ophtha lec aids&theye

8/7/2019 OPHTHA lec aids&theye

1/101

Ocular Manifestations in HIV

Infections

Clinically apparent ocular lesions seen in

94% of AIDS patients

Four categories of involvement

Neoplasms (kaposis sarcoma)

Lesions related to microvascular disease

Opportunistic ocular infections

Neuro-ophthalmic abnormalities


2/101


3/101


4/101


5/101


6/101

Kaposi sarcoma

AdvancedEarly

Pink, red-violet lesion

Vascular tumour occurring in patients with AIDS

Usually associated with advanced disease

Very sensitive to radiotherapy

May ulcerate and bleed


7/101

Kaposis sarcoma

May be overlooked unless lower lids are

pulled down during exam

Ocular surface or eyelid usually first site fordevelopment of this multifocal neoplasm in

4% cases

Ocular lesion may be the initial or only lesion


8/101


9/101


10/101

Conjunctiva Dilated vessels at the limbus

Isolated vascular segments of irregular caliber

Sludging of blood flow


11/101


12/101


13/101


14/101


15/101

Cotton wool spots Most common retinal manifestation (at

least 2/3 of AIDS cases)

Nerve fiber layer swelling

Stasis of axoplasmic flow

Reflection of retinal ischemia

Spontaneously regresses in 4-6 weeks


16/101


17/101


18/101


19/101


20/101


21/101


22/101


23/101


24/101

Cytomegalovirus retinitis Early CMV difficult to distinguish from cotton

wool spots

No spontaneous resolution

Relentlessly progressive

Individual foci coalesce and spread outwards

Necrotic retina replaced by thin, glioticmembrane -> retinal detachment

NEED FOR SERIAL EXAMINATION


25/101


26/101


27/101


28/101


29/101


30/101


31/101


32/101


33/101


34/101


35/101

Cytomegalovirus retinitis Most common ocular infection (25%)

Full thickness retinal necrosis

Dry, granular, retinal opacification(edema / necrosis)

Hemmorhage and vasculitis


36/101


37/101


38/101


39/101


40/101


41/101


42/101


43/101


44/101


45/101

Cytomegalovirus retinitis Hematogenous spread

Microvasculopathy ->damage vesselwall ->allow access of viral particles to

retinal tissue

Cotton-wool spots precede or occur

concurrently


46/101

Cytomegalovirus retinitis Early lesions adjacent to major vascular

arcades (vascular orientation)

May also occur first in the peripheralretina

Little inflammatory reaction; vitreous

remains clear


47/101


48/101


49/101


50/101


51/101


52/101


53/101


54/101

Cytomegalovirus retinitis

Treatment

Ganciclovir (IV or intravitreal at 200

ug/0.1cc); watch out for neutropenia Foscarnet (IV); watch out for kidney damage

(need proper hydration)

AZT (azidothymidine) effective against HIV

but no effect on CMV

Laser - failure to prevent spread of CMV

retinitis


55/101


56/101


57/101


58/101


59/101


60/101


61/101


62/101


63/101


64/101


65/101


66/101


67/101

CONGENITAL

CATARACT

most are bilateral

associated with maternal infection

Rubella, Toxoplasmosis,

Cytomegalic Inclusion Disease

may cause nystagmus


68/101


69/101


70/101


71/101


72/101


73/101


74/101


75/101


76/101


77/101


78/101


79/101


80/101


81/101


82/101


83/101

Lagophthalmos

Insufficient or weak

eyelid closure

May result toexposure keratitis

Treatment: eyelid

taping when

sleeping; artificialtears


84/101

Fungal Keratitis

Rare, but not in P.I.

Farmers

Causative agents: Aspergillus

Fusarium

Candida


85/101

Fungal Keratitis Signs and Symptoms:

Redness, pain, profuse

mucoid discharge ,

intense anterior chamber

reaction(non specific) Slow progression

feathery borders

Satellite lesions

Endothelial plaque


86/101

Fungal Keratitis

Treatment:

Difficult

Drops: Natamycin 5%

Amphotericin B 0.15% eye drops

IV/ Systemic antifungal drugs

If large and with impending perforation


87/101

Fungal Keratitis

Surgery

Therapeutic

transplant

Perforated ulcers


88/101

Acanthamoeba

Protozoa

Contact lens wearers Differentiate from

Pseudomonas (fastprogression, cornealmelt, profuse discharge)

PAIN Radial keratoneurtitis

Disproportionate toclinical signs

Infiltrates Start out as satellite

lesions

Coalesce to form acentral ulceration

ring inflitrates


89/101

Acanthamoeba

Slow progression

Epithelium may be intact

CLUES:Severe pain

Cultures negative for bacterial or fungal

growth

No response to typical antimicrobial or

antifungal therapy


90/101

Acanthamoeba

Treatment: Antiamoebic drugs

Propamidine isothionate

Polyhexamethylene biguanide chlorhexidine

Steroids

controversial

May decrease pain but case delayed healing

NSAIDS: better alternative

Surgery Therapeutic transplants

CONTRAINDICATED in inflamed eyes


91/101


92/101

Sample Question

Which therapy is least appropriate for treatment of

dendritic epithelial keratitis due to herpes simplex

virus?

a. Vidarabine ointment 4 times a day

b. Trifluoridine solution 4 times a day

c. Oral acyclovir 2 grams a day

d. Prednisolone acetate 1% qide. Minimal debridement with a dry cotton-tipped applicator


93/101

Viral Keratitis

Herpes Simplex

DNA virus

Common: up to 90% of human population seropositive

HSV1(face, lips, eyes)

Primary infection

In children, usually droplet

subclinical

Recurrence

Immunocompromised state


94/101

Viral Keratitis

Herpes Simplex

Keratitis

Two types Epithelial (HSEK)

Disciform

keratitis


95/101

Viral Keratitis

HSEK Reduced corneal

sensation

Epithelial ulceration Anterior stromal infiltrates

Dendrites

Terminal bulbs

Centrifugal spread toform geographic lesions


96/101

Viral Keratitis

Disciform Keratitis

Reduced corneal

sensation

Epithelial edema

overlying stromal

infiltrates

DM folds

Anterior uveitis

IOP may be elevated


97/101

Viral Keratitis

HSEK Treatment:

Topical Antivirals

Ganciclovir 0.15%

Trifluorothymidine 1%

Toxic

Debridment

Systemic Drugs

Effect disappearswhen drug is removed

For those with 2 ormore attacks/year

Disciform Keratitis Treatment:

Topical Antivirals

Steroids

Given withantivirals

Tapering dose

Small lesions may beobserved


98/101


99/101

Viral Keratitis

Herpes Zoster Ophthalmicus(HZO)

Caused by varicella (VZV)

Face lesions (Vesicles)

follow nerve distribution,respects midline

HutchinsonsSign

Keratitis:

Epithelial

Dendrites with nobulbs

NummularSubepithelialopacities

Disciform keratitis

Similar to Herpessimplex


100/101

Viral Keratitis

Herpes Zoster Ophthalmicus:

Other findings

Blepharoconjunctivitis Associated with lid vesicles

Episcleritis

Scleritis

Anterior uveitis Sectoral iris atrophy


101/101

ophtha lec aids&theye

Documents