Ocular lesions in 1,000 consecutive HIV-positive patients in India: a long-term study.

1.1 MB·English

by  Sudharshan, Sridharan

Sudharshanetal.JournalofOpthalmicInflammationandInfection2013,3:2
http://www.joii-journal.com/content/3/1/2
ORIGINAL RESEARCH Open Access
Ocular lesions in 1,000 consecutive HIV-positive
patients in India: a long-term study
Sridharan Sudharshan1*, Sheikh Kaleemunnisha1, Akbar Ashraf Banu1, Sankaran Shrikrishna1, Amala E George1,
B Rajesh Babu1, Bella Devaleenal2, Nagalingeshwaran Kumarasamy2 and Jyotirmay Biswas1
Abstract
Background: Ocular lesions in patients on highly active antiretroviral therapy (HAART) have shown changesin
disease prevalence and pattern.Although they have been described inthe Western population,thereare not many
such studies intheHAART era from India. Thisstudy aims to presentthe clinical profile, systemic correlation, and
visual outcome inHIV-positivepatientsin relation to HAART incomparison withpre-HAART Indian studies and
current Western data. Ocular findings and systemic correlationin 1,000consecutive patients with HIVseen at a
tertiary eye care center were analyzed. Thisstudy uses a prospective observational case series design.
Results: Age range of the patients was 1.5to 75 years. Ocular lesions were seen in 68.5%of the patients
(cytomegalovirus (CMV) retinitis was the commonest).The commonest systemic disease was pulmonary TB. Mean
interval between HIVdiagnosis and onset ofocular lesions was 2.43 years. CD4counts range from 2to 1,110cells/
mm3.Immunerecovery uveitis (IRU) was seen in 17.4%. Interval between HAART initiation and IRUwas 4 months to
2.5years. Recurrence ofocular infection was seen in 2.53%(post-HAART) and >20% (pre-HAART). Overall visual
outcome showed improvement inabout 14.3% and was maintained in71.6% of thepatients.
Conclusions: CMV retinitis is the commonest ocular opportunistic infectionin India, even in theHAART era. Newer
manifestations of known diseases and newer ocular lesions are being seen. Incontrast to Western studies, inour
patients on HAART, ocular lesions do not always behave as in immunocompetent individuals. Ocular TB needs to
be kept in mind in India, as well as other neuro-ophthalmic manifestations related to cryptococci, especially in
gravely ill patients. Occurrence and frequency of various ocular opportunistic infections in developing nations
such as India have significant variations from those reported in Western literature and need to be managed
accordingly.
Keywords: HIV, AIDS, Immune recovery uveitis, CMV retinitis, Ocular lesions, CMV retinitis, Ocular TB
Background especially in developing nations such as India. We studied
OcularlesionsattributabletoHIV[1]areseeninupto2/ the ocular lesions and systemic correlation of 1,000 con-
3rd of the estimated 2.5 million HIV-positive population secutive patients with HIV in India especially with respect
[2]inIndiaatsomepointintheirlifetime. toHAARTincomparisonwithpre-HAARTIndianstudies
Ocular lesions in patients on highly active antiretroviral andcurrentWesterndata.
therapy (HAART) have shown changes in disease preva-
lence and pattern and have been described in the Western Results
population. Ocular lesions associated with AIDS in India One thousand HIV-positive patients were included in
havebeendescribedinthepastduringthepre-HAARTera the study. Their age ranged between 18 months to
[3-9]. There are not many long-term studies on ocular 75 years (median age, 35 years). Male-to-female ratio
lesions of HIV-positive patients in relation to HAART, was 7:3. The most common presenting complaints were
decreased vision and floaters. Overall, ocular lesions at-
*Correspondence:[email protected] tributable to HIV/AIDS were found in 68.5% of the
1MedicalResearchFoundation,18,CollegeRoad,SankaraNethralaya,
patients (Table 1). Interval between diagnosis of HIV
Chennai600006,India
Fulllistofauthorinformationisavailableattheendofthearticle and onset of ocular lesions ranged from 10 days to
©2013Sudharshanetal.;licenseeSpringer.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
Sudharshanetal.JournalofOpthalmicInflammationandInfection2013,3:2 Page2of7
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Table1OcularlesionsduetoHIVinthepre-andpost- Table2Underlyingsystemicdiseaseassociationsin
HAARTera patientswithHIV
Ocularlesions Jabsetal.[10] Biswasetal.[9] Present Systemicdisease Percentage(%)
duetoHIV (pre-HAART) (pre-HAART) study
Pulmonarytuberculosis 38.01
Totalnumberof 781 100 1,000
Extrapulmonarytuberculosis 5
patients
Cryptococcaldisease 6.39
CMVretinitis 37 17 248
Pneumocystispneumonia 2.49
HIVretinopathy 50 15 43
CNStoxoplasmosis 0.66
Opticatrophy 1 1 19
CMVesophagitis 0.22
Ocular - - 26
tuberculosis Anemia 0.44
Active 1 - 28
toxoplasmosis
Herpeszoster 3 1 22 weretreatedwithinductiontherapywithintravenousgan-
ophthalmicus ciclovir(5mg/kgofbodyweightevery12h)alongwithan
Panuveitis - - 2 intravitrealinjectionofganciclovir,inmostcasesfollowed
by maintenance therapy. In our study, two patients with
Fibrinousanterior - - 16
uveitis CMV retinitis on HAART presented with neovasculariza-
Cranialnerve 1 1 5 tion and vitreous and subretinal hemorrhage and were
palsies managedaccordingly.
STBRVO,HCRAO 2 - 3 Ocular toxoplasmosis (Figure 2) was the next most
common ocular opportunistic infection and was seen in
Endophthalmitis - - 7
(Leptospira) 28 patients (4.09%). Most of them were diagnosed based
Colorvision - - 1 on clinical features and supportive anterior chamber tap
defects findings, positive polymerase chain reaction (PCR) or
Pre-septalabscess - - - antibodies for toxoplasmosis. All patients were treated
with combined anti-toxoplasma therapy based on clin-
Orbitalcellulitis 1 - -
icalandserological evidence.
Molluscum - 1 4
contagiosum Ocular tuberculosis (Figure 3) was seen in 26 patients
(3.8% patients), presenting as choroidal tubercles, subret-
SJsyndrome - - 2
(nevirapine) inalabscess,conjunctivaltuberculosis,andpanophthalmi-
tis. All cases had evidence of pulmonary tuberculosis.
ARN - 1 11
Coexistent central nervous system and abdominal tuber-
ARN,acuteretinalnecrosis;CMV,cytomegalovirus;SJsyndrome,Steven-
Johnsonsyndrome. culosisweretheassociations.CD4+cellcountsinpatients
with ocular tuberculosis were between 14 to 560 cells/μl
10.24 years (mean, 2.43 years). CD4 counts range from 2 (mean, 160.85 cells/μl). HIV retinopathy was seen in
to 1,110 cells/mm3 (mean 270.82+213.36, median 6.28% of the patients. Other lesions noted significantly
224.50) at the time of inclusion into the study. Mean were acute retinal necrosis in 1.6%, progressive outer
follow-up was 67 months (range between 1 month and retinal necrosis in (PORN) in 1.17%, syphilis (1.2%),
11 years), and median duration of HIV disease was endophthalmitis (1.02%), fungal corneal ulcer (0.3%),
360days.Morethan65%ofthepatientshadatleast1year
follow-up. About 51.3% of the patients had an underlying Table3Ocularlesionsincorrelationwithsystemic
systemicdisease.Systemictuberculosis,themostcommon disease
opportunistic systemic infection in our study, was seen in Ocularlesions Withsystemic Withoutsystemic
43%,ofwhichpulmonarytuberculosiswasseenin38.01% disease disease
of patients (Table 2). Other systemic diseases included (n(%)) (n(%))
Cryptococcus infection, pneumonia, central nervous sys- CMVR(n=248) 164(66.13) 84(33.87)
tem (CNS) toxoplasmosis, and others. Out of 48.70% HIVretinopathy(n=43) 28(65.12) 15(34.88)
without any underlying systemic disease, 74.74% were
OcularTB(n=26) 17(65.38) 9(34.62)
withoutocularlesions,while25.26%hadocularlesionsat-
Toxoplasmosis(n=28) 17(60.71) 11(39.29)
tributabletoHIV(Table3).
Among patients with ocular lesions, CMV retinitis HZO(n=22) 18(81.82) 4(18.18)
(Figure 1) was the commonest and was seen in 248 Others(n=318) 142(44.85) 176(55.3)
patients (36.2%). All patients with active CMV retinitis CMVR,cytomegalovirusretinitis;HZO,herpeszosterophthalmicus.
Sudharshanetal.JournalofOpthalmicInflammationandInfection2013,3:2 Page3of7
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Figure1Compositecolorfundusphotographsshowingacase
ofactiveandhealedCMVretinitis.Pre-(left)andpost-treatment
(right)withganciclovir.
retinal vessel occlusions (0.44%), and anemic retinopathy
(0.73%).
One hundred three patients (15.04%) had anterior seg-
Figure3Colorfundusphotographshowingacaseofactive
ment, adnexal, and/or ocular surface lesions. CD4 count choroidalgranulomaduetotuberculosis.
range in this subgroup of patients was 19 to 964 cells/
mm3. HZO was the commonest, seen in 21.4% of patients
with anterior segment manifestations (Figure 4). Others Confirmation of the etiological agent was done in se-
includedanterioruveitisin16patients(15.57%),ulcerative lect cases by intraocular fluid evaluation in 8.6% patients
blepharitis, keratitis, conjunctival microvasculopathy, kera- with a 72% yield. Specific ocular medical and surgical
toconjunctivitis, conjunctival squamous cell carcinoma, therapywasadministeredbasedonthediagnosis.
molluscumcontagiosum,episcleritis,Stevens-Johnsonsyn- The commonest combination regimen of HAART was
drome, lid abscess, and herpetic sclerouveitis. Most viral lamivudine, nevirapine, and stavudine in 84% of patients.
anterior segment lesions had higher CD4 counts of >250 Drug combinations were individualized based on re-
cells/mm3. Significantly, 12 patients (13.3%) were not sponse to treatment or development of resistance under
known to be HIV-positive and were diagnosed based on careofanAIDS carephysician.
clinicalsuspicion. When comparing patients on antiretroviral therapy
Neuro-ophthalmic lesions were seen in 61 patients. (ART)andthosenotonARTwithrespecttothediagno-
Optic atrophy, seen in 49.45%, and disk edema, seen in sis of ocular lesions, it was found that 52.2% of patients
21.97%, were the most prominent manifestations. Others were on ARTat the time of ocular lesion diagnosis, 62%
includedoptic neuritis in 14.28%, cranial nerve palsies in of them had CD4<200 while the rest had CD4 counts
9.89%, retrobulbar neuritis in 2.19%, and optic nerve more than 200. While among patients on ARTand with-
head infiltration and cortical blindness in one patient out ocular lesions, 31% had CD4 counts less than 200,
each. Cryptococcus infection was the commonest under- and significantly, in spite of this, no ocular opportunistic
lyinginfectionin66%patients. infectionwasnoted evenduringtheperiodoffollow-up.
Multipleocularopportunisticinfectionsinthesameeye/ There were 47.7% of patients who were not on
patientwereseenintenpatients.Thecommonestcombin- HAART at the time of ocular lesion diagnosis; 69% of
ation was presence of toxoplasmic and cytomegalovirus
retinitis, seen in four patients. Others included ocular TB
and CMVR, and herpetic retinitis and CMVR in two
patients each, and ocular toxoplasmosis with ocular syph-
ilisandocularTBinonepatienteach.
Figure2Compositecolorfundusphotographsshowingacase Figure4Externalphotographshowingherpeszoster
ofactive(left)andhealed(right)toxoplasmicretinochoroiditis. ophthalmicus.
Sudharshanetal.JournalofOpthalmicInflammationandInfection2013,3:2 Page4of7
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them had CD4 counts less than 200. While among Table5Pre-andpost-treatmentvisualacuity:
patients not on ARTand without ocular lesions, 73% of comparisonbetweenvariousgroupsbasedonseverityof
patients understandably had CD4 counts more than 200, visualimpairment
while significantly 27% of them had CD4 counts less Visualacuity Pre-treatment(%) Post-treatment(%)
than 200(Table 4). <6/12 57.0 58.3
Immune recovery uveitis (IRU) was seen in 17.4% of the
6/12to6/60 13.9 13.0
patientsonHAART.IntervalbetweenthestartofHAART
>6/60 29.1 28.8
and onset of IRU was 4 months to 2.5 years, and 52% of
the patients developed IRU when the increase in CD4
counts was between 100 and 150 cells. Seventeen patients
weretreatedwithtopicalsteroidsandcycloplegics,onepa- many long-term large-scale studies based on HIV-
tient was treated with topical and periocular steroid injec- positive population and ocular lesions in India. In our
tion,andfivepatientsweretreatedwithanadditionalshort published series of first 100 patients, 77% of the HIV-
courseoforalsteroidsalongwithtopicalsteroids. positive patients were men in the age group of 20 to
In our series of patients, immune recovery uveitis was 40 years; with national figures ranging from 45.6% to
seen predominantly post-CMVR in 88% of patients, while 74.2% occurring due to heterosexual transmission [9],
IRU post-tuberculous and post-cryptococcal infection was homosexual transmission was only between 5% and 10%
noted in 6% and 2% of patients with IRU, respectively. inIndia.Ourstudyalsorevealedthatocularinvolvement
Whereas in 4% of patients, there was inflammation post- was more common in children who has acquired the
immune recovery; the cause remained undetermined. Re- disease due to perinatal transmission (66.7%) and in
currence of ocular infection was seen in 2.53% (post- homosexualpatients(60%).Ocularinvolvementwascom-
HAART)and>20%(pre-HAART)ofpatients. paratively less common in patients who had contracted
Based on the severity of visual impairment, the patients this disease through blood transfusion (33%) or exposure
were divided into groups with visual acuity better than 6/ toacommercialsexworker(24.3%).
12, between 6/12 and 6/60, and worse than 6/60. Pre- and India alsohasa uniquepopulationofundertreatedHIV
post-treatment (i.e., at presentation and at final follow-up) disease, and they seem to have much lower CD4 counts.
were analyzed (Table 5). At presentation, 57% had visual Surprisingly, the opportunistic infections seem to have
acuitybetterthan6/12,whileatfinalfollow-up58.3%fellin many similarities to the West, with very few differences.
this group; 13.9% had moderate visual impairment, and at Whether long-term exposure to infectious pathogens, or
theend oftreatment,13%wereinthisgroup.Atpresenta- herdimmunity,contributestothetoleranceofIndianeyes
tion, 29.1% had vision poorer than 6/60, and 28.8% toopportunisticinfectionsisdebatable.
belongedtothisgroupatthefinalanalysis.The visualout- The commonest ocular opportunistic infection even in
come among various groups, pre- and post-treatment, is our study was CMV retinitis as reported in Western lit-
giveninTable6. erature [9,10]. The next most common lesion was HIV
Consideringatwo-lineimprovementinSnellen’svisual retinopathy (6.28%), which is much lesser when com-
acuity, overall visual outcome showed improvement in pared to studies in Western countries (50%) [8]. In
about 14.3% and was maintained in 71.6% of patients. India,patientsinfectedwithHIVdonotundergoroutine
While in 14.1% of patients, vision deteriorated due to ophthalmic evaluation. They are often referred for oph-
complications such as retinal detachment, optic atrophy, thalmic examination only if they present with visual
macularscarring,andothers. complaints. This fact may result in the underestimation
of asymptomatic HIV retinopathy or early peripheral
Discussion CMV retinitis. CMV retinitis was seen even in patients
India has a large HIV-positive population when com- on HAART. Patients on regular HAART and with
pared to many other countries. There have not been improved CD4 counts, when treated with systemic and/
or intravitreal ganciclovir therapy, showed complete
Table4Comparisonofpresenceofocularlesionsin resolution of retinitis without the need for maintenance
patientswith/withoutHAARTinrelationtoCD4counts
therapy. More importantly, the number of recurrences
WithART WithoutART was found to be much lesser in such patients, and sys-
Ocularlesions(%) 52.2 47.8 temic ganciclovir therapy could be discontinued after
CD4<200+OI(%) 62 69 resolution of lesions. The progression of retinitis in
patients on HAART, even with low CD4 counts, was
Noocularlesions
lesser in Western studies even though they were
CD4<200(%) 31 27
expected to behave like pre-HAART-era patients. Al-
CD4>200(%) 69 73
though the prognosis was better in most patients on
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Table6Visualoutcomepre-andpost-treatmentinthevariousgroups
VAoutcome Pre-treatment Post-treatment
<6/12 6/12to6/60 >6/60 <6/12 6/12to6/60 >6/60
Improved(%) 12.80 26.30 60.90 80.50 12.80 6.80
Maintained(%) 63.40 10.50 26.10 63.30 10.50 26.20
Worsened(%) 68.90 18.90 12.10 10.60 25.80 63.60
HAARTand ganciclovir, CMVR was also seen to be pre- Shalaby et al. [15] and Kuo et al. [16] have described
senting with neovascularization, vitreous hemorrhage, variouspresentationsofsyphilisinHIV-positivepatients.
and retinal detachment with proliferative vitreoretinal Ocular syphilis was found in 1.2% of patients in our
changes,asisseeninanimmunocompetent state. study. Two of our patients were serologically positive for
In contrast to the study by Jabs et al. [11], in our syphilis and then were diagnosed to be HIV-positive;
study, we found that the progression of retinitis leading suspicion was based on suggestive eye findings and posi-
to complications was significantly more in patients with tive syphilis serology [17]. Both of these patients were
lower CD4 counts in spite of regular HAART. In an treated with systemicpenicillin alongwith HAART.
earlier publication from the same center, low CD4 Retinal vessel occlusions have been described in
counts were commonly associated with drug resistance. patients with HIV infection [10,17,18]. In our study, we
Forty six percent ofthe patients experiencedclinicalfail- had two patients (two eyes) with superior temporal
ure and developed a new WHO-defined opportunistic branch retinal vein occlusion and one patient with CMV
infection [12]. We hypothesize that this could be an im- retinitis and hemi-central retinal vessel occlusion, all of
portant contributing factor for low CD4 counts in spite whom respondedwell toanti-CMV treatment.
ofHAARTeven inourstudy. Steven-JohnsonsyndromeinHIV-positivepatientstrea-
Involvement of the second eye and the occurrence of ted with nevirapine has been reported [19] and was seen
retinal detachment in patients who were on regular in our series of patients too. Cryptococcal ocular involve-
HAART have been studied by Jabs et al. [13]. Signifi- ment secondary to intracranial involvement manifesting
cantly, 88% of the patients with unilateral disease who as papilledema [20,21], optic atrophy, and ophthalmople-
were on regular HAART did not have involvement of gias was noted. Though CMVR was the commonest ocu-
theothereye throughoutthedurationofthefollow-up. lar opportunistic infection even in patients on HAART,
Importantly, a CD4 count limit of 200 had a better cryptococcal infection and related complications were
clinical correlation with HAART and the occurrence of morecommoningravelyillpatients.
ocular lesions, with lesions seen in a larger number of In 72% of patients on whom aqueous tap was done, a
patients not on HAART and with low CD4 counts. confirmed clinical diagnosis could be made based on
Interestingly, 27% of the patients were not on HAART aqueous fluid analysis by PCR and/or antibody titers.
and had persistently low CD4 counts for more than The usefulness of AC tap for PCR and antibody produc-
6 months and did not develop any ocular lesion attribut- tion has been studied by several authors [22,23]. Though
abletoHIV. AIDS-related lymphomas have been reported to have a
In the Indian scenario [14], although systemic TB is better prognosis in the HAART era [24], one patient
the commonest underlying systemic infection, ocular TB with non-Hodgkin’s lymphoma in our study developed
is relatively rare. Ocular TB is found in all CD4 count hard palate necrosis and orbital cellulitis with complete
ranges,andasymptomaticchoroidal tubercles areamong loss of vision.
the commonest manifestations of ocular TB in AIDS. IRU [25-29] has been extensively studied, and we
Resolution of systemic and ocular TB with antitubercu- have seen it in 17.4% of patients on HAART.
losis treatment (ATT) is not always concurrent. PCR Nguyen et al. [27] have studied the incidence of im-
and HPE methods have been helpful in diagnosis. Clin- mune recovery uveitis in 33 patients with CMV ret-
ical profile with histopathological and microbiological initis, and they found six patients with immune
correlation of ocular tuberculosis in patients with AIDS recovery uveitis. The incidence rate of immune re-
hasbeen reported. covery uveitis was 0.109/person-year in their study.
Herpetic viral retinitis in our patients on HAART pre- Kempenetal. [28] concluded thatpatientswithIRU have
sented with significant inflammatory reactions, more in a higher risk of additional morbidity over and above that
the form of acute retinal necrosis (ARN) than the clas- seen in patients with CMV retinitis.Similar findings were
sical description of PORN in immunosuppressed indivi- notedinourseriesofpatients.Immunerecoverystatehad
duals. There were 11 patients with ARN in our study, led to differences in the way the ocular lesions presented
muchhigherthanthose inthepre-HAARTera. alongwithdrug-inducedreactions.
Sudharshanetal.JournalofOpthalmicInflammationandInfection2013,3:2 Page6of7
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Conclusions diagnosed with HIV infection who were either referred
CMV retinitis is still the leading cause of ocular oppor- to the institute for evaluation of their visual complaints
tunistic infection in India, and ocular toxoplasmosis is or with low CD4 counts/advanced systemic disease were
the second commonest. Although HAART reduced the included. Patients with a minimal follow-up of 3 months
riskofOIs,newermanifestationsofknowndiseasessuch and/orwithatleasttwofollow-upvisitstoboththeoph-
as in CMVand neovascularization or retinal detachment thalmic clinic and the AIDS care center were the inclu-
and newer ocular lesions such as drug-related reactions sion criteria. Other patients presenting to our clinic who
are being seen in patients on HAART. Ocular opportun- were not originally known to be HIV-positive and were
istic infections may present with significant inflamma- subsequently tested for and diagnosed to be HIV-
tory reaction in patients on HAART. Ocular TB is positive because of suspicious ocular lesions were also
common in India although not proportional to systemic included. Complete ophthalmic evaluation findings in-
TB in the Indian HIV-positive population. Paradoxical cluding thorough history, best corrected visual acuity,
worsening post-TB infection is also noted in patients on external eye examination, clinical features, and fundus
HAARTandATT. evaluation by indirect ophthalmoscopy were analyzed.
Even in comparison with the previous study in India Fundus fluorescein angiography, ultrasound examin-
[9], other opportunistic infections such as ocular toxo- ation, ultrasound biomicroscopy, and other ancillary
plasmosis, ocular tuberculosis, and HZO were found in investigations such as electroretinogram and optical co-
large numbers in the present study. It could perhaps be herence tomography were obtained in all cases wherever
due to the increased awareness and referral by physi- necessary. All these patients had a thorough systemic
cians in India. This also indicates the need for regular evaluation at an AIDS care and research center in the
ophthalmic evaluation of all patients with HIV/AIDS ir- city. All patients in our series were screened for asso-
respective of CD4 counts as ocular lesions are noted in ciated opportunistic systemic infections such as tubercu-
spiteofHAART. losis, syphilis, toxoplasmosis, cryptococcal infection, etc.
Treatment options need to be modified based on local along with routine blood investigations. Information was
needs and resource constraint settingssuchas the use of recorded in a precoded proforma. CD4+ and CD8+
intravitreal ganciclovir. In contrast to Western studies, countswere obtainedinallcases atthe time ofinclusion
in our patients on HAART, ocular lesions do not always into the study. The antiretroviral drugs used for the
behaved as in immunocompetent individuals. Ocular TB treatmentofAIDSand theireffectonthe disease andon
needs to be kept in mind in India, as well as other the eye were also analyzed. Lab investigations related to
neuro-ophthalmic manifestations related to cryptococci, ocular and systemic findings were also analyzed in
especially in gravely ill patients. Interestingly in India, detail.
even with incomplete or irregular HAART, the occur-
Studydesign
rence of opportunistic infections did not vary much
A prospective observational case series design was used
when compared tomanyotherWestern studies.
inthisstudy.
Early recognition and treatment of vision-threatening
ocularopportunisticinfectionandIRUcanleadtomain- Consent
tenance/improvement of visual acuity in most patients. Institutional review board and ethics committee ap-
Importantly, our study included patients spanning the proval andpatients’consent wasobtained.
pre- and post-HAART era with a regular ocular and sys-
Competinginterests
temic follow-up using a standard protocol at both the
Noneoftheauthorshaveanycompetinginterestswiththestudy.
tertiary care eye center and the AIDS care center. Al-
though there are a few limitations as in any long- Authors’contributions
NK,JB–overviewofthestudyandclinicalmanagementofpatients.
duration study due to changes in the disease pattern,
SS–overview,concept,planning,execution,analysis,manuscriptandclinical
which have also been studied, our study has shown that managementofpatientsandcoordination.KS,SK,AB–Datacollectionand
the occurrence and frequency of various ocular oppor- entryandanalysis.BD,AEG–clinicalmanagementofpatientsandinputs.
RB,–clinicalmanagement,execution.
tunistic infections in developing nations such as India
has significant variations from those reported in West- Authors’information
ernliteratureandneed tobemanagedaccordingly. Noneoftheauthorshaveanyfinancialinterestsinthestudy.
Acknowledgement
Methods
Noothercontributors.Noexternalfundingnoranylanguageeditor’shelp
The first 1,000 consecutive patients found to be HIV- wasobtained.
positive who were seen in the outpatient department of
Authordetails
a tertiary eye care institute in India between December
1MedicalResearchFoundation,18,CollegeRoad,SankaraNethralaya,
1993 and June 2010 were analyzed. All patients Chennai600006,India.2YRGCareCentreforHIV/AIDS,Chennai600113,India.
Sudharshanetal.JournalofOpthalmicInflammationandInfection2013,3:2 Page7of7
http://www.joii-journal.com/content/3/1/2
Received:11September2012Accepted:12September2012 22. GeorgeAE,BiswasJ,AgarwalR,KumarasamyN,SolomonS(1999)
Published:3January2013 SubretinalcysticercosisinanAIDSpatient:treatmentwithXenonarc
photocoagulation.Retina19:467–468
23. deBoerJH,VerhagenC,BruinenbergM(1996)Serologicandpolymerase
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