RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1.Name of the candidate and Address:Dr. K.N.UDAYAKUMAR
#16/1,NEAR
GOVT.PRIMARYSCHOOL,KANNAMANGALA(P&V),
DEVANAHALLI(TQ.)
BANGALORE-562110.
2.Name of the Institution:KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES AND RESEARCH CENTRE.
3.Course of Study and Subject:M.S. (OPHTHALMOLOGY)
4.Date of admission to course:4 th JUNE 2008.
5.Title of the Topic:OCULAR MANIFESTATIONS IN. RELATION TO CD4 COUNT IN
HIV/AIDS PATIENTS
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6.BRIEF RESUME OF THE INTENDED WORK:
6.1NEED FOR THE STUDY:
Nearly 34 million people are currently living with HIV/AIDS worldwide;ocular complications affect 50 to 80% of all such patients at some point during the course of illness. The common ocular manifestations are cytomegalovirus retinitis,retinal detachment,HIV vasculopathy(conjunctivitis,retinitis,choroiditis),immune recovery uveitis,acute retinal necrosis,neuro-ophthalmic manifestations,complicated cataract,keratouveitis and corneal ulcer.
Cytomegalovirus retinitis is by far the most frequent cause of vision loss in patients with AIDS,although the prevalence has decreased with widespread availability of HAART(10 to 20 % of HIV infected patients worldwide can be expected to loss vision in one or both eyes because of cytomegalovirus retinitis).
Other rare ocular manifestations of HIV are herpes zoster ophthalmicus,molluscum contagiosum,kaposissarcoma,retinal vasculopathy,ocular syphilis,ocular tuberculosis,toxoplasmosis,unusual malignancies.
Early diagnosis and prompt treatment prevents visual deterioration so that the patient can lead a independent life.
6.2REVIEW OF LITERATURE:
Virtually unknown prior to 1981 AIDS had struck more than 3,61000 persons in USA by 1993 resulting in 2,20 000 deaths,40 million people in year 2000 & estimated 50 million in first 5 years of 21 st century.The first report was published in June 1981 & it had described 5 young homosexual men in whom a rarely seen pulmonary infection (pneumocystis carini ) had developed & all these patients showed very low leucocyte count(CD4 count). In 2002 WHO & UNAIDS estimated that more than 40 million people were infected & approximately 25 million had died. On an average,16000 new infections occur everyday with sub-saharan Africa & Asia bearing the brunt of the disease(1).
Dr.Robert Gallo at national cancer institute in Bethesda,Maryland & a group of scientists headed by American virologist Jay Levy at the university of California at San Francisco & French virologist Luc Montagnier & scientists from Pasteur Institute at Paris were the pioneers for the detection of the HIV virus & its effects on the body (AIDS).
HIV enters the human cells by binding with a receptor protein known as CD4,located on human immune cell surfaces. HIV carries on its surface a viral protein gp120,which specifically recognizes & binds to the CD4 molecule on the outer surface of human immune cells.HIV virus belongs the subgroup Lentivirus of family retroviridae.
HIV-1:the common virus causing the infection throughout the world.
HIV-2:First identified in West African patients in 1986.(1)
Ocular disease continues to be a major cause of morbidity in these patients,affecting 50 to 75% of all of them.Inspite of the availability of HAART the cytomegalovirus retinitis is responsible for 10 to 20% of HIV/AIDS patients visual loss in one or both eyes.Less frequent but important causes of bilateral vision loss are varicella zoster & herpes simplex virus retinitis,HIV related ischemic microvasculopathy,ocular syphilis,ocular tuberculosis, cryptococcal meningitis,& ocular toxic or allergic drug reactions.(2)
Two major subtypes of ocular lesions occur in patients with HIV/AIDS,the first consists of those due to actual infection of the such as HIV conjunctival vasculopathy & HIV retinopathy. The second subgroup,which is commoner, consists of oppurtinistic infections & is due to the state of immunodeficiency that exists in these patients. The CD4 count is the most common marker used amongst the existing numerous laboratory investigations.(1)
CD4 levels/mm3Manifestations
<500Kaposi’s sarcoma,lymphoma,&
Tuberculosis.
<250Pneumocystis carini and toxoplasmosis.
<100Retinal or conjunctival microvasculopathy,
Cytomegalovirus retinitis,varicella-zoster Virus retinitis,Mycobacterium avium Infection,cryptococcosis,microsporidiosis, HIV encephalopathy,and Progressive MultifocalLeucoencephalopathy.(1)
Cytomegalovirus retinitis is the most common AIDS-related ocular opportunistic infection and can develop in up to 40 to 50% of AIDS patients prior to HAART.Although its incidence has declined markedly since the advent of HAART in the western world, it still remains the leading cause of ocular morbidity in the developing countries. In India, CMV retinitis still remains the commonest ocular manifestation in AIDS cases.In a series of 1286 cases, the incidence of CMV retinitis remains high even in the era of HAART. It may be unilateral to start with, but up to 52% will eventually develop bilateral disease. Cytomegalovirus retinitis occurs almost exclusively in patients whose CD4+ counts are <50 cells/µl. However, its diagnosis cannot be excluded based on CD4+ count alone in patients taking HAART. In exceptionally rare instances, CMV retinitis may develop in patients with elevated CD4+ counts shortly after the initiation of HAART(4).Retinal detachment occurs in 70% of CMV retinitis cases(3).
Immune recovery uveitis (IRU) is a noninfectious intraocular inflammation which develops in patients with inactive CMV retinitis who have had a substantial elevation in CD4+ count with HAART. Immune recovery uveitis is the leading cause of new visual loss in persons with AIDS seen in about 16 to 63% of HAART responders(4).The severity of the inflammation depends on the degree of immune reconstitution, extent of CMV retinitis, amount of intraocular CMV antigen, and previous treatment.HIV microangiopathy (conjunctivitis,retinis and choroiditis) occur in about 40 to 60% of cases(4). Corneal and anterior segment lesions affect more than 50% of all HIV patients.(6). Ocular adnexal lesions seen in about 25% of cases ,can be a sign of severe systemic immunosupression(6). The other lesions seen rarely include herpes zoster ophthalmicus,kaposis sarcoma,keratouveitis, molluscum contagiosum,ocular syphilis,ocular tuberculosis,ocular toxoplasmosis,cryptococcosis,unsual malignancies.The ocular lesions diagnosed early and treated specifically respond most of the times, and prevent the worsening of visual impairment.
6.3OBJECTIVES OF THE STUDY:
1.To study the ocular manifestations in HIV/AIDS patients
2.To study the relationship between ocular findings and CD4 count in HIV/AIDS patients.
3. To study the ocular manifestations of cytomegalovirus infection.
4. To prevent the visual handicap in HIV/AIDS patients by early diagnosis and prompt treatment of opportunistic infections.
7.MATERIAL AND METHODS:
7.1SOURCE OF DATA
All patients attending ART centreKIMSHospital being reffered to ophthalmology department in KIMSHospital,Bangalore over a period of 2 years.
7.2METHOD OF COLLECTION OF DATA
a.Patient data collection and evaluation.
•Patient data will be collected from all patients attending ART centre KIMS hospital referred to ophthalmology department , all age groups irrespective of the gender.The patients will be evaluated with a protocol.
•Detailed history of patient will be entered in proforma.
•Patient will be informed about procedure and consent taken.
Patient data collected regarding:
Age, gender, visual acuity at the point of examination,progress of visual deterioration,CD4 count,
Recruitment of cases:3-4 months.
Follow-up of cases: minimum of six months.
b.Inclusion Criteria:
All HIV/AIDS patients attending ART centre,
KIMS hospital, Bangalore,irrespective of age and gender,
Diagnosed by ELISA or TRIDOT method.
c.Exclusion Criteria: ALL HIV/AIDS patients with the following comorbidities;
a)Diabetes Mellitis
b)Systemic Hypertension
c)Age related macular degeneration and any other macular degenerations.
d)Patients on longterm steroids or immunosupressants for any medical or surgical conditions.
e)Patients with disseminated metastases.
f)HIV/AIDS patients who are terminally ill/ comatose and cannot be examined completely.
g)Patients refusing repeated examination and who lose follow-up.
d.Sample size:
100 HIV/AIDS patients with ocular manifestations.
e.Study design:
Descriptive study.
f.Sample design:
Purposive sampling.
g.Duration of study:
2 years.
h.Study place:
KIMSHospital, Bangalore.
7.3Does the study required any investigations or interventions to be conducted on patients ? If so, please describe briefly.
a)Direct and indirect ophthalmoscopy,
b)Slit lamp examination,
c)Fundus photography,
d)Tonometry and gonioscopy if required are performed with standard universal precautionary measures,
e)Fundus Flouresciene Angiography if required.
7.4Has ethical clearance been obtained from your institution, in case of 7.3.
Yes
- LIST OF REFERENCE:
1. Ashok garg,Scott W Cousins,Kirit Mody , David Meyer,Clinical diagnosis & management of HIV/AIDS in eye, Jaypee publishers,first edition.
2.Philippe G.Kestelyn & Emmet T.Cunnigham Jr, HIV/AIDS and blindness,Bulletin of WHO,2001,79:208-213.
3.Sujith Gharai, Pradeep venkatesh, Satpaj Garg, S.K.Sharma, Rajpal Vohra, Ophthalmic manifestations of HIV infections in India in the Era of HAART:Analysis of 100 consecutive patients evaluated at a tertiary eye care centre in India,Ophthalmic epidemiology, july 2008;15(4 ): 264-271.
4.Banker AS,Posterior segment manifestations in HIV/AIDS,Indian journal of ophthalmology,October 2008,56:377-383.
5.Doan S,Cochereau I,Guvenisik N,Diraison MC,Mousalatti H,Hoang-Xuan T. Cytomegalovirus retinitis in HIV-infected patients with and without HAART therapy.Am J Ophthalmology 1999;128:250-1.
6.Jyothirmay Biswas,S Sudarshan,Anterior segment manifestations in HIV/AIDS,Indian journal of ophthalmology 2008;56:363-75.
9.SIGNATURE OF THE CANDIDATE:
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- REMARKS OF THE GUIDE:
Nearly 34 million people are currently livingwith HIV/AIDS and ocular manifestations are common affecting 50-75% of all such patients. Ocular disease continues to be a major cause of morbidity in these patients and as ophthalmologists in developing world we will be in the frontlines in diagnosis and management as an effort to reduce the visual morbidity. As the access to HAART has increased the life expectancy and the prevalence of blindness related to HIV/AIDS can be expected to increase dramatically
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11.NAME AND DESIGNATION OF:
11.1.GUIDE: DR.NIVEDITHA.H
Assistant Professor of Ophthalmology.
11.2.SIGNATURE:
11.3.CO-GUIDE: DR.K.L.RAVIKUMAR
Professor and H.O.D
Department of microbiology
11.4 SIGNATURE:
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11.5.HEAD OF THE DEPARTMENT:Dr. N. V. V. HIMAMSHU,
M. S. (Ophthalmology)
Professor and Head
Department of Ophthalmology
11.6.SIGNATURE:
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12.REMARKS:
12.1.CHAIRMAN AND PRINCIPAL:
12.2.SIGNATURE:
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