Bilateral ischemic maculopathy in acquired immune deficiency syndrome

Abstract

BackgroundThis brief report aims to report a case of bilateral macular ischemia as a cause of sudden decreased vision in a patient with acquired immune deficiency syndrome (AIDS).FindingsA 26-year-old male with disseminated cryptococcal meningitis, Candida thrush, Pneumocystis jiroveci pneumonia, and positive human immunodeficiency virus (HIV) infection with CD4 count of 4 cells/μl complained of sudden blurred vision in both eyes while on treatment with systemic antiviral, antifungal, and antibiotic medications. Ocular examination revealed HIV retinopathy changes with significant macular ischemia in both eyes, which was confirmed by fluorescein angiography. One dose of intravitreal foscarnet (1.2 mg/0.1 cc) was injected in both eyes. Laboratory work-up of serum and vitreous samples showed negative cytomegalovirus (CMV) titers. At 2 weeks of follow-up, he was started on treatment with atripla, a combination anti-retroviral therapy for AIDS. At 6 weeks of follow-up, there was an improvement in visual acuity and clinical findings.ConclusionsNoninfectious HIV retinopathy in AIDS is common, but bilateral macular ischemia is a rare presentation. It is important to rule out CMV retinitis as it is a major cause of visual morbidity among AIDS patients.

Unilateral ischemic maculopathy associated with cytomegalovirus retinitis in patients with AIDS: Optical coherence tomography findings

“…In addition, CMV plays a role in the pathogenesis of ischemic maculopathy. [ 7 8 ] Although our patients were immunosuppressed, were not on HAART and had concurrent CMV retinitis (which by itself may involve the macula or cause optic neuritis), there were no sign of macular involvement due to CMV.…”

“…However, most reported cases are bilateral cases. [ 6 7 ] Opacification of the superficial retina in the macular area and intraretinal edema suggested the diagnosis. Fluorescein angiography changes were similar in the two cases with enlargement of the foveal avascular zone and late staining of juxtafoveal vessels.…”

Peripheral Retinal Neovascularization with Vitreous Hemorrhage in HIV Retinopathy

“…Previous studies have suggested that immune complex deposition, HIV infection of retinal endothelial cells, or other hematologic factors may lead to HIV microvasculopathy [ 8 , 10 ], which can in turn lead to focal capillary closure, axoplasmic stasis, and nerve fiber layer ischemia. Therefore, although cotton wool spots and intraretinal hemorrhages are more commonly associated with HIV retinopathy, peripheral retinal ischemia in the setting of HIV/AIDS is certainly possible from a pathophysiology point of view, especially given that macular ischemia is a known entity among HIV/AIDS patients [ 11 , 12 , 13 , 14 ].…”