History of Presenting Illness: 40 y-old AAM presenting with blurry vision in the left eye for 7-8 months.

Medical/ Ocular History: significant for AIDS diagnosed 3 yrs ago, disseminated TB for which he received 9 months of antiTB treatment, and one episode of zoster eruption in his left shoulder. last eye exam on record was 3 yrs PTP. He was found to have HIV retinopathy and enlarged C/D ratio.

Social History: currently disabled. Contracted HIV through unprotected sex with other men.No IVDU. Smokes mariujuana daily

Family History: mother has glaucoma

Allergies: None

Review of Systems: Noncontributory

Current meds: zithromax, dapsone, kaletra (lopinavir-ritonavir), Combivir (lamivudine-zidovudine).

Ocular Exam:

-No external/periorbital lesions -EOM full -Orthophoric at distance/near -Superior field defect OS -No APD -Vision: DV sc : OD 20/20      OS 20/60  NIPH (Cyclo retinoscopy +0.75 OU) -IOP  OD 14 mmHg  OS 12mmHg -SLE L/L: clean OU C/S: white OU K: arcus OU; fine pigmented KP center OS A/C: D/Q OU I/P: RR, 6à4, 2+ OU Lens: 1+ NS OU Anterior vitreous: OD quiet, OS few pigmented cells

Diagnostic tests

-Current labs: absolute CD4 544 (nadir was 8 one yr ago). HIV viral load undetectable (>750K one yr ago)

-Fundus pictures

Fluorescein Angiogram:

 
Ocular Coherence Tomography (OCT):

 

Differential Diagnosis

• Infectious vitritis
• Inflammatory vitritis
• Healed retinitis ( CMV/HSV/HZV) with possible reactivation.
• Pars planitis
• Immune Recovery Uveitis (IRU)

Discussion:

• Immune Recovery Uveitis: described in patients with inactive CMV retinitis who experience an increase in CD4 count as a result of HAART (>50, 60 or 100 c/mm3 for at least 2 months, depending on series)

Epidemiology

• Developed in 26/44 eyes (19/30 patients)
• 29 patients were off anti-CMV treatment
• Onset 2-84 wks (median 20 wks) following increase in the CD4 count
• Risk factor: area of inactive CMV retinitis.
• If > 30% of retina was involved, the risk of developing IRU was 4.5x higher compared to eyes with a healed CMV retinitis area < 18%.
• CD4 count NOT associated with severity of inflammation

Signs

• Vitritis
• Papillitis
• CME
• ERM

Symptoms

• Blurry vision
• Floaters

Pathophysiology

• HAART mediated recovery of immune function induces an inflammatory reaction to residual viral particles, or to a chronic subclinical viral replication along the border of healed CMV retinitis

Treatment

CME with VA > 20/30: observation. Most patients stabilized  or improved spontaneously.

• CME with vision < 20/30: subtenon steroids. Vitritis improved in 60% of treated eyes, macular edema in 20%, and vision in 40%.
• ERM : PPV
• Topical steroids less effective. Patients with IRU and who were placed on oral steroids for other indications had improvement in their VA.
• Valganciclovir 900 mg/d for three months improved VA in 5 patients (20/80à20/50).
• No difference in IRU incidence in patients who were maintained on anti-CMV Rx vs patients how were taken off Rx.
• IRU is less severe when HAART is started after the CMV retinitis has treated.

• 1-Marietta PK et al. Immune recovery vitritis and uveitis in Aids. Clinical predictors, sequelae and treatment outcomes. Retina 2001; 21:1-9.
  2-Mohamed HE, et al. Long term results of treatment of macular complications in eyes with immune recovery uveitis using a graded treatment approach. Retina 2004; 24:376-382.
  3-Brian RK, et al. Valganciclovir therapy for immune recovery uveitis complicated by macular edema. Am J Ophthalmol 2004;137:636-638.

Message from the Director | Information for Patients
Pat and Willard Walker Eye Research Center | Information for Students and Residents
Giving to Jones Eye Institute | Lions Eye Bank and Laboratory
UAMS | Home Notice of Privacy Practices