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 ,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 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 , 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 3 1 4 Blurred vision 55 53 106 3 2 5 Diplopia1 2 Purulent discharge 5 5 10 Burning sensation 3 2 5 Photopsia 2 1 3 1 Two persons suffered from

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 (n=1) Area of full thickness retinal necrosis 2 1 1 0 Dendritic scars on 1 0 Undetermined vitritis (n=1) disciform and necrotizing stromal keratitis 0 1 TB choroiditis (n=3) CMV (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) of 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 ,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,,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+ .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. Considering TB theeraofhighlyactiveantiretroviraltherapy. 2000;30(1):231-233 5JabsDA,VanNattaML,KempenJH,ReedPavanP,LimJI,MurphyRL, choroiditisasthemostdiagnosisinthissurveysuggeststhat HubbardLD.Characteristicsofpatientswithcytomegalovirusretinitisintheeraof periodicocularexaminationinHIV-infectedwithTB highlyactiveantiretroviraltherapy. 2002;133(1):48-61 superimpositionorhistoryofTBinfectioneveniftherewere 6HollandGN,VaudauxJD,ShiramizuKM,YuF,GoldenbergDT,GuptaA, novisualcomplaintsismandatory.Thisstudywasthefirst CarlsonM,ReadRW,NovackRD,KuppermannBD;SouthernCaliforniaHIV/Eye Consortium.CharacteristicsofuntreatedAIDS-relatedcytomegalovirusretinitis:II surveyofocularburdenofHIVinIran.Therewasnocontrol Findingsintheeraofhighlyactiveantiretroviraltherapy(1997to2000). groupinthissurvey.So,someofourfindingscouldnotbe 2008;145(1):12-22

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