Vision function in HIV-infected individuals without retinitis: report of the Studies of Ocular Complications of AIDS Research Group.

PURPOSE: To evaluate the prevalence and risk factors for vision loss in patients with clinical or immunologic AIDS without infectious retinitis. DESIGN: A prospective, multicenter cohort study of patients with AIDS. METHODS: One thousand three hundred and fifty-one patients (2,671 eyes) at 19 clinical trials centers diagnosed with AIDS but without major ocular complications of HIV. Standardized measurements of visual acuity, automated perimetry, and contrast sensitivity were analyzed and correlated with measurements of patients' health and medical data relating to HIV infection. We evaluated correlations between vision function testing and HIV-related risk factors and medical testing. RESULTS: There were significant (P<.05) associations between measures of decreasing vision function and indices of increasing disease severity, including Karnofsky score and hemoglobin. A significant relationship was seen between low-contrast sensitivity and decreasing levels of CD4+ T-cell count. Three percent of eyes had a visual acuity worse than 20/40 Snellen equivalents, which was significantly associated with a history of opportunistic infections and low Karnofsky score. When compared with external groups with normal vision, 39% of eyes had abnormal mean deviation on automated perimetry, 33% had abnormal pattern standard deviation, and 12% of eyes had low contrast sensitivity. CONCLUSIONS: This study confirms that visual dysfunction is common in patients with AIDS but without retinitis. The most prevalent visual dysfunction is loss of visual field; nearly 40% of patients have some abnormal visual field. There is an association between general disease severity and less access to care and vision loss. The pathophysiology of this vision loss is unknown but is consistent with retinovascular disease or optic nerve disease.

Contrast sensitivity and color vision in HIV-infected individuals without infectious retinopathy.

PURPOSE: To investigate the relationship between abnormal contrast sensitivity and abnormal color vision among human immunodeficiency virus (HIV)-infected individuals who have normal visual acuity and to seek host factors that predict these abnormalities. DESIGN: Noninterventional, cross-sectional study. METHODS: We evaluated 71 HIV-infected subjects with visual acuity of 20/25 or better, clear media, and no vision-threatening retinal lesions. Visual function was determined using the Pelli-Robson contrast sensitivity test and the Farnsworth-Munsell 100-Hue color test (FM-100). Results were compared with published values for normal populations and to measures of HIV disease severity. We evaluated two levels of impairment for each visual function. "Mild dysfunction" was defined as > or =1 standard deviation (SD), but <2 SD from normal means. "Abnormal" was defined as > or =2 SD from normal means. RESULTS: The prevalences of abnormal contrast sensitivity and abnormal color vision were 7.0% and 9.9%, respectively. We did not identify relationships between impaired contrast sensitivity and impaired color vision. Impaired color vision was associated with increasing age (r = 0.36, P = .002). We could not identify significant correlations between either contrast sensitivity or color vision values and the following factors: current or nadir (lowest previous) CD4+ T-lymphocyte count, HIV blood level, and Karnofsky score. CONCLUSIONS: Abnormal contrast sensitivity and abnormal color vision can occur independently in HIV-infected individuals and can be present in the absence of severe immunosuppression.

Longitudinal cohort study of patients with birdshot chorioretinopathy II: color vision at baseline.

PURPOSE: To describe color vision at the baseline examination of 80 participants in a longitudinal cohort study of birdshot chorioretinopathy and to identify relationships between color vision and visual acuity, symptoms, and ophthalmic signs. DESIGN: Single center cross-sectional study. METHODS: Color vision was evaluated with the desaturated Lanthony 15-Hue test. Relationships were sought between the square root of the color confusion scores (CCS) and the following factors: best-corrected visual acuity (BCVA), symptoms, cataract, vitreous inflammatory reactions, retinal vasculitis, cystoid macular edema (CME), and birdshot lesion characteristics. RESULTS: When compared with published, age-matched normal control subjects, 49 patients (61.3%; 76 eyes [47.5%]) had abnormal CCS values. Abnormal CCS values were found in nine of 51 phakic eyes (18%) with normal BCVA (>or=1.0) and without cataract. Although most eyes did not have classifiable defects, 30 eyes (18.8%) had tritan (blue-yellow) defects (88% of eyes with classifiable defects). With the use of multivariate analyses, there were significant associations between increased CCS values and the symptoms of altered color vision (P = .005) and altered contrast sensitivity (P = .015). There was a significant, but weak, relationship between CCS values and birdshot lesion morphologic condition (P = .049), but no relationships were found with other lesion characteristics or with vitreous inflammatory reactions, retinal vasculitis, or CME. CONCLUSION: The Lanthony 15-Hue test provides an objective technique to assess complaints of altered color vision in people with birdshot chorioretinopathy. Color vision can be abnormal in eyes with normal visual acuity; therefore, this parameter may be useful as an additional measure for monitoring the disease.

Birdshot chorioretinopathy.

Birdshot chorioretinopathy is a well-known, yet poorly understood, form of posterior uveitis, characterized by multiple, distinctive, hypopigmented choroidal lesions, and strongly associated with human leukocyte antigen (HLA)-A29. We reviewed all English language publications regarding birdshot chorioretinopathy and performed analyses of combined patient data taken from these articles. The mean age at presentation was 53 years, with a slight female predominance (54.1%). At least 95.7% of reported patients have been HLA-A29-positive. Blurring of vision and floaters are the most prevalent presenting complaints, even in patients with visual acuity of 20/20 or better in both eyes. Birdshot chorioretinopathy is a slowly progressive disease with profound dysfunction of vision that may not be reflected in Snellen visual acuity. Two or more lines of Snellen visual acuity were lost in approximately 20% of eyes over a median follow-up of 3.5 years; macular edema was the most common cause of reduced visual acuity. Overall, patients had a slow decline in visual acuity, despite the fact that nearly all were treated with anti-inflammatory therapies. Final visual acuity in the better eye was 20/40 or better in 75.1% of patients and 20/200 or worse in 9.8% of patients. Oral corticosteroids and cyclosporine were the most commonly used medications. Using a regression model, patients in the literature that have been treated with cyclosporine alone had better final visual acuity than patients treated with oral corticosteroids alone. Further study is needed to determine the optimal methods for treating and monitoring patients with birdshot chorioretinopathy.

Posterior intracorneal opacities in patients with HIV infection.

PURPOSE: To describe a keratopathy in patients with the human immunodeficiency virus (HIV) infection. METHODS: Retrospective review of ophthalmic and medical records, including laboratory evaluations, of seven patients with HIV infection and posterior intracorneal opacities. RESULTS: Each patient had a bilateral peripheral keratopathy located at the level of the Descemet membrane that was unassociated with intraocular inflammation. All patients were receiving highly active antiretroviral therapy (HAART). All patients had elevations in their CD4+ T-lymphocyte counts due to HAART prior to presenting with the corneal opacities. Five of the seven patients had elevated serum cholesterol, triglycerides, or both. Best-corrected visual acuity was 20/25 or better in six of the seven patients at the time of diagnosis, and vision remained stable through the follow-up period in all patients (median follow-up: 25 months; range: 14-82 months). The corneal opacities remained unchanged in all seven over the follow-up period. CONCLUSION: These patients have a bilateral keratopathy that appears to be non-progressive and has no effect on visual acuity.

Resolution of Coccidioides immitis endophthalmitis with an aggressive surgical and medical therapeutic approach.

INTRODUCTION: Coccidioides immitis endophthalmitis usually results in enucleation, and there is evidence that vitrectomized eyes are more likely to become enucleated. METHODS: A 55-year-old man presented to us with steroid-resistant granulomatous uveitis and was eventually diagnosed with C. immitis endophthalmitis. He was treated with an aggressive medical and surgical approach, receiving a total of 16 intravitreal antifungal injections and three vitrectomies, as well as lensectomy and penetrating keratoplasty. RESULTS: At 13 months after presentation, the patient's eye was free of inflammation, and his best corrected visual acuity was 20/25. DISCUSSION: This is the first reported case of culture-proven C. immitis endophthalmitis with a favorable final outcome. We propose that the good outcome may have been due to our aggressive therapeutic approach.

Association between abnormal contrast sensitivity and mortality among people with acquired immunodeficiency syndrome.

PURPOSE: To investigate the relationship between contrast sensitivity (CS) and mortality among people with acquired immunodeficiency syndrome (AIDS); and to explore the hypothesis that abnormal CS is a marker of systemic, life-threatening microvascular disease. DESIGN: Longitudinal, observational cohort study. METHODS: We evaluated 3395 eyes of 1706 individuals enrolled in the Longitudinal Study of the Complications of AIDS (1998-2008). CS was evaluated as a risk factor for death, and was compared to the presence of systemic diseases characterized by microvasculopathy (diabetes, cardiovascular disease, stroke, renal disease) and to laboratory markers of those diseases. Abnormal CS was defined as logCS <1.5 (lower 2.5th percentile for a normal control population). RESULTS: CS was abnormal in 284 of 1691 (16.8%) study participants at enrollment. There was a positive relationship between the presence of abnormal CS at study entry and mortality (relative risk 2.0, 95% confidence interval 1.7-2.3, P < .0001). Abnormal CS was related to the presence of cardiovascular disease, stroke, and renal disease (all P values

Intraocular inflammation associated with ocular toxoplasmosis: relationships at initial examination.

PURPOSE: To describe characteristics of intraocular inflammation in eyes with active ocular toxoplasmosis and to identify relationships between signs of inflammation, complications (including elevated intraocular pressure [IOP]), other disease features, and host characteristics. DESIGN: Multicenter, retrospective, cross-sectional study. METHODS: We reviewed the medical records of 210 patients with toxoplasmic retinochoroiditis at seven international sites (North America, South America, and Europe) for information from the first examination at each site during which patients had active retinal lesions. Signs of inflammation included anterior chamber (AC) cells and flare and vitreous humor cells and haze. Retinal lesion characteristics included size (< or =1 disc area [DA] or >1 DA) and presence or absence of macular involvement. RESULTS: AC cells and flare were related to vitreous inflammatory reactions (P < or = .041). One or more signs of increased inflammation were related to the following factors: older patient age, larger retinal lesions, and extramacular location. In 30% of involved eyes, there was evidence of elevated IOP (despite use of glaucoma medications by some patients); other complications were uncommon. IOP of more than 21 mm Hg was associated with both increased AC cells and elevated flare (both P < or = .001) and with macular involvement (P = .009). Inflammation seemed to be more severe among patients in Brazil than among those at other sites. CONCLUSIONS: There is substantial variation between patients in the severity of intraocular inflammation associated with ocular toxoplasmosis, attributable to multiple host- and disease-related factors. Results suggest that disease characteristics also vary in different areas of the world. Elevated IOP at initial examination reflects the severity of inflammation.