear$ Henerally# su-stantial inflammation does not occur in eyes .ithout prior 8MV retinitis$ +herefore# immune reco'ery u'eitis may -e caused -y an immune response related to the persistence of 8MV antigen in the eye$ +here are some reports sho.ing that protease inhi-itors may -e associated .ith increased cytomegalo'irus) specific lymphocyte proliferation and production of inflammatory cyto2ines$9A# DA: (ong et al$ sho.ed that the ris2 of immune reco'ery u'eitis .as strongly correlated .ith prior use of cidofo'ir$ It .as not clear .hether continuing noncidofo'ir anti)8MV therapy after immune reco'ery .ould reduce the ris2 of immune reco'ery u'eitis$9/0: !ecent reports sho. that 8MV retinitis progression does not necessarily correlate .ith 'iral 8MV loads# .hich is different from other 8MV diseases# such as colitis and pneumonitis$9D>: Henerally# 8MV retinitis is characteri4ed -y hemorrhagic necrosis that may e1tend along the 'ascular arcade# as .ell as retinal .hitening$ 9Figure <-: +he lesion tends to enlarge o'er time$ +he patients may also present .ith mild 'itreal inflammation# anterior u'eitis# and up to @0 of them may ha'e in'ol'ement of the optic disc$ Visual field loss# -lurred 'ision and photopsias are common complaints -y the patients$9/# D@: +he administration of systemic anti)8MV medication may pre'ent the occurrence of retinitis in the fello. eye$ +he choice of a drug for the treatment of 8MV retinitis should -e -ased on the response to pre'ious treatments# side effects as .ell as e1tension and se'erity of the disease$ In patients on chronic suppressi'e# maintenance therapy# 8MV resistant to the treatment -eing used may de'elop$ +he identification of resistant 'irus in the -lood or urine may ha'e an association .ith ad'erse clinical outcomes of the 8MV retinitis$ +here may -e an increased ris2 of retinitis progression# as .ell as an increase in the amount of retinal area affected -y 8MV$ Patients treated .ith ganciclo'ir implant alone pro-a-ly ha'e a higher rate of contralateral ocular or 'isceral disease than the ones recei'ing concomitant oral ganciclo'ir$ +he detection of 8MV 'iral load in the -lood or direct seBuencing of -lood specimens for 8MV &"A/ gene mutations may -e important in the clinical setting# in order to determine the patients .ith resistant 'irus$9/<: Intra'enous ganciclo'ir may -e indicated .hen there is -ilateral retinitis or .hen systemic treatment is reBuired$9/2: Ho.e'er# it may cause myelosuppression$ Intra'itreal ganciclo'ir in3ection is another option# though freBuent in3ections are reBuired and the fello. eye and distant organs are not protected$ (tandard doses range from 200 Gg to 400 Gg administered t.ice a .ee2# for up to > .ee2s# follo.ed -y .ee2ly maintenance in3ections$ , report presented -y Vele4 et al$ suggested that higher doses of ganciclo'ir may -e tolerated -y the eye# and .hen associated .ith intra'itreous foscarnet# they may -e effecti'e in controlling 8MV retinitis in patients .ho do not respond to con'entional treatment$9/># /4# /@: , controlled trial of 'alganciclo'ir -y Martin et al$ sho.ed that it appears to -e as effecti'e as intra'enous ganciclo'ir for induction treatment and is effecti'e for long)term management of 8MV retinitis$9/D: , ganciclo'ir intra'itreal implant has -een de'eloped as a local treatment option that does not in'ol'e intra'itreal in3ections and a'oids systemic side)effects$9//: It is a non) eroda-le drug deli'ery de'ice# .hich can pro'ide therapeutic le'els of ganciclo'ir to the posterior segment of the eye$ +he implants are designed to release ganciclo'ir o'er a period of months$ Factors in the decision to use the ganciclo'ir implant include the location and se'erity of 8MV retinitis# the patientKs potential for immunologic impro'ement# and the ris2s and costs associated .ith implantation and concomitant oral ganciclo'ir therapy$ 7ndophthalmitis is an uncommon complication of ganciclo'ir implant surgery$9/C: Intra'enous foscarnet is another treatment optionI ne'ertheless# it is associated .ith renal insufficiency$9/2: 8om-ined intra'enous ganciclo'ir and foscarnet offers the ma1imal protection of other eye and distant organs disease# though long daily infusions are reBuired and the side effects are com-ined$9/A: In resistant cases# cidofo'ir therapy may -e used$ Ho.e'er# it has -een associated .ith iritis and hypotonia and has the potential for nephroto1icity# particularly in patients .ith history of 2idney disease$9/2# /A: Other treatment alternati'es are formi'irsen in3ected into the 'itreous or oral 'alganciclo'ir$9/2: (yphilis !etinitis (yphilis may affect the retina in HIV positi'e patients$ ,s +reponema pallidum and HIV may -e -oth transmitted se1ually# it is not uncommon to detect -oth pathogens in the same patient$ +he retinitis is characteri4ed -y a deep yello. lesion$ !etinal 'asculitis and intraocular inflammation may -e present$ +he diagnosis can -e confirmed -y the serum fluorescent treponema anti-ody a-sorption test 9F+, ,(: and microhemagglutination assay 9MH,)+P:$ *hen the diagnosis is confirmed# 'igorous treatment should -e started .ith <2)24 million units of intra'enous penicillin H for /)<0 days$9C0: +etracycline# erythromycin and chloramphenicol are options for patients allergic to penicillin$ (ome authors -elie'e that HIV positi'e patients may reBuire maintenance therapy# -ecause ocular symptoms may recur$9C<# C2: FreBuently# there may -e atypical presentations of ocular syphilis in these patients# such as 'itritis$9C2: 8andidal 7ndophthalmitis 8andidal endophthalmitis generally presents as a focal .hite infiltrate in the choroid# and may -rea2 through the retina into the 'itreous$ &sually# an o'erlying 'itritis is present$ Vitreous a-scesses may also -e seen$ Once the diagnosis is confirmed# the patients should recei'e intra'enous amphotericin$9@: +o1oplasmic !etinochoroiditis ,round <E20 of HIV infected patients may present .ith to1oplasmic retinochoroiditis$ +he pre'alence of +$ gondii infection 'aries -et.een geographic regions and -et.een population groups$ +o1oplasmic retinochoroiditis still has a high pre'alence in regions such as southern ra4il# .here it may -e as high as C0 9<04:$ Ocular lesions may first de'elop many years after +$ gondii infection$ It is usually -ilateral and presents multifocal sites of infection# .hich is not common in immunocompetent persons$ !etinochoroidal scars and retinal hemorrhage may -e a-sent$ +he appearance of the lesions 'aries .ith intensity of inflammation and duration of acti'e retinal infection$ Patients usually complain of seeing floaters# pain and decrease in 'isual acuity$ (erologic studies should -e performedI ho.e'er they may -e negati'e e'en in the presence of disease$ P8! of the ocular fluid may -e helpful in distinguishing -et.een to1oplasmic retinochoroiditis and other ocular diseases$ +he treatment consists of oral sulfadia4ine# com-ined .ith pyrimethamine or clindamycin# or -oth$ +rimethoprim)sulfametho1a4ole may also -e effecti'e$ ,to'aBuone may -e used in immunocompromised patients .ho are at increased ris2 of -one marro. to1icity from sulfonamides$ +he patients may ha'e fe.er relapses .hen recei'ing maintenance sulfadia4ine or trimethoprim)sulfametho1a4ole$ !ecent studies ha'e sho.n that a half)dosage regimen is also effecti'e in pre'enting recurrences# .hich are -elie'ed to -e caused either -y the release of parasites from tissue cysts in the retina or dissemination of parasites from non)ocular sites$ 9C>)CD# <04: Infectious 8horoiditis Myco-acterium tu-erculosis# 8andida species# 8ryptococcus species# Pneumocystis carinii and +reponema pallidum are among the most common entities related to infectious choroiditis# .hich is seen in less than <0 of HIV positi'e patients$ Multiple# -ilateral# round or o'oid# yello.).hite lesions characteri4es Pneumocystis carinii choroiditis$ +hese lesions are usually slo.ly progressi'e and are not associated .ith iritis# 'itritis# or 'asculitis$ +he treatment is the same for Pneumocystis carinii pneumonia$9C/)CA# AC: VI)?euro)Ophthalmic Manifestations of HIV Infection Optic neuropathies in HIV positi'e patients may -e related to compression# infiltration# infection# 'aso occlusion or inflammation$ 8ryptococcal meningitis and intracere-ral to1oplasma cysts# .hich are intracranial manifestations associated .ith HIV# can affect the eyes# causing ner'e palsies$ ?euro ophthalmic complications of HIV ha'e also -een reported in the a-sence of associated opportunistic infections$ Optic neuritis associated .ith a multiple sclerosis li2e illness in the presence of HIV has also -een descri-ed$9A0: Other neuro ophthalmic complications are 'isual field defects# papilledema# secondary to ele'ated intracranial pressure and ocular motility disorders# occurring in up to <@0 of HIV)infected patients$9@# A<: HIV may also cause diplopia due to palsies of cranial 'er'es III# IV# and VI$ ?eurosyphilis# progressi'e multifocal leu2oencephalopathy 9PM":# .hich is caused -y J8 polyoma'irus# meningeal and parenchymal lymphoma# and intracere-ral infection .ith herpes 'irus ha'e also -een related to neuro)ophthalmic manifestations$ +he diagnosis of PM" should -e considered in immunocompromised patients .ith neuro) opthalmic findings# especially in those presenting .ith homonymous hemianopia and nystagmus$9A2: Herpes 'irus may present .ith papilledema and e1traocular muscle palsies$ Micro'ascular oculomotor ner'e palsies may occur in association .ith HIV$ Premature atherosclerosis is commonly seen in HIV)infected patients due to an un2no.n mechanism$9A>: "um-ar puncture and magnetic resonance imaging are usually reBuired in order to determine the pathogen causing the neuro ophthalmic symptoms# and to start the proper treatment$ Henerally# intracranial lymphoma is treated .ith radiation and chemotherapy$ +he infections are treated .ith specific antimicro-ial drugs$9/: +he optic ner'e may -e affected -y HIV due to direct infection$ ,nother e1planation is related to HIV 'iral proteins$ +at and gp <20# .hich are 'iral proteins# may ha'e direct and indirect to1ic effects on neurons$ Moreo'er# HIV may induce the production of +?F alpha# I" I and arachidonic acid meta-olites# .hich may cause neuroto1icity$ (ome studies suggest that non)nucleoside and nucleoside re'erse transcriptase inhi-itors 9?!+Is: may impair mithocondrial function$9A0: HIV infected persons differ in measures of the retinal ner'e thic2ness# cross sectional area and cup shape$ Most defects are found in patients .ith associated 8MV retinitis$ , study -y Plummer et al$ demonstrated that HIV positi'e patients .ithout 8MV retinitis still ha'e statistically significantly a-normal measures in retinal fi-er layer thic2ness# rim 'olume# retinal fi-er layer area and dis2 area# indicating that there may -e destruction of the retina as a complication of HIV infection# .ith or .ithout 8MV retinitis$9A4# A@: VII E Ocular Manifestations in the Pediatric Hroup +he first reports of HIV infection in children are from <AC2# after the description of the disease in intra'enous drug a-users and homose1ual men$9AD: , glo-al summary of HIV=,ID( epidemic dating from Decem-er 200> from &?,ID(=*HO estimates that there are 2$@ million children under <@ years .orld.ide li'ing .ith HIV=,ID(# and /00#000 .ere ne.ly infected .ith HIV in 200>$ ,ppro1imately @00#000 children died from the disease in 200>$92: +he most freBuent mode of transmission of HIV in the pediatric group is mother to child transmission$ +he incu-ation period tends to -e shorter in children$ (ome -acterial infections are more common in this age group than in adults# .hereas cryptococcosis and to1oplasmosis are less freBuent$ +herefore# HIV infection may -e different in children in se'eral .ays$ +he occurrence of ophthalmic complications associated .ith HIV infection is significantly lo.er in the pediatric group$ +he first reports of eye complications in children related to HIV infection are from <AC2$ 5aposi6s sarcoma# as .ell as 8MV retinitis are not as common as in the adult population$ +he reason for this fact is still unclear# -ut may -e related to an altered immune response to HIV in children$ +he most freBuent manifestation in the pediatric group is dry eye syndrome# .hich occurs in appro1imately 200 of patients$ (ome authors descri-ed peri'asculitis of the peripheral fundus 'essels as a common finding in children .ith ,ID($9AD# AA: , report -y 5estelyn et al$# .ho follo.ed <D2 HIV infected children in ,frica# sho.ed a high incidence 9>C0: of peri'asculitis and=or sheathing of the peripheral retinal 'essels$ ilateral in'ol'ement .as 'ery common and the se'erity tended to -e symmetrical$ Veins .ere affected more often than arteries$ +he lesions freBuently originated in the periphery# sometimes e1tending to.ards the posterior pole .ithout in'ading it$ +he authors also descri-ed a possi-le lin2 -et.een lymphocitic interstitial pneumonia# parotitis# lacrimal gland in'ol'ement# and peri'asculitis of the retinal 'essels as the e1pression of the same immunopathological process in different sites$ 8MV retinitis and cotton).ool spots# the most freBuent ocular finding in adult HIV infection# as .ell as e1ternal lesions# such as herpes 4oster ophthalmicus and 5aposi6s sarcoma of the eyelids .ere rare in the ,frican pediatric group$9AD: Purdy et al$ reported three cases of -ilateral progressi'e outer retinal necrosis due to 'aricella)4oster 'irus in children .ith HIV infection$ ,ll three lost 'ision in -oth eyes$ 9<00: top ,c2no.ledgements +he author .ishes to than2 the ?ational 7ye Institute# ?ational Institutes of Health for pro'iding the clinical pictures and the anonymous re'ie.ers for their constructi'e comments$ top !eferences <)(leasman J*# Hoodeno. MM$ HIV)< infection$ J ,llergy 8lin Immunol 200>I <<<L@C2EA2$ 2)&?,ID(=*HO report on the glo-al HIV=,ID( epidemic$ Hene'aL *orld Health Organi4ation# Decem-er 200>$ >)is.as J# Madha'an H?# Heorge ,7# et al$ Ocular lesions associated .ith HIV infection in IndiaL a series of <00 consecuti'e patients e'aluated at a referral center$ ,m J Ophthalmol 2000I <2ALAE<@$ 4)Preliminary de'elopment of the *orld Health Organi4ationKs Juality of "ife HIV instrument 9*HOJO")HIV:L analysis of the pilot 'ersion$ (ocial (cience M Medicine# In Press# 8orrected Proof# ,'aila-le online 2/ March 200># *HOJO" HIV Hroup$ @)(arraf D# 7rnest J+$ ,ID( and the 7yes$ +he "ancet <AADI >4CL@2@E2C$ D)Holland H?# Hottlie- M(# Nee !D# et al$ Ocular disorders associated .ith a ne. se'ere acBuired cellular immunodeficiency syndrome$ ,m J Ophthalmol <AC2I A>L>A>E402$ /)8unningham 7+ Jr# Margolis +P$ Ocular manifestations of HIV infection$ ? 7ngl J Med <AACI >>AL2>DE44$ C)+urner J# Hecht FM# Ismail !$ 8D4F +)"ymphocyte measures in the treatment of indi'iduals infected .ith human immunodeficiency 'irus type <L a re'ie. for clinical practitioners$ ,rch Intern Med <AA4I <@4L<@D<E/>$ A)!o-inson M!# !eed H# 8sa2y 5H# et al$ Immune reco'ery u'eitis in patients .ith cytomegalo'irus retinitis ta2ing highly acti'e antiretro'iral therapy$ ,m J Ophthalmol 2000I <>0L4AE@D$ <0)8ollier ,8# 8oom-s !*# (choenfeld D,# et al$ +reatment of human immunodeficiency 'irus infection .ith saBuina'ir# 4ido'udine# and 4alcita-ineL ,ID( 8linical +rials Hroup$ ? 7ngl J Med <AADI >>4L<0<<E</$ <<)Hammer (M# (Buires 57# Hughes MD# et al$ , controlled trial of t.o nucleoside analogues plus indina'ir in persons .ith human immunodeficiency 'irus infection and 8D4 cell counts of 200 per cu-ic millimeter or lessL ,ID( 8linical +rial Hroup >20 (tudy +eam$ ? 7ngl J Med <AA/I >>/L/2@E>>$ <2)*hitcup (M# Fortin 7# ?ussen-latt !# et al$ +herapeutic effect of com-ination antiretro'iral therapy on cytomegalo'irus retinitis$ J,M,<AA/I 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radiotherapy$ International Journal of !adiation Oncology iology Physics 200>I @@LCA2) AC$ <A),2duman "# Pepose J($ ,nterior segment manifestations of acBuired immunodeficiency syndrome$ (emin Ophthalmol <AA@I <0L<<<EC$ 20)+schachler 7# ergstresser P!# (tingl H$ HIV related s2in diseases$ +he "ancet <AADI >4CLD@AED>$ 2<)Moore P(# 8hang N$ Detection of herpes 'irus li2e D?, seBuences in 5aposi sarcoma in patients .ith and .ithout HIV infection$ ? 7ngl J Med <AA@I >2L<<C<EC@$ 22)Palestine ,H# Palestine !F$ 71ternal ocular manifestations of the acBuired immunodeficiency syndrome$ Ophthalmol 8lin ?orth ,m <AA2I @L><AE24$ 2>)5iro'a NM# elem-aogo 7# Fri2ha H# et al$ !adiotherapy in the management of epidemic 5aposiKs sarcomaL a retrospecti'e study of D4> cases$ !adiother Oncol <AACI 4DL<A)22$ 24)(gadari 8# Monini P# arillari H# 7nsoli $ &se of HIV protease inhi-itors to -loc2 5aposiKs sarcoma and tumour gro.th$ "ancet Oncol 200>I 4L@>/)4/$ 2@)"ooney D$ Herpes 4oster ophthalmicus$ 8linical 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4oster ophthalmicus$ Hraefes ,rch 8lin 71p Ophthalmol 200>I 24<L<C/)A<$ >>)ardenstein D(# 7lmets 8$ Hyperfocal cryotherapy of multiple Molluscum contagiosum lesions in patients .ith the acBuired immunodeficiency syndrome$ Ophthalmology <AA@I <02L<0><E4$ >4)8hard (8# *orlidge PJ# Holder M,# et al$ ?e. treatment for molluscum contagiosum in patients .ith HIV infection$ J 7ur ,cad Dermatol Venereol <AA/I AL(<4C$ >@)+ufail ,# Meiselman HJ# 7ngstrom !7# et al$ Hemorheologic a-normalities and ophthalmic disease in patients .ith human immunodeficiency 'irus infection$ iorheology <AA@I >2L>>D$ >D)7ngstrom !7 Jr# Holland H?# Hardy *D# Meiselman HJ$ Hemorheologic a-normalities in patients .ith human immunodeficiency 'irus and ophthalmic micro'asculopathy$ ,m J Ophthalmol <AA0I <0AL<@>ED<$ >/),ga-a 8,$ 8on3uncti'al sBuamous)cell carcinoma associated .ith HIV infection in 5ampala# &ganda$ +he "ancet <AA@I >4@LDA@)AD$ >C),2duman "# Pepose J($ ,nterior segment manifestations of acBuired immunodeficiency syndrome$ (emin Ophthalmol <AA@I <0L<<<EC$ >A)Hrit4 D8# (cott +J# (edo (F# et al$ Ocular flora of patients .ith ,ID( compared .ith those of HIV)negati'e patients$ 8ornea <AA/I <DL400)@$ 40)5aufman H7$ +reatment of 'iral diseases of the cornea and e1ternal eye$ Prog !etin 7ye !es 2000I <ALDA)C@$ 4<)Parrish 8M# OKDay DM# Hoyle +8$ (pontaneous fungal corneal ulcer as an ocular manifestation of ,ID($ ,m J Ophthalmol <AC/I <04L>02E>0>$ 42)Hemady !5$ Micro-ial 2eratitis in patients infected .ith the human immunodeficiency 'irus$ Ophthalmology <AA@I <02L<02DE>0$ 4>)"o.der 8N# McMahon J+# Meisler DM# et al$ Microsporidial 2eratocon3uncti'itis caused -y (eptata intestinalis in a patient .ith acBuired immunodeficiency syndrome$ ,m J Ophthalmol <AADI <2<L/<@E/$ 44)8han 8M# +heng J+# "i "# +an D+$ Microsporidial 2eratocon3uncti'itis in healthy indi'idualsL , case series$ Ophthalmology 200>I <<0L<420)2@$ 4@)8hu D(# ;aidman H*# Meisler DM# et al$ Human immunodeficiency 'irus positi'e patients .ith posterior intracorneal precipitates$ Ophthalmology 200<I <0CL <C@>E@/$ 4D)Heier (,# "i-era (# 5lauss V# Hoe-el FD$ (icca syndrome in patients infected .ith the human immunodeficiency 'irus$ Ophthalmology <AA@I <02L<><A)24$ 4/)"ucca J,# Farris !"# ielory "# 8aputo ,!$ 5eratocon3uncti'itis sicca in male patients infected .ith human immunodeficiency 'irus type <$ Ophthalmololgy <AA0I A/L <00CE<0$ 4C)!os-erger DF# Heinemann MH# Fried-erg D?# Holland H?$ &'eitis ,ssociated *ith Human Immunodeficiency Virus Infection$ ,m J Ophthalmol <AACI <2@L>0<E0@$ 4A)Parra J8# "opis MD"# 8ordo-a J# et al$ ,cute iridocyclitis in a patient .ith ,ID( diagnosed as to1oplasmosis -y P8!$ Ocul Immunol Inflamm 2000I CL <2/E>0$ @0)?ichols 8*$ Myco-acterium a'ium comple1 infection# rifa-utin# and u'eitis E is there a connectionP 8lin Infect Dis <AADI 22L (uppl$ <L(4>E(4/$ @<)Da'is J"# +as2intuna I# Freeman *!# et al$ Iritis and hypotony after treatment .ith intra'enous cidofo'ir for cytomegalo'irus retinitis$ ,rch Ophthalmol <AA/I <<@L/>>E/$ @2)8unningham 7+ Jr# "e'inson !D# Jampol "M# et al$ Ischemic maculopathy in patients .ith acBuired immunodeficiency syndrome$ ,m J Ophthalmol 200<I <>2L/2/E>>$ @>)!uhs.urm ID# 5iss # !ainer H# et al$ Ocular -lood flo. in patients infected .ith human immunodeficiency 'irus$ ,m J Ophthalmol 200<I <>2L/20E2D$ @4)+eich (,# (onna-end J$ 8entral retinal 'ein occlusion in a patient .ith ,ID($ ,rch Ophthalmol <ACCI <0DL<@0CE<@0A$ @@)Nassur N# iedner # Fa-ri2ant M$ ranch retinal artery occlusion in acBuired immunodeficiency syndrome prodrome$ ,nn Ophthalmol <ACCI 20L<A<EA2$ @D)"e'inson !D# Vann !# Da'is J"# et al$ 8hronic Multifocal !etinal Infiltrates in Patients Infected *ith Human Immunodeficiency Virus$ ,m J Ophthalmol <AACI <2@L><2E24$ @/)!ummelt V# !ummelt 8# Jahn H# et al$ +riple retinal infection .ith human immunodeficiency 'irus type <# cytomegalo'irus# and herpes simple1 'irus type <L light and electron microscopy# immunohistochemistry and in situ hy-ridi4ation$ Ophthalmology <AA4I <0<L2/0E/A$ @C)Freeman *!# +homas 7"# !ao ?,# et al$ Demonstration of herpes group 'irus in acute retinal necrosis syndrome$ ,m J Ophthalmol <ACDI <02L/0<E0A$ @A)Moorthy !(# *ein-erg DV# +eich (,# et al$ Management of 'aricella 4oster retinitis in ,ID($ r J Ophthalmol <AA/I C<L<CAEA4$ D0)is.as J# De2a (# Padma3a (# et al$ 8entral retinal 'ein occlusion due to herpes 4oster as the initial presenting sign in a patient .ith acBuired immunodeficiency syndrome 9,ID(:$ Ocul Immunol Inflamm 200<I AL<2@)>0$ D<)8unningham 7+ Jr# (hort H,# Ir'ine ,!# et al$ ,cBuired immunodeficiency syndrome associated herpes simple1 'irus retinitisL clinical description and use of a polymerase chain reaction)-ased assay as a diagnostic tool$ ,rch Ophthalmol <AADI <<4LC>4E40$ D2)Mar2omichela2is ??# 8ana2is 8# ;afira2is P# et al$ 8ytomegalo'irus as a cause of anterior u'eitis .ith sectoral iris atrophy$ Ophthalmology 2002I <0ALC/AEC2$ D>)(chol4 M# Doerr H*# 8inatl J$ Human cytomegalo'irus retinitisL pathogenicity# immune e'asion and persistence$ +rends Micro-iol 200>I <<L</<E/C$ D4)5empen JH# Ja-s D,# *ilson ",# et al$ !is2 of 'ision loss in patients .ith cytomegalo'irus retinitis and the acBuired immunodeficiency syndrome$ ,rch Ophthalmol 200>I <2<L4DD)/D$ D@)Doan (# 8ochereau I# Hu'enisi2 ?# et al$ 8ytomegalo'irus retinitis in HIV infected patients .ith and .ithout highly acti'e antiretro'iral therapy$ ,m J Ophthalmol <AAAI <2CL 2@0E@<$ DD)5empen JH# Ja-s D,# *ilson ",# et al$ Mortality ris2 for patients .ith cytomegalo'irus retinitis and acBuired immune deficiency syndrome$ 8lin Infect Dis 200>I >/L<>D@)/>$ D/)5empen JH# Martin 5# *u ,*# et al$ +he effect of cytomegalo'irus retinitis on the Buality of life of patients .ith ,ID( in the era of highly acti'e antiretro'iral therapy$ Ophthalmology 200>I <<0LAC/EA@$ DC)"illeri D# Piccinini H# aldanti F# et al$ Multiple relapses of human cytomegalo'irus retinitis during H,,!+ in an ,ID( patient .ith reconstitution of 8D4F + cell count in the a-sence of H8MV)specific 8D4F + cell response$ J 8lin Virol 200>I 2DLA@E<00$ DA)!o-inson M!# 8sa2y 5H# "ee ((# et al$ Fi-ro'ascular changes misdiagnosed as cytomegalo'irus retinitis reacti'ation in a patient .ith immune reco'ery$ 8lin Infect Dis 2004I >CL<>A)4<$ /0)(ong M5# ,4en (P# uley ,# et al$ 7ffect of anti) cytomegalo'irus therapy on the incidence of immune reco'ery u'eitis in ,ID( patients .ith healed cytomegalo'irus retinitis$ ,m J Ophthalmol 200>I <>DLDAD)/02$ /<)Ja-s D,# Martin 5# Forman M(# et al$ 8ytomegalo'irus resistance to ganciclo'ir and clinical outcomes of patients .ith cytomegalo'irus retinitis$ ,m J Ophthalmol 200>I <>@L2DE>4$ /2)200< &(PH(=ID(, Huidelines for the Pre'ention of Opportunistic Infections in Persons Infected .ith Human Immunodeficiency Virus$ ?o'em-er 2C# 200<$ ,'aila-le atL httpL==...$aidsinfo$nih$go'$ ,ccessed March <A# 2004$ />)Vele4 H# !oy 87# *hitcup (M# et al$ High)dose intra'itreal 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