58.1 Features
Ocular features of human immunodeficiency virus (HIV) were first identified in the 1980s. The most common ocular manifestation of HIV is noninfectious occlusive microangiopathy, more commonly known as HIV retinopathy. This pathology is the result of ischemic changes in the retinal nerve fiber layer, resulting in intraretinal hemorrhages and cotton wool spots. HIV retinopathy has been shown to affect almost 58% of patients with acquired immunodeficiency syndrome and 3% of patients with asymptomatic HIV infection. It is difficult to know the true incidence of HIV retinopathy as it is likely underreported due to its asymptomatic presentation. The cause of HIV retinopathy is unknown; various theories have proposed a primary cause involving direction infection of vascular endothelial cells versus a secondary cause involving immune complex deposition or an increased hypercoagulable state.
58.1.1 Common Symptoms
Most remain asymptomatic; potential symptoms include subtle loss of color vision and/or contrast sensitivity, visual field deficits, and subnormal electrophysiological responses thought to occur due to the microischemic infarcts in the retinal nerve fiber layer, which can cause subjective visual changes.
58.1.2 Exam Findings
The most common exam findings are those similar to any occlusive vasculitic disease and can include cotton wool spots, microaneurysms, telangiectatic vascular changes, or intraretinal hemorrhages. Cotton wool spots, seen as fluffy white lesions, are the most characteristic and involve ischemic changes of the nerve fiber layer thought to be caused by retinal vascular disease (▶ Fig. 58.1). They are the earliest sign of HIV retinopathy and seen in approximately half of the patients who have advanced HIV disease. Some studies have also demonstrated increased tortuosity of retinal arterioles and decreased retinal arteriolar caliber compared to normal healthy subjects. Rarely, retinal vascular occlusions have been observed in patients with HIV without any other risk factors.
Fig. 58.1 Fundus photograph of human immunodeficiency virus retinopathy, demonstrating retinal whitening and vascular telangiectatic changes.
58.2 Key Diagnostic Tests and Findings
58.2.1 Optical Coherence Tomography
Demonstrates similar findings to those in other arterial occlusive diseases. Inner retina is hyper-reflective, causing shadowing of the outer retina with loss of detail in affected areas (▶ Fig. 58.2). These hyper-reflective areas generally correlate to the cotton wool spots seen on retinal examination. Over time, the inner retina can become atrophic and thin due to the chronic retinovascular disease. Cone photoreceptor density is rarely reduced with ellipsoid zone disruption.
Fig. 58.2 Optical coherence tomography of the retina, demonstrating localized thickening of the inner retina with hyper-reflectivity with shadowing of the outer retina correlating to the area of ischemic changes from human immunodeficiency virus retinopathy.
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