陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 3熏晕燥援 4袁 Dec.18, 圆园10 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-83085628 耘皂葬蚤造押陨允韵援圆园园园岳员远猿援糟燥皂 窑ClinicalResearch窑 Clinicalspectrumof15patientswithHIV-related ocularinvolvementinTehran
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1DepartmentofOphthalmology,EyeResearchCenter,Farabi andneurophthalmiclesionsarethemostcommonHIV-related Hospital,TehranUniversityofMedicalSciences,Tehran,Iran ocularinvolvementsinTehranthatisdifferentfromthoseof 2 StudentofMD/MPH,TehranUniversityofMedicalSciences, recentpublicationsindevelopedcountries. Tehran,Iran ·KEYWORDS:HIV;ocularinvolvement;highlyactiveanti- 3 DepartmentofInfectiousdiseases,IranianResearchCenterfor retroviraltherapy HIV/AIDS,TehranUniversityofMedicalSciences,Tehran,Iran DOI:10.3980/j.issn.2222-3959.2010.04.13 Correspondenceto: MohammadTaherRajabi.Departmentof Ophthalmology,EyeResearchCenter,FarabiHospital,Tehran AbdollahiA,Heidari-BateniG,ZareiR,KheirandishP,Malekmadani UniversityofMedicalSciences,Tehran,Iran.mt_rajabi@yahoo. M,MohrazM,AbdollahiM,RajabiMT.Clinicalspectrumof15 com patientswithHIV-relatedocularinvolvementinTehran. Received:2010-11-08Accepted:2010-11-30 2010;3(4):331-336
Abstract INTRODUCTION · AIM:TodeterminethefrequencyofHIV-relatedocular irstdescriptionofHIV-relatedocularinvolvementwas involvementandtodescribethecharacteristicsof F reportedmorethantwoandahalfdecadeago.Inthe involvementinaspecialclinicinTehran. earlyepidemicofAIDS,presenceofcotton-woolspotswas ·METHODS:Inthiscrosssectionalstudy,141patients(125 themostcommonophthalmicfindinginAIDSpatients. Sincethen,precisedescriptionofdifferentformofocular maleand16female,282eyes)ofHIV-infectedpatientswith involvementinHIV-infectedpatientswasmadesothat variousstagesofHIVinfectionthatwerereferredtoCenterof behavioraldiseaseswereevaluatedduringaperiodof7 nowadays,diagnosticcriteriaformanyformofocular months.Everypatienthadacompleteprofileincluding diseaseinHIVinfectedpatientshavebeenproduced. demographicdata,methodofHIVtransmission,recentCD4T SurveysonocularinvolvementofHIVwereconductedin celllymphocytecount,serologicalstudiesforcommonsexual fewstudiesaroundthedevelopingworld.Puttingthesedata orblood-bornvirusesandtoxoplasmosis,historyof togetherwiththoseofdevelopedcountriesrevealsthatthe antiretroviraltherapy,andassociatedsystemicdisease. spectrumofHIVandAIDS-relatedoculardiseasesis [1] · RESULTS:Atotalof141patientswereevaluated. differentinvariouspartsoftheworld .Forexample, CytomegalovirusRetinitisisthemostcommoncauseof HIV-relatedocularinvolvementwasdetectedin15patients retinitisinHIV-infectedpatientsin developedworld (10.6%),including3mycobacteriumtuberculosis-related choroiditis,2cytomegalovirusretinitis,2retinaltoxoplas- althoughitseemslessprevalentindevelopingcountries. mosis,2herpessimplexvirus-relatedlesions,1HIV- Ontheotherhand,aftertheintroductionofhighlyactive associatedretinopathy,1herpeszosterophthalmicus,1 anti-Retroviraltherapy (HAART),whichbecamewidely undeterminedvitritis,and3casesofcranial nerve availablein1996,clinicalfeaturesofocularinvolvement involvementincluding2casesofgazepalsyand1caseof associatedwithHIVinfectionhavebeenchangedand papilitis.Inourstudy,meanCD4Tcelllymphocytecountwas frequencyofocularinvolvement,whichaffects70to80 fewerinpatientswithocularinvolvementthaninpatients percentofallHIVinfectedpatientsatsomepointduring withoutocularinvolvement(204.7 123.8 403.7 339.7, = theirillness,decreaseddramatically.Basedonthereported 依 依 0.029),buttherewasnodifferenceinotherpossible data,theHIVepidemicinIranappearstobeacceleratingat associatedfactorsbetweentwogroups. analarmingtrend [2].Accordingtothelatestdata,about ·CONCLUSION:Mycobacteriumtuberculosis-relatedchoroiditis 66000(36000-160000)peoplearelivingwithHIVinIran, 331 HIV-relatedocularinvolvementinTehran thustheprevalencerateisabout0.2% [0.1-0.4]among SPSSversion13.Statisticalsignificancewasdeterminedby adultsaged15to49[2]. analysisandStudent's testforcategoricalandnumerical RecentattentiontoHIVepidemiologyandprogramsforcase variables,respectively. detectionandsupportivecareinIranmakeitpossibletofind RESULTS outthepatternofocularinvolvementinthisdeveloping Systemic Findings Duringthestudyperiod,141 countryintheeraofhighlyactiveantiretroviraltherapy.This HIV-infectedpatientunderwent completeophthalmic crosssectionalstudywasconductedasapartofalarger examination.Themeanage standarddeviationofpatients 依 consultingandsupportiveprogramforbehavioraldiseases, was37 9yearsandnoneofthemwasagedmorethan55 依 whichwasholdinginImamKhomeinihospitalandaimedto years.Fromthoseparticipatedinthestudy,125patientswere determinethefrequencyofocularinvolvementandto male(88.7%)and16werefemale(11.3%).Themeantime describethecharacteristicsofinvolvementsinIranian betweenophthalmic examination andHIV antibody patientswithvariousstagesofHIVinfectionreferredto detectionbyWesternblottingwas4yearsand2months centerofbehavioraldiseasesinTehran. (range:2months-16years).Twelvepatientshadactiveora MATERIALSANDMETHODS recenthistoryofpulmonarytuberculosisand52.4%of Materials DuringJun.2006toDec.2006,anycase patientshadcoinfectionwithhepatitisCvirus.Table1lists attendedtothecenterforroutineappointments,aftergiving theclinicalcharacteristicsofpatients. aninformedconsent,wasconsequentlyincludedinthe Fromallpatients,46.2%weretakinghighlyactive study.Participantswerecommittedtoattendintheeye antiretroviraltherapy(HAART)atthetimeofocular examinationprogram,whichwasheldeveryweekintheeye examinationandnoneofthepatientshaddocumentationfor clinicestablishedinthecenter.Forallofthesepatients, takingbutdiscontinuingHAARTatanytimeinthepast.At diagnosisofHIVseropositivityhadbeenprovedbya thetimeoftheeyeexamination,25ofHIV-positives positiveenzymelinkedimmunosorbentassay(ELISA)anda (17.7%)hadCD4Tlymphocytecountoffewerthan positiveimmunoblotting(Westernblot)testforHIV.All 200cells/mm3 andeightpatientshadCD4TLymphocyte patientshadamedicalrecordincludingdemographicdata, countoffewerthan100cells/mm3. methodofHIVtransmission,historyofdrugtherapy,past Accordingtothe1993CentersforDiseaseControland medicalhistoryandresultsofsystemicexaminationsfor PreventioncasesurveillancedefinitionofAIDS,39patients signsofopportunisticoranyothersystemicdisease,which wereinAIDSphase(27.6%). wascompletedineveryappointmentbyaninfectiousdisease OcularInvolvement Blurredvision(lowvision)wasthe specialist.Inaddition,serumanalysisforhepatitisCvirus commonestcomplainamongHIV-infectedpatientsandwas antibody,hepatitisBsurfaceantigen,toxoplasmaantibody seenin106eyes(37.6%).Infifteeneyeswithblurredvision, andnecessarylaboratorydataincludinghematologyand thiscomplaintconsideredtobeduetoHIV-relatedeye lymphocytesubsetanalysiswereincluded. involvement (Table2).However,refractiveerrorwasthe Methods Patientsareseenroutinelyevery3monthsandat mostcommoncauseoflowvision(84.9%).Onlyoneofthe othertimesiftheyareill.Afterobtainingthemedicalrecord, patientswithlowvisionhadcataract.Afteracompleteeye every patient underwentacompleteophthalmologic examination,ocularinvolvement,regardlessofcataractand examinationintheeyeexaminationclinic.Registeringof refractiveerrors,wasfoundin18patients(28eyes).Cellsin visualcomplainswasperformedbyatrainedeyenurseand ACandVitreousandmultiplelesionsofchoroiditiswerethe visualacuitywascheckedwithanEchartbyanoptometrist. mostcommoninvolvements(Table3).Ocularinvolvement Thenpupilsweredilatedwith10g/LTropicamideand in15patients(10.6%)wasHIV-related. 20-50g/L Phenylephrine.Twoexpertophthalmologists Oculartuberculosis(TB)wasdiagnosedin7.7%ofpatients examinedtheexternaleyeandanteriorsegmentwithaslit inAIDSphaseand2.1%amongHIV-infectedpatientsinour lamp,andthen examinedtheretinabyindirect study.Threeof12patientswithrecentorhistoryofprevious ophthalmoscopy. When there wasan ophthalmic TBreactivationhadTBocularinvolvement.Allofthemhad involvement,thepatientwasreferredtoFarabiEyeHospital CD4T-cellcountoffewerthan200cells/mm3.Oneofthem asatertiarycenterandcomplementarydiagnosticworkup wasa48year-oldmanonHAARTwithprevioushistoryof wasperformedthere.Thefrequencyanddescriptionof activeTBinfectionwhowasunderisoniazidprophylaxisand ocularinvolvementsandcomparisonofassociatedfactors withaCD4countof150cells/mm3.Theotheronewasa26 betweenpatientswitheyeinvolvementandthosewithout year-oldmanwithactiveTBinfectionwhowasonanti-TB involvementwereinvestigatedinthisstudy. treatmentregimen.HisCD4countwas123cells/mm3.The StatisticalAnalysis Analysiswasperformedbysoftware lastpatientwasa37year-oldmanwithactiveTBinfection 332 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 3熏晕燥援 4袁 Dec.18, 圆园10 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-83085628 耘皂葬蚤造押陨允韵援圆园园园岳员远猿援糟燥皂
Table 1 Clinical and demographic characteristics of HIV-positive patients Variable With eye involvement1 Without eye involvement Total Number of patients 15 (10.6%) 126 (89.4%) 141 (100%) Mean age 34.5±9.0 37.0±8.7 36.7±8.8 Presence of a systemic infection 25.0% 13.6% 14.9% IV drug use 56.2% 50.4% 51.1% HBS antigen positive 6.2% 6.4% 6.4% HCV antibody positive 68.8% 50.4% 52.4% Toxoplasma seropositivite 31.2% 23.2% 27.2% HAART 50.0% 44% 44.7% Mean CD4 T cell count 204.7±123.8a 403.7±339.7 a 369.1±322.8 Mean Refraction Right eye -0.35±1.02 -0.26 ±1.73 -0.27±1.65 Left eye -0.39±1.09 -0.26 ±1.09 -0.28 ±1.08 1Patients with only ocular symptoms but no ophthalmic sign were categorized in patients without eye involvement. Patients with diagnosis of blepharitis, glaucoma and refractive errors were also excluded from those with eye involvement. aP = 0.029.
Table 2 Frequency of ocular symptoms in 282 eyes of HIV+ patients Symptoms Right Left Total Redness 3 2 5 Pain 3 1 4 Blurred vision 55 53 106 Scotoma 3 2 5 Diplopia1 2 Purulent discharge 5 5 10 Burning sensation 3 2 5 Photopsia 2 1 3 1 Two persons suffered from diplopia
Table 3 Frequency of ocular involvements and final diagnosis in 141 HIV-infected patients Type of lesion Right Left Final diagnosis Cotton wool spots 1 1 HIV related Retinopathy (n=1) Area of full thickness retinal necrosis 2 1 Retinal detachment 1 0 Dendritic scars on cornea 1 0 Undetermined vitritis (n=1) disciform keratitis and necrotizing stromal keratitis 0 1 TB choroiditis (n=3) CMV retinitis (n=2) Multiple or focal lesions of choroiditis 3 3 chorioretinal toxoplasmosis (n=2) Superficial retinal necrosis 1 1 herpes keratitis (n=2) Intraretinal hemorrhage 2 1 AC and/or vitreous inflamation 5 5 Horizontal gaze paresis 2 1 Horizontal Ophthalmoplegy (n=2)1 Vertical gaze paresis 0 1 Vertical Ophthalmoplegy (n=1) Papilitis 1 0 Undetermined papilitis (n=1)2 Periocular vesicular lesions 1 0 Herpes Zoster Ophthalmicus infection (n=1) Inflammation of eyelids 2 2 blepharitis (n=2) Elevated cup to disc ration 1 2 Possible cases of glaucoma (n=2) 1 One patient had horizontal ophthalmoplegy in right eye and vertical in the contralateral eye. 2 With elevated cup to disk ratio in the contralateral eye andCD4countof100cells/mm3. CMVretinitiswasdiagnosedinonlytwopatientsandthree Visualacuitywassparedinthelattertwopatientsbutthe eyes(pointprevalenceof1.4%amongHIV-infected firstonehadvisualacuityofcountingfingersinbotheye. patients).ConsideringpatientsinAIDSphase,CMVretinitis
333 HIV-relatedocularinvolvementinTehran wereseenin5.1%ofthem.Oneofthemwasa36year-old earlystagesofHIVinfectionandpresentedwithdiseases womanwith areaoffullthicknessretinalnecrosis, suchaspneumococcalpneumonia,invasivesalmonella,and intraretinalhemorrhageandsignsofretinaldetachmentin tuberculosis. herrighteye.HereCD4countwas105cells/mm3.Shehad ThespectrumofHIVocularinvolvementseemstobe signofblepharitisonherlefteye. dependenttotheburdenofdiseaseandthereforein Theotherwasa33-year-oldmanwithaCD4countof developingcountries,itispotentiallydifferentfromthosein 110cells/mm3 withthesamelesionsinbotheyes.Both developedones.Thisalteredpatternwasinvestigatedinfew patientshadareducedvisualacuityintheaffectedeyes. studiesallofthemconductedbeforeHAARTera.This Chorioretinaltoxoplasmosiswasdiagnosedintwopatients, alteredspectrumofocularinvolvementinHIV-infected withcomplaintsofphotopsiaandscotomoasandblurred patientsindevelopingcountriesisnotonlyrelatedtothe vision.BothpatientshadpositiveserumimmunoglobulinG higherfrequenciesofexposuretocausativeinfectiousagents levelsto .Twocasesofherpeticlesions butalsotothehigherratesofdeathearlyinthecourseof (acaseofherpetickeratitisandacaseofstromalcorneal disease.Inourstudy,overall44.7%ofpatientswereon herpes)acaseofundeterminedvitritisandanHIV-infected HAARTregimen.Somethingthatiscomparabletorecent patientwithherpeszosterophthalmicuswerealsofound. ocularsurveysonHIV-infectedpatientsaroundtheworld.In BothpatientswithherpaticlesionswereinAIDSphase thereportofenrollmentdatafromTheLongitudinalStudyof (5.1%ofAIDSpatients).HIV-relatedretinopathywas theOcularComplicationsofAIDS(LSOCA),77.9%of diagnosedinbotheyesofonlyonepatient. patientswereunderHAARTalthoughallofthemwerein Neurophthalmicinvolvementwasprimarilydiagnosedin AIDSphase.Itisnecessarytoemphasizethatourstudywas threepatients.Thereweretwocaseswithgazepalsies.One conductedonpatientsinallstagesofdiseaseandonly27.6% ofthemwasa25yearsmanwithrighteyehorizontalgaze ofourpatientswereinAIDSphase.Themostcommon palsywithaCD4countof534cells/mm3.Theotherperson ocularsymptominourstudywasblurredvisionandthiswas wasa34yearsmanwithahorizontalgazepalsyofrighteye compatiblewithpreHAARTresultindevelopingcountries. andaverticalgazepalsyofthecontralateraleye.Hehada InastudyinUgandamainreasonforlowvisionwas visualacuityof2/10intherighteyeand1/10intheleft.He cataract,butinourstudyrefractiveerrorwasthemost wasonHAARTwithaCD4countof326cells/mm3. commonunderlyingetiology. Opticnervepapilitiswasprimarilydiagnosedina34-year Noneofourpatientswasmorethan55yearsoldandcataract manwithCD4countof218cells/mm3,unfortunately wasnotacommonfindinginourstudy.Themostcommon complementaryworkupwasnotachievedinthepatientdue ocularinvolvementinourserieswasTBchoroiditis.Today, todiscontinuationofconsultingfromthesideofpatient. tuberculosisisthemostcommonopportunisticinfection Analysisofdatabetweenpatientswitheyeinvolvementand amongHIV-infectedpatientsinIran[3].Nowadays,intheera thosewithoutinvolvement(regardlessofpresenceor ofglobalHIVepidemics,theincidenceofocular absenceofocularsymptom)showedthatinpatientswith tuberculosishasincreasedaspartofthetotalincreaseinthe ocularinvolvementthemean standarddeviationofCD4 numberofpatientswithextrapulmonarytuberculosis.Allof 依 positiveTcellswere204.7 123.8cells/mm3.Thiswassig- ourocularTBcaseshaddocumentationofongoingor 依 nificantlyfewerthanthosewithoutocularinvolvementin previousactiveTBintheirmedicalrecordsandCD4T whichmean standarddeviationcountofCD4Tcellswere lymphocytecountofallthree,werefewerthan200cells/ L. 依 滋 403.7 339.7cells/mm3( =0.029).Noassociationwerefound Accordingtotheliterature,ocularinvolvementinTBcan 依 betweenocularinvolvementandvariablessuchasmeanage, presentinmanydifferentways,includingchoroiditisand methodofHIVtransmission,proportionofseropositive anterioruveitis(themostcommonpresentations),choroidal patientsforHBSantigen,HCVantibodyandToxoplasma tubercles,papillitis,retinitis,vitritis,scleritis,keratitis, antibody. dacryoadenitisandalidmass. DISCUSSION Theclinicalfeatureinourpatientswasbilaterallymultiple Ourstudywasconductedtofindoutthefrequencyofocular lesionsofchoroiditisintwopatientsandtwofocalsitesof involvementinadevelopingcountry. Basedonour choroiditisintheotherpatient.Mildtomoderatecellsand observation,10.6%ofHIV-infectedpatientshadocular flaresinbothACandvitreouswerealsoseen. involvement,whichwasHIV-relatedandmycobacterium Twoof141patientsinourstudywerefoundtohaveCMV tuberculosiswasthemostcommoncausativeagent.Data retinitis.AlthoughCMVretinitiswasthemostcommon investigatingburdenofHIVdiseaseinAsiabeforeHAART causeofretinitisintheliteraturebeforetheHAARTera, showedthatHIV-infectedpatientsinAsiaweremostlyin studiesfromdevelopingcountriesshowedthatinthese 334 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 3熏晕燥援 4袁 Dec.18, 圆园10 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-83085628 耘皂葬蚤造押陨允韵援圆园园园岳员远猿援糟燥皂 countriesCMVretinitisisnotascommonasdeveloped inourresults.Becausewedidnotknowwhetherthisfinding worldwithaprevalenceof0-8.5%.IntroductionofHAART wasbecauseofHIVinducedimmunocompromisationora ledtoanestimated80%decreaseintheincidenceofCMV randomlyassociatedfindingsinthesepatients,particularly retinitis[4]. those withblepharitishadCD4countofmorethan Ignoringthemildreductionintheseverityofdisease,It 500cells/ Linourstudy. 滋 seemsthatintroductionofHAARTdoesnotchangethe ThefrequencyofblepharitisinIraniansocietyisnotknown basicclinicalfeaturesofCMVretinitis[5,6].Inourstudy,both soitdidnotmakesenseforusifweincludedblepharitisas patientshadthebasicclinicalcharacteristicsofCMV oneofHIV-relatedlesionsinthestudy,althoughithas retinitis.However,noneofthemhadCD4Tlymphocyte mentionedinliterature.EvidencenumberofVZVorHSV countoflessthan50cells/ L.LowfrequencyofCMV keratitiswereconsiderableinourseriesandtherewasacase 滋 retinitisinourstudywascompatiblewithprevioussurveysin ofherpeszosterophthalmicus(HZO).HZOcanbe developingcountries.ConsideringthefactthatCMVretinitis associatedwithconjunctivalinjection,epithelialkeratitis, mostlyoccursinthoseHIV-infectedindividualswithsevere stromalkeratitis,scleritisorepiscleritisandinflammationof levelsofimmunodeficiency,asmanifestedbyCD4+ iris.Althoughthereissomecontroversyaboutthegreater T-lymphocytecountsoflessthan50cells/ L.Onecan incidenceofHSVkeratitisamongHIV-infectedpatientsbut 滋 presumethatHAARTwaseffectiveindecliningthenumber ithasbeensuggestedthatHZOaffectsHIV-infectedpatients ofpatientswithlowcountofCD4TcellsinIranand morecommonthannon-infectedindividuals. introductionofHAARThasdeclinedthenumberof InLSOCAthefrequencyofactivekeratitisandcornealscars opportunisticocularinfectionlikeCMVretinitis.Onthe reachedto1.2%togetherandherpeszosterophthalmicus otherhand,itshouldbetakenintoconsiderationthatin prevalencewas0.1%ofAIDSstagepatients.Comparing Africa,mostofHIVinfectedpatientsdiebeforeocular withLSOCAresults,5.1%ofourpatientsinAIDSphase opportunisticinfectionsoccur. hadHSV-inducedkeratitis. Thisfactmaybetrueinanyotherdevelopingcountrieslike ToxoplasmachorioretinitiswasanotherHIV-relatedocular Iran.Conclusively,itisnotclearthatlowfrequencyofCMV involvementwhichwasseenin2patientsinoursurvey. retinitisisduetoeffectiveroleofHAARToroccurrenceof Oculartoxoplasmosisaffected1to2percentofHIV-positive deathbeforepresentingthedisease.Inthereportof patientsinpreHAARTera,anditwasoftendiagnosedby enrollmentdatafromTheLongitudinalStudyoftheOcular the occurrenceofanterior-chamberandvitreous ComplicationsofAIDS(LSOCA),themostfrequentocular inflammation,pigmentedchorioretinalscarsandarelative diagnosiswasCMVretinitis,affecting22.1%ofpatients. absenceofretinalhemorrhage.Involvementinbothcasesin ThisstudysuggeststhatnewcasesofCMVretinitiscontinue ourstudywasunilateralandbothhadthetypicalpresentation tooccurandthereisapopulationofpatientswith ofdisease.CD4+ Tlymphocytecountwas200-500cells/ L 滋 long-standingretinitiswhowillrequiremanagement. inbothcases.ExternalocularmanifestationsofHIV-related InLSOCAsurvey,allofthepatientswereinAIDSphase. neurophthalmicabnormalitiesoccurredinabout7%ofAIDS ConsideringonlythepatientsinAIDSphase,CMVretinitis patientspriortotheintroductionofHAART.Considering accountedfor5.1%ofpatientsinourstudy.Inastudyin ourstudyasaninvestigationonHIV-infectedpatientsand ruralUganda,noneoftheHIVinfectedpatientshadocular notjustthoseinAIDSphaserevealsthatneurophthalmic signsofCMVinpreHAARTera.LowprevalenceofHIV involvementincludedasignificantproportionofocular associatedretinopathywasalsoseeninourstudy.Therewas involvementinourstudy.Unfortunately,complementary onlyonecasewithbotheyeinvolvementswithCD4countof workupforapatientwithunilateralpapilitisfailed,andthe morethan200cells/ L.CD4countinthispatientisnot diagnosisofthepatientremainedunknown.Inourstudy,two 滋 compatiblewithotherliteraturesinwhichCD4countin ofourpatientssufferedfromelevatedcuptodiskratio. HIV-relatedretinopathyisfewerthan200cells/ L. AssociationofchronicopenangleglaucomawithHIV 滋 InHIV-relatedretinopathy,themostcommonlyobserved infectionwasnotseeninanyliterature.Ultimately,wefound manifestationsincludecotton-woolspots,intraretinal that,themeancountofCD4Tlymphocytewere hemorrhages,andretinalmicroaneurysms.Multiplecotton significantlyfewerinHIV-infectedwitheyeinvolvement woolspotsandintraretinalhemorrhagewereseeninour thanthosewithoutinvolvement.LowCD4countwasa patient. reliablepredictorforocularcomplicationsinHIVpatients. VZVkeratitiswasconsistedtwoofour15HIV-related Ourstudyfailedtofindanyotherpossibleriskfactorfor ocularinvolvementinourstudy.Wedeliberatelyexclude predictionofriskofocularcomplicationinHIV-infected twopatientswithblepharitisfromHIV-relatedinvolvements individuals. 335 HIV-relatedocularinvolvementinTehran Inconclusion,ourfindingwascompatiblewiththatof interpretedas HIV-relatedinvolvement,likecasesof previousfindingsindevelopingcountries. Ocular blepharitisorassociationofhighnumberofrefractiveerrors complicationsoftuberculosis,toxoplasmosis,herpeszoster, withHIV.Althoughthemethodofpatientselectionwasthe andparticularlyHSVkeratitisweremoreprevalentinour bestachievablewayforconductingacross-sectionalstudyin survey.Thesefindingsseemtobeduetohigherfrequencies oursettings,butsomecautionmustbekeptinmindwhile ofexposuretothesecausativeinfectiousagents. interpretingdatafromthisstudy.Undoubtedly,thepatients AlthoughantibodiestoCMVarewidespreadinthegeneral werenottheexactrepresentativesofthegeneralpopulation populationofAsianadults,butCMVretinitiswaslowerin ofHIV-infectedinTehran.Inparticular,thoseparticipatedin frequencyincomparisonwithrecentsurveysindeveloped thefollowupappointmentofcenterofbehavioraldiseases countries.Thereisnoevidencefromocularinvolvement werepatientsselectedforcompliancewithfollow-upvisits. frompre-HAARTerainIran,butfrequencyofocular REFERENCES 1BelfortRJr.TheophthalmologistandtheglobalimpactoftheAIDSepidemicLV involvementobservedinthisstudywaslowerthanavailable EdwardJacksonMemorialLecture, 2000;129(1):1-8 pre-HAARTliteraturesthroughouttheworld,which 2UNAIDS/WHOepidemiologicalfactsheetsonHIV/AIDSandSexually suggeststhedramaticeffectofHAARTontheprevalenceof TransmittedInfections2006 HIV-relatedocularinvolvement.FewerCD4countinthe 3Sharifi-MoodB,Alavi-NainiR,SalehiM,HashemiM,RakhshaniF.Spectrum ofclinicaldiseaseinaseriesofhospitalizedHIV-infectedpatientsfromsoutheast HIV-infectedpatientswithocularinvolvementinthisstudy ofIran. 2006;27(9):1362-1366 incomparisonwiththosewithoutinvolvementshowsthat 4JacobsonMA,StanleyH,HoltzerC,MargolisTP,CunninghamET.Natural ocularinvolvementisrelatedtodegreeofimmunocom- historyandoutcomeofnewAIDS-relatedcytomegalovirusretinitisdiagnosedin petency in theHIV-infectedpatient. 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