Hiv-Associated Retinopathy in the Haart Era

In Brief 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. Before HAART, HIV-related retinopathies were associated with great visual morbidity and poor survival and mandated lifelong burdensome maintenance therapy. Owing to restored immunity in patients with AIDS treated with protease inhibitors during the HAART era the visual and survival prognosis of these conditions have greatly improved and recommendations for their management have changed. Patients with AIDS with regressed CMV retinitis on HAART, however, still lose vision from a newly evolved syndrome called immune recovery uveitis.