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Ocular HIV/AIDS Related Diseases
(Initial and Follow-up Evaluation)

(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus of
expert opinion in absence of evidence for I & II)
General - Initial Exam History
 Ocular symptoms including laterality (A:III)
 Complete review of systems (A:III)
 Prior ocular history (A:III)
 Prior medical history (A:III)
 Prior surgical history (B:III)
 History of other sexually transmitted diseases (A:III)
illnesses or complications (A:III)
 Method of HIV acquisition (B:III)
 Duration of HIV infection (A:III)
 Past and current risk factors – sexual behavior, intravenous drug abuse, transfusion history (A:III)
 Current anti-HIV regimen – duration and compliance (A:III)
 Current CD4 count (A:II)
 Current viral load (A:II)

General - Initial Physical Exam
 External examination – face, ocular adnexa (A:III)
 Lymphatics – preauricular and submandibular nodes (A:III)
 Confrontation visual fields (A:III)
 Eyelids – lid closure, interpalpebral fissure height (B:III)
film – Schirmer, rose bengal and fluorescein staining (A:III)
o Vitreous – cell/flare, blood, condensations (A:III)
o Optic
o Peripheral retina with scleral depression (A:III)
o Choroid

General - Diagnostic Tests
 HIV infection – for increased risk populations and/or suspected infection o Anti-HIV ELISA to screen for infection, followed by confirmation with Western blot (A:II)
o Presence of AIDS-defining illness(es) (A:III)
o CD4 (< 200 cells/µl, per CDC criteria) (A:II)

General - Care Management
 Management of HIV/AIDS should involve a multidisciplinary team, including an infectious disease specialist and an ophthalmologist (A:III)
 Anti-Retroviral Therapy (ART) or Highly Active Anti-Retroviral Therapy (HAART), where available (A:II)
 Emphasis on prevention of disease transmission (A:III)
 Identification and treatment of HIV/AIDS associated illnesses/infections (particularly tuberculosis and syphilis) (A:II)

HIV Retinopathy – Initial Exam History
 Ocular symptoms – usually asymptomatic (B:III)

HIV Retinopathy – Initial Physical Exam
 Slit lamp examination (B:III)
ophthalmoscopic examination (A:II)
 Screen for other HIV/AIDS related illnesses/infections (B:III)

HIV Retinopathy - Care Management
 Treat immune compromise with HAART (A:II)
(B:III) or focal laser (A:II) for macular edema

HIV Retinopathy – Follow-up Evaluation
 Lesions usually resolve over weeks to months (A:II)
 Dilated ophthalmoscopic examination every 3 months for CD4 counts persistently below 50 cells/µl (A:II)

Cytomegalovirus (CMV) Retinitis – Initial Exam History
 Interval since AIDS diagnosis (A:II)
 History of CMV related systemic complications (A:II)
 Ocular symptoms –blurred vision, floaters, photopsias, scotomata (A:II)

Cytomegalovirus (CMV) Retinitis – Initial Physical Exam
 Cornea for small endothelial deposits (B:III)
 Anterior chamber for signs of inflammation (A:II)
 Dilated ophthalmoscopic examination of both eyes – including optic disc, macula, and retinal periphery. The choroid should be examined to rule out co-infection
with other agents (A:II)

Cytomegalovirus Retinitis – Diagnostic Tests
 CD4 count – typically less than 50 cells/µl (A:II)

Cytomegalovirus Retinitis – Ancillary Testing
 Fundus photography may be useful to document disease progression or response to treatment and fluorescein angiography as indicated to evaluate for
the presence of macular edema or ischemia (A:III)
 Test for syphilis and vitreous biopsy for other causes of necrotizing retinitis (varicella zoster virus, herpes simplex virus, toxoplasmosis) when diagnosis
uncertain (A:II)
Cytomegalovirus – Care Management
 Main objectives include direct treatment of CMV retinitis with anti-CMV medications, and improvement of immune status with initiation/optimization of
HAART if not already taking anti-retroviral therapy (A:II)
 To reduce the possibility of immune recovery uveitis, patients with newly diagnosed CMV retinitis who are not on HAART should be treated with anti-CMV
medications until the retinitis is inactive, or at least less active. HAART should
then be initiated (A:II)
 Also, in cases with expected persistent immune suppression, e.g. poor response to or unavailability of ART, immediate treatment is indicated (A:II)
 Local anti-CMV therapy, as might be achieved using intravitreal injection of ganciclovir or foscarnet, may be used immediately when active CMV retinitis
either involves or threatens the optic disc or macula (A:II)
 Induction followed by indefinite maintenance therapy in cases of persistent immune suppression (A:II)
o Intravenous – 5 mg/kg every 12 hours for 2 to 3 weeks, then 5 mg/kg/day 5 to 7 times per week indefinitely. (A:I) Monitor for leukopenia, the risk of
which may be lessened by administering leukocyte-stimulating factors
such as granulocyte colony-stimulating factor (A:II)
o Intraocular – 2 to 2.5 mg/0.1 ml intravitreal injection twice per week until inactive, then weekly (A:I)
implant (Vitrasert) – 4.5 mg implant that releases 1 µg/hr for eight months. This should be combined with oral
valganciclovir therapy for systemic coverage (A:I)
o Intravenous – 60 mg/kg every 8 hours or 90 mg/kg every 12 hours for 14 days, then 90 to 120 mg/kg/day. Monitor for renal toxicity (A:I)
o Intraocular – 1.2 mg/0.05 ml (or 2.4 mg/0.1 ml) (A:I)
o Oral – 900 mg twice daily for 2 weeks, (A:I) then 900 mg daily indefinitely.
(A:II) Monitor for leukopenia (A:II)

Cytomegalovirus – Follow-up Evaluation
 Recurrence is very common, and patients being treated with anti-CMV medications should be evaluated monthly (A:II)
 Intervals may be extended when CD4 counts are elevated, anti-CMV medications are discontinued, and the disease remains inactive in the setting of
immune recovery (A:II)
 CD4 count and HIV viral load (A:II)
 Review of systems for CMV related systemic complications or drug-induced side effects (A:II)

Cytomegalovirus – Follow-up Examination
 Slit lamp examination (B:II)
 Ophthalmoscopic examination – including the macula and peripheral retina (A:II)
 Serial fundus photography (B:II)

Cytomegalovirus – Follow-up Management
 No treatment can eliminate CMV from the eye (A:II)
 Patient education about the symptoms of CMV retinitis is crucial (A:III)
 For recurrences, first line is re-induction with the same therapy in the absence of side effects or evidence of drug resistance (A:II)
 Persistent or progressive retinitis after 6 weeks of induction-level therapy implies resistance or incorrect diagnosis (A:II)
 UL97 and UL54 mutations in CMV DNA are associated with relative ganciclovir resistance (A:II)
 Anti-CMV drugs may be discontinued in patients on HAART with no signs of active CMV retinitis in whom CD4 counts are above 100 to 150 cells/µl for at
least three to six months (A:II)

Tuberculosis – Initial Exam History
 CD4 count (typically < 200 cells/µl) (A:II)
 Visual and ocular symptoms (A:II)
M. Tuberculosis infection, systemic complications, or exposure (A:II)
Tuberculosis – Initial Physical Exam
including eyelids and adnexa (B:III)
 Slit lamp examination (B:III)
 Dilated ophthalmoscopic examination - optic disc, macula, retinal periphery, and choroid (A:II)

Tuberculosis – Diagnostic Tests
 Presumptive diagnosis by clinical examination combined with PPD skin testing and chest x-ray (A:II)
 Requires a high index of clinical suspicion (B:III)
 Consider leukocyte stimulation based assays where available, particularly when PPD skin testing is unreliable (QuantiFERON -TB Gold Test; T.SPOT-TB test)
(A:II)
 Definitive diagnosis requires biopsy with histopathologic examination (A:III)
Tuberculosis – Ancillary Testing
 Fluorescein angiography to evaluate suspected retinal vasculitis (A:III)
 Indocyanine green angiography may be helpful to detect subclinical choroidal involvement (A:III)
 Optical coherence tomography to diagnose and monitor for cystoid macular edema (A:III)

Tuberculosis – Care Management
 Systemic treatment is indicated with rifampin (500 mg/day for weight > 50 kg and 600 mg/day for weight < 50 kg), isoniazid (5 mg/kg/day), pyrimethamine (25 to 30
mg/kg/day, and ethambutol (15 mg/kg/day) for 2 months then rifampin and
isoniazid for another 4 to 7 months (A:II)
 Oral prednisone (1 mg/kg/day), taper as directed by clinical response (A:II)
 Initiate/optimize HAART if not already taking anti-retroviral therapy (A:II)
 Coordinate care with an infectious disease specialist (A:III)
Tuberculosis – Follow-up Evaluation
 Monitor all patients for medication toxicity (A:II)
 Examine patients monthly until there is significant clinical improvement (A:III)

Toxoplasmosis (T. gondii) – Initial Exam History
 CD4 count (typically < 200 cells/µl) (A:II)
 Visual and ocular symptoms (A:III)
T. gondii infection, systemic complications, or exposure (A:III)

Toxoplasmosis – Initial Physical Exam
 Slit lamp examination (C:II)
ophthalmoscopic examination (A:II)

Toxoplasmosis – Diagnostic Tests
 Primarily a clinical diagnosis (A:III)
 Serologic testing for anti-T. gondii IgM/IgG antibodies (A:II)
 In unclear cases, can perform PCR on aqueous or vitreous for T. gondii DNA
Toxoplasmosis – Care Management
 Initial treatment involves oral antimicrobials for 4 to 6 weeks. Options include: (800/160) 500 mg PO twice daily (A:II)
o Pyrimethamine (100 mg loading dose given over 24 hours, followed by 25 to 50 mg daily) and sulfadiazine (1 g given four times daily) for 4 to 6
weeks. Should be given concurrently with folinic acid (3 to 5 mg twice
weekly) to prevent leukopenia and thrombocytopenia (B:II)
o Clindamycin (300 mg orally every 6 hours) for 3 or more weeks (B:II)
o Atovaquone (750 mg orally four times daily) for 3 months (B:II)
o Consider use of Azithromycin in patients with sulfa-related allergy (B:III)
at least one of the above medications is recommended for patients with ocular toxoplasmosis who remain severely immunodeficient
(A:III)
 Oral corticosteroids may be considered when inflammation contributes to vision loss (vitritis, vasculitis, serous retinal detachment, lesion involving or threatening
the optic disc or macula) - 0.5 mg/kg/day with taper, initiated and ended
concurrent with antimicrobial therapy (A:III)
 Topical corticosteroids may be considered for significant anterior chamber inflammation (A:III)

Toxoplasmosis – Follow-up Evaluation
 Initial follow-up should be one week after initiation of treatment, then as indicated by examination and treatment response (A:III)
 Lesions typically take several months to resolve (A:III)

Syphilis – Initial Exam History
 CD4 count (often less than 200 cells/µl). However, ocular syphilis in the setting of HIV/AIDS may occur at any CD4 count. (A:II)
 Visual symptoms and rapidity of onset (A:III)
 Previous syphilis infection, related complications, or exposure (A:III)
 History of other sexually-transmitted diseases (B:III)

Syphilis – Initial Physical Exam
 Slit lamp examination (B:III)
ophthalmoscopic examination (A:II)

Syphilis – Diagnostic Tests
 Both non-treponemal (RPR or VDRL) and treponemal (MHA-TP or FTA-ABS) testing should be obtained (up to one-third of patients with syphilitic uveitis have
a negative non-treponemal test) (A:II)
 Patients with profound immune suppression may present with seronegative syphilis (A:II)
 CSF examination (RPR or VDRL) in all HIV/AIDS patients with ocular syphilis
Syphilis – Care Management
 Treat as neurosyphilis (A:II)
 Involve an infectious disease specialist in coordinating systemic management  First-line treatment is with IV penicillin G, 18 to 24 million units for 14 days (A:II)
 Worsening ocular inflammation following the initiation of penicillin may be indicative of a Jarish-Herxheimer reaction (A:II)

Syphilis – Follow-up Evaluation
 Serial serum and CSF antibody levels every month for 3 months, then every 6 months until CSF cell count normalizes and CSF VDRL/RPR becomes non-
reactive (A:III)
 Serum quantitative nontreponemal testing every 3 months for one year, then yearly (A:III)
not necessary or recommended (B:II)
Table 1. Adnexal Manifestations of HIV/AIDS (A:III unless otherwise indicated)
History Examination Key
Findings
Diagnostic
Management Follow-up
 Vesiculobullous dermatitis in  Clinical  IV acyclovir 10 mg/kg every 8 hours for 7 days (A:II)
infection (A:II)
CN V1 distribution (A:II)
 Alternatives: valacyclovir (1 gram PO 3 times daily) or oral acyclovir (800 mg PO 5 times daily); close follow-up for signs of disseminated infection including cerebritis  Patient receiving high doses of valacyclovir should be monitored for TTP/HUS (A:II)
 Maintain on oral acyclovir 800 mg, 3 to 5 times daily indefinitely (A:II)
 Alternatively, can maintain on oral famciclovir or  Topical corticosteroids for iridocyclitis and/or stromal keratitis (A:II)
 Immune reconstitution (A:II)
 Indications for treatment: 1) loss of normal lid function, membranes (A:II)
 Treatment depends on the size and location of lesions conjunctiva (A:II)
 Treatment options include intralesional vinblastine or  Pain (rare) (B:II)
a purplish nodule (A:II)
lesions (A:II)
interferon-alpha, local radiation therapy, excision, and cryotherapy (A:II)
(rare) (C:II)
mimic SCH (B:II)
 Systemic chemotherapy if disseminated disease (A:II)
 Reduce size of large lesions prior to excision  Immune reconstitution (A:II)
 Topical agents: liquid nitrogen, trichloracetic acid, exposure (A:II)
membranes (A:II)
cantharadin (A:II)
 Incision with curettage, excision, or cryotherapy (A:II)
lesions (A:II)
 Wide excision with cryotherapy for non-invasive lesions risk in Africa (A:II)
interpalpebral limbus (A:II)
 Frozen section pathologic examination (A:II)
 Alternatives include MMC, 5-FU, and interferon (A:II)
infection (B:II)
more common (A:II)
 Biopsy (A:II)
 Radiation (A:II)
eyelid or conjunctiva (A:II)
 Chemotherapy (A:II)
lymphoma (A:II)
 DOE (C:III)
SLE = slit lamp examination, AC = anterior chamber, DOE = dilated ophthalmoscopic examination, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, HIV = human immunodeficiency virus, SCH = subconjunctival hemorrhage, HPV = human papilloma virus, VA = visual acuity, MMC = mitomycin C, 5-FU = 5-fluorouracil, FBS = foreign body sensation = visual acuity, MMC = mitomycin C, 5-FU = 5-fluorouracil, FBS = foreign body sensation Table 1. (continued) Adnexal Manifestations of HIV/AIDS (A:III unless otherwise indicated)
History Examination Key
Findings
Diagnostic
Management Follow-up
 Inferior perilimbus (A:II)
 DOE (B:III)
and narrowing (A:II)
fragments (A:II)
 Microaneurysms (A:II)
 Conjunctival erythema (A:II)
 Guided by results of gram stain and culture  Clinical examination should be used to initiate empiric discharge (A:II)
discharge (A:II)
gram stain of
discharge
(A:II)
 Topical corticosteroids (i.e. hydrocortisone 0.5% cream) skin (A:II)
 Topical calcineurin inhibitors, Elidel (pimecrolimus) and Protopic (tacrolimus) are contraindicated in immunosuppressed patients (B:II)
 Triggers (A:II)
eyelid margins (A:II)
 Consider culture in high-risk patients SLE = slit lamp examination, AC = anterior chamber, DOE = dilated ophthalmoscopic examination, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, HIV = human immunodeficiency virus, SCH = subconjunctival hemorrhage, HPV = human papilloma virus, VA = visual acuity, MMC = mitomycin C, 5-FU = 5-fluorouracil, FBS = foreign body sensation = visual acuity, MMC = mitomycin C, 5-FU = 5-fluorouracil, FBS = foreign body sensation Table 2. Corneal and Anterior Segment Manifestations of HIV/AIDS (A:III unless otherwise indicated)
Diagnostic
History Examination
Findings
Management Follow-up
encephalopathy (B:III)
rate (B:II)
testing (A:II)
HIV (B:III)
gland (C:III)
meniscus (B:III)
 TBUT (B:II)
 Rapid TBUT (A:II)
staining (A:II)
bengal or
fluorescein (A:II)
keratitis (A:II)
daily or 10 mg/kg IV tid (A:II)
of zoster dermatitis (A:II)
sensation (A:II)
 Elevated IOP (B:II)
postherpetic neuralgia (B:III)
herpes infection (A:II)
 Iris atrophy (B:II)
acyclovir (600 mg PO tid) (A:II)
PCR (B:II)
times daily) (A:II)
stromal
involvement (B:II)
times daily (A:II)
alone (A:II)
involvement (B:II)
acyclovir 400 mg PO bid for 1
year (A:I)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, TBUT = tear film breakup time, VZV = varicella zoster virus, HSV = herpes zoster virus, IOP = intraocular pressure, DOE = dilated ophthalmoscopic examination, DFA = direct fluorescent antibody, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, AIDS = acquired immunodeficiency syndrome, FBS = foreign body sensation, AC = anterior chamber, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus Table 2. (continued) Corneal and Anterior Segment Manifestations of HIV/AIDS (A:III unless otherwise indicated)
History Examination Key
Findings
Diagnostic
Management Follow-up
 Guided by culture results (B:II)
infiltrate (A:II)
 DOE (C:III)
agents (A:II)
perforation (A:II)
 Immune reconstitution (A:II)
keratopathy (A:II)
topical propamidine isethionate, topical conjunctivitis (A:II)
itraconazole (A:II)
inflammation (A:II)
lesions (A:II)
 Consider debulking (B:III)
medication, if possible (A:II)
e,
chlorproma
zine,
ganciclovir,
acyclovir)
(A:II)
 Topical corticosteroids with or without  IOP (B:III)
 DOE (B:III)
hypopyon (A:II)
offending medication (B:III)
status
(B:III)
on HAART
(B:III)
CMV
retinitis
(A:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, TBUT = tear film breakup time, VZV = varicella zoster virus, HSV = herpes zoster virus, IOP = intraocular pressure, DOE = dilated ophthalmoscopic examination, DFA = direct fluorescent antibody, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, AIDS = acquired immunodeficiency syndrome, FBS = foreign body sensation, AC = anterior chamber, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus Table 3. Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
CD4 count
Examination
Key Findings
Diagnostic workup
Management
Follow-up
 SLE (B:III)
HAART (A:II)
over weeks to months (A:II)
 DOE (A:II)
 Screen for other infections/illnesses  CWS (A:II)
 Consider corticosteroids (B:III) or
 IRH (A:II)
focal laser (A:II) for macular edema
 MAs (A:II)
 Retinal ischemia (A:II)
 CME (A:II)
 VA (A:II)
AIDS (A:II)
 SLE (B:II)
the eye (A:II); patient education
 DOE (A:II)
retina (A:II)
 CD4 count (A:II)
infection (A:II)
risk of IRU (A:II)
inflammation (B:II)
retinitis (A:II)
medications (A:II)
stellate KP (B:II)
floaters (A:II)
mg/kg/day) (A:I); IO (2-
retinitis (A:II)
photography (B:II)
inactive) (A:I); intraocular implant
(A:I), combine with oral anti-CMV
or resistance (A:II)
mg/kg/day) (A:I); IO (1.2 mg/0.05
ml) (A:I)
150 cells/µl (A:II)
2 weeks, then 900 mg daily).
Monitor for leukopenia (A:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, DOE = dilated ophthalmoscopic examination, CWS = cotton wool spots, IRH = intraretinal hemorrhages, MA = microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU = Immune recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD = purified protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid plasma reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN = progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional retinal detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction syndrome, PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxazole, EOM = extraocular motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable Table 3. (continued) Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
Examination
Key Findings
Diagnostic workup
Management
Follow-up
 VA (A:II)
 Initially every 3 to 5 days, then as symptoms (A:II)  IOP (B:II)
 SLE (C:II)
inflammation (B:II)
IgM/IgG (A:II)
weeks (A:II)
 DOE (A:II)
unclear cases (B:II)
hemorrhage (A:II)
azithromycin) (B:II)
hours) for 3 or more weeks (B:II)
anterior uveitis(C:II)
months (B:II)
 Vitritis (A:II)
symptoms (A:II)  External
toxicity (A:II)
tuberculomas (A:II)
and CXR (A:II)
 SLE (B:III)
retinal detachment (B:II)
 IOP (B:III)
 DOE (A:II)
to 7 months (A:II)
text) (B:III)
taper as directed by clinical
response (A:II)
 Immune reconstitution (A:II)
 Involve an infectious disease
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, DOE = dilated ophthalmoscopic examination, CWS = cotton wool spots, IRH = intraretinal hemorrhages, MA = microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU = Immune recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD = purified protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid plasma reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN = progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional retinal detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction syndrome, PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxazole, EOM = extraocular motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable Table 3. (continued) Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
CD4 count
Examination
Key Findings
Diagnostic workup
Management
Follow-up
 VA (A:II)
 RPR or VDRL (A:II)
 Treat as neurosyphilis (A:II)
symptoms (A:II)  IOP (B:II)
inflammation (A:II)
 SLE (B:II)
ATP (A:II)
 DOE (A:II)
 Subretinal plaque (B:II)
units for 14 days (A:II)
becomes non-reactive (A:III)
or neuroretinitis (A:II)
recommended (B:II)
Herxheimer reaction (A:II)
 VA (A:II)
 Can progress rapidly (A:II)
 IOP (B:III)
 SLE (B:III)
8 hours) (A:II)
 DOE (A:II)
areas of retinitis (A:II)
diagnosis (B:II)
 Rapid progression (A:II)
indicated (A:II)
inflammation (B:II)
be considered (B:II)
for TTP/HUS (A:II)
should be monitored for leukopenia
(A:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, DOE = dilated ophthalmoscopic examination, CWS = cotton wool spots, IRH = intraretinal hemorrhages, MA = microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU = Immune recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD = purified protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid plasma reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN = progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional retinal detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction syndrome, PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxazole, EOM = extraocular motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable Table 3. (continued) Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
CD4 count
Examination
Key Findings
Diagnostic workup
Management
Follow-up
 VA (A:II)
 IOP (B:II)
predominance (A:II)
corticosteroids (A:II)
 SLE (A:II)
 DOE (A:II)
formation, or CME (A:II)
out CME (B:III)
 VA (A:II)
 TMP-SMX or pentamidine  Monthly until resolution – usually  SLE (C:III)
(4 mg/kg/day) (A:II)
posterior pole (A:II)
vasculitis (A:II)
count above 200 cells/µl) (A:II)
 SLE (B:II)
 EOM (A:II)
infection (A:II)
 DOE (A:II)
 Papilledema (A:II)
meningitis (A:II)
for 10 weeks (A:II)
scotomata (A:II)
neuritis (B:II)
weeks (A:II)
vitritis, necrotizing
retinitis, and eyelid or
conjunctival mass (B:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, DOE = dilated ophthalmoscopic examination, CWS = cotton wool spots, IRH = intraretinal hemorrhages, MA = microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU = Immune recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD = purified protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid plasma reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN = progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional retinal detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction syndrome, PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxazole, EOM = extraocular motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable Table 3. (continued) Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
CD4 count
Examination
Key Findings
Diagnostic workup
Management
Follow-up
symptoms (A:II)  IOP (C:II)
retinitis (A:II)
to regression (A:II)
 SLE (C:III)
 Retinal vasculitis (A:II)
 DOE (A:II)
syphilis (A:II)
inflammation (B:II)
hemorrhage (B:II)
 Slow progression (B:II)
 Floaters (A:II)
 VA (A:II)
 Radiation and chemotherapy (A:II)
 DOE (A:II)
 Poor prognosis (A:II)
 Retinal vasculitis (B:II)
 Immune reconstitution (B:II)
 Subretinal mass (A:II)
 Vitritis (A:II)
treatment (A:II)
examination (A:II)
 CNS symptoms (A:II)
lymphoma (A:II)
 VA (A:II)
 SLE (B:II)
detachment (A:II)
retinitis (A:II)
 DOE (A:II)
trauma (B:II)
myopia (B:II)
detachment, number,
size, and location of
retinal holes, and
involvement of the
macula (A:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, DOE = dilated ophthalmoscopic examination, CWS = cotton wool spots, IRH = intraretinal hemorrhages, MA = microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU = Immune recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD = purified protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid plasma reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN = progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional retinal detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction syndrome, PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxazole, EOM = extraocular motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable

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