HIV-associated retinopathy in the HAART era.
BACKGROUND
The effectiveness of highly active antiretroviral therapy (HAART) in restoring immune function in patients with acquired immunodeficiency syndrome (AIDS) has led to changes in the incidence, natural history, management, and sequelae of human immunodeficiency virus (HIV)-associated retinopathies, especially cytomegalovirus (CMV) retinitis.


METHODS
The medical literature pertaining to HIV-associated retinopathies was reviewed with special attention to the differences in incidence, management strategies, and complications of these conditions in the eras both before and after the widespread use of HAART.


RESULTS
In the pre-HAART era, CMV retinitis was the most common HIV-associated retinopathy, occurring in 20%-40% of patients. Median time to progression was 47 to 104 days, mean survival after diagnosis was 6 to 10 months, and indefinite intravenous maintenance therapy was mandatory. Retinal detachment occurred in 24%-50% of patients annually. Herpetic retinopathy and toxoplasmosis retinochoroiditis occurred in 1%-3% of patients and Pneumocystis carinii choroiditis, syphilitic retinitis, tuberculous choroiditis, cryptococcal choroiditis, and intraocular lymphoma occurred infrequently. In the HAART era the incidence of CMV retinitis has declined 80% and survival after diagnosis has increased to over 1 year. Immune recovery in patients on HAART has allowed safe discontinuation of maintenance therapy in patients with regressed CMV retinitis and other HIV-associated retinopathies. Immune recovery uveitis (IRU) is a HAART dependent inflammatory response that may occur in up to 63% of patients with regressed CMV retinitis and elevated CD4 counts and is associated with vision loss from epiretinal membrane, cataract, and cystoid macular edema.


CONCLUSIONS
The incidence, visual morbidity, and mortality of CMV retinitis and other HIV-associated retinopathies have decreased in the era of HAART and lifelong maintenance therapy may safely be discontinued in patients with restored immune function. Patients with regressed CMV retinitis, however, may still lose vision from epiretinal membrane, cystoid macular edema, and cataract secondary to IRU.
Goldberg
Daniel E
DE
Vitreous, Retina, Macula Consultants of New York, LuEsther T. Mertz Retinal Research Laboratory, Manhattan Eye, Ear and Throat Hospital, New York, New York 10022, USA. dgoldberg@vrmny.com
Smithen
Lindsay M
LM
Angelilli
Allison
A
Freeman
William R
WR
D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000276:immunology; D019380:Anti-HIV Agents / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active; D015828:Eye Infections, Viral / Q000188:drug therapy / Q000453:epidemiology* / Q000276:immunology; D006801:Humans; D007107:Immune System / Q000502:physiology; D015994:Incidence; D012164:Retinal Diseases / Q000188:drug therapy / Q000453:epidemiology* / Q000276:immunology; D015996:Survival Rate; D014605:Uveitis / Q000276:immunology; D014792:Visual Acuity
D019380:Anti-HIV Agents