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PURPOSE: Some human immunodeficiency virus (HIV)einfected individuals have evidence of optic nerve or retinal dysfunction that manifests as decreased contrast sensitivity, even with good best-corrected visual acuity (BCVA). This condition, termed HIV-related neuroretinal disorder (HIV-NRD), is a risk factor for vision impairment (BCVA

Purpose To describe the long-term outcomes of patients with cytomegalovirus (CMV) retinitis and AIDS in the modern era of combination antiretroviral therapy. Design Prospective, observational cohort study. Participants Patients with AIDS and CMV retinitis. Methods Immune recovery, defined as a CD4+ T-cell count >100 cells/μl for ≥3 months. Main Outcome Measures Mortality, visual impairment (visual acuity Results Patients without immune recovery had a mortality of 44.4/100 person-years (PYs) and a median survival of 13.5 months after the diagnosis of CMV retinitis, whereas those with immune recovery had a mortality of 2.7/100 PYs ( P Conclusions Among persons with CMV retinitis and AIDS, if there is immune recovery, long-term survival is likely, whereas if there is no immune recovery, the mortality rate is substantial. Although higher than the rates in the population not infected by human immunodeficiency virus, the rates of bilateral visual impairment and blindness are low, especially when compared with rates in the era before modern antiretroviral therapy.

Objective To report the clinical features on eye examination of patients with AIDS in the era of highly active antiretroviral therapy (HAART). Design Cohort study. Participants Patients with AIDS, age ≥ 13 years. Methods Ophthalmologic examination, contrast sensitivity, visual fields, and laboratory testing at enrollment. Main Outcome Measures Eye examination findings at enrollment. Results As of March 31, 2003, 1632 participants with AIDS were enrolled. Evidence of intraocular inflammation was substantially more common among patients with cytomegalovirus (CMV) retinitis or other major ocular complications than among those without, as were the complications of infection and inflammation, including cataracts, pseudophakia, macular edema, and epiretinal membrane. Among patients with CMV retinitis, macular edema and epiretinal membrane formation were most common among patients with long-standing retinitis and immune recovery. Patients with newly diagnosed retinitis had eye examination findings similar to those reported in the pre-HAART era. Visual impairment ( P Conclusions In the HAART era, CMV retinitis and other ocular opportunistic infections are associated with intraocular inflammation, structural ocular complications, and visual impairment. Patients with newly diagnosed CMV retinitis have eye examination findings similar to those seen in the pre-HAART era.

Purpose To describe the course of cytomegalovirus (CMV) retinitis in patients with AIDS in the era of highly active antiretroviral therapy (HAART). Design Multicenter, prospective, observational study. Participants Two hundred seventy-one patients with AIDS and CMV retinitis. Methods Follow-up every 3 months with medical history, ophthalmologic examination, laboratory testing, and fundus photographs. Photographs were evaluated for relapse of the retinitis (progression) by graders at a centralized reading center. Main outcome measure Retinitis progression (movement of the border of a CMV lesion ≥750 μm over a ≥750-μm front or occurrence of a new lesion one-quarter disc area or more in size). Results The overall rate of retinitis progression was 0.10/person-year (PY); among those with CD4+ T-cell counts of P Conclusions Compared with the rate of retinitis progression (∼3.0/PY) reported in the pre-HAART era, the rate of retinitis progression was reduced among patients in the HAART era, even among those with low CD4+ T-cell counts, who might be expected to behave most like patients from the pre-HAART era. However, these events also occurred among patients with high CD4+ T-cell counts and presumed immune recovery. Continued ophthalmologic follow-up of patients with immune recovery is recommended to detect early retinitis progression. This article contains additional online-only material available at http://www.ophsource.com/periodicals/ophtha.

To describe the long-term outcomes of patients with cytomegalovirus (CMV) retinitis and AIDS in the modern era of combination antiretroviral therapy.Prospective, observational cohort study.Patients with AIDS and CMV retinitis.Immune recovery, defined as a CD4+ T-cell count100 cells/μl for ≥3 months.Mortality, visual impairment (visual acuity20/40), and blindness (visual acuity ≤20/200) on logarithmic visual acuity charts and loss of visual field on quantitative Goldmann perimetry.Patients without immune recovery had a mortality of 44.4/100 person-years (PYs) and a median survival of 13.5 months after the diagnosis of CMV retinitis, whereas those with immune recovery had a mortality of 2.7/100 PYs (P0.001) and an estimated median survival of 27.0 years after the diagnosis of CMV retinitis. The rates of bilateral visual impairment and blindness were 0.9 and 0.4/100 PYs, respectively, and were similar between those with and without immune recovery. Among those with immune recovery, the rate of visual field loss was approximately 1% of the normal field per year, whereas among those without immune recovery it was approximately 7% of the normal field per year.Among persons with CMV retinitis and AIDS, if there is immune recovery, long-term survival is likely, whereas if there is no immune recovery, the mortality rate is substantial. Although higher than the rates in the population not infected by human immunodeficiency virus, the rates of bilateral visual impairment and blindness are low, especially when compared with rates in the era before modern antiretroviral therapy.

Patients with AIDS have an abnormality of retina/optic nerve function, manifested as decreased contrast sensitivity (in the absence of ocular opportunistic infections or media opacity), abnormalities on automated perimetry, and loss of retinal nerve fiber layer, even among those with good visual acuity, termed the "human immunodeficiency virus (HIV) neuroretinal disorder." The objectives of this study were to determine the prevalence, incidence, risk factors, and outcomes of HIV neuroretinal disorder.Prospective cohort study.A total of 1822 patients with AIDS without ocular infections or media opacities.Patients with HIV neuroretinal disorder were identified by a contrast sensitivity1.50 log units in either eye in the absence of ocular opportunistic infections or media opacity.Incidence of HIV neuroretinal disorder, mortality, visual impairment (visual acuity ≤20/50), and blindness (≤20/200) on logarithmic visual acuity charts.Sixteen percent of participants had HIV neuroretinal disorder at enrollment. The estimated cumulative incidence by 20 years after AIDS diagnosis was 51% (95% confidence interval [CI], 46-55). Human immunodeficiency virus neuroretinal disorder was more common in women and African Americans. Risk factors for HIV neuroretinal disorder included hepatitis C infection, low CD4+ T cells, and detectable HIV RNA in the blood. Patients with HIV neuroretinal disorder had a 70% excess mortality versus those without it, even after adjusting for CD4+ T cells and HIV load (hazard ratio [HR], 1.7; 95% CI, 1.3-2.1; P0.0001). Patients with HIV neuroretinal disorder had increased risks of bilateral visual impairment (HR, 6.5; 95% CI, 2.6-10.6; P0.0001) and blindness (HR, 5.9; 95% CI, 2.8-13.7; P = 0.01) versus those without HIV neuroretinal disorder.Human immunodeficiency virus neuroretinal disorder is a common finding among patients with AIDS, and it is associated with an increased mortality and an increased risk of visual impairment. Successful antiretroviral therapy decreases but does not eliminate the risk of HIV neuroretinal disorder.

To describe the outcomes of different treatment approaches for cytomegalovirus (CMV) retinitis in the era of highly active antiretroviral therapy (HAART).Prospective cohort study, the Longitudinal Study of the Ocular Complications of AIDS.A total of 250 patients with CMV retinitis and a CD4+ T-cell count100 cells/μl (n = 221) at enrollment or incident retinitis (n = 29) during cohort follow-up.The effects of systemic therapy (vs. intraocular therapy only) on systemic outcomes and the effect of intraocular therapies (ganciclovir implants, intravitreal injections) on ocular outcomes were evaluated.Mortality, CMV dissemination, retinitis progression, and treatment side effects.Regimens containing systemic anti-CMV therapy were associated with a 50% reduction in mortality (adjusted hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.3-0.7; P = 0.006), a 90% reduction in new visceral CMV disease (adjusted HR, 0.1; 95% CI, 0.04-0.4; P = 0.004), and among those with unilateral CMV retinitis at presentation, an 80% reduction in second eye disease (adjusted HR, 0.2; 95% CI, 0.1-0.5; P = 0.0005) when compared with those using only intraocular therapy (implants or injections). Compared with systemic treatment only, regimens containing intravitreal injections had greater rates of retinitis progression (adjusted HR, 3.4; P = 0.004) and greater visual field loss (for loss of one half of the normal field, adjusted HR, 5.5; P0.01). Intravitreal implants were not significantly better than systemic therapy (adjusted HR for progression, 0.5; P = 0.26; adjusted HR for loss of one half of the visual field, 0.5; P = 0.45), but the sample size was small. Hematologic and renal side effect rates were similar between those groups with and without systemic anti-CMV therapy. The rate of endophthalmitis was 0.017 per eye-year (EY) (95% CI, 0.006-0.05) among those treated with intravitreal injections and 0.01 per EY (95% CI, 0.002-0.04) among those treated with an implant.In the HAART era, systemic anti-CMV therapy, while there is immune compromise, seems to provide benefits in terms of longer survival and decreased CMV dissemination.Proprietary or commercial disclosure may be found after the references.

Purpose To describe visual field (VF) loss among patients with cytomegalovirus (CMV) retinitis and the risk factors for such loss. Design Multicenter, prospective, observational study. Participants A total of 476 patients with AIDS and CMV retinitis, and VF data. Methods Follow-up every 3 months with medical history, ophthalmologic examination, Goldmann visual fields, and laboratory testing. Main Outcome Measures Incidence of VF loss in eyes affected with CMV retinitis and characteristics associated with such VF loss. Results Over a median follow-up of 4 years (range, 0.5–9 years), the incidence rates of VF loss to 75% and 50% of normal were 0.22/eye-year (EY, 95% confidence interval [CI], 0.20–0.25) and 0.08/EY (95% CI, 0.06–0.10), respectively. The observed rates were 6- to 7-fold less than those observed rates of VF loss in the era before highly active antiretroviral therapy (HAART). Decreased CD4+ T-cell count, whether measured at enrollment or over follow-up time, was associated with increased rates of VF loss for all VF outcomes in a dose-dependent fashion. Risk factors for VF loss included lower CD4+ T-cell count, CMV lesion size >25% of the total retinal area, and active CMV retinitis after controlling for potential confounding. Highly active antiretroviral therapy use and immune recovery (CD4+ T-cell count >100 cells/μL) were associated with reduced risk of VF loss in multiple regression models. Immune recovery was statistically significantly associated with a lower risk of VF loss to 75% of normal (relative risk [RR] = 0.63; 95% CI, 0.49–0.86; P = 0.003) and to 50% of normal (RR = 0.60; 95% CI, 0.44–0.82; P = 0.001) after controlling for demographic characteristics, HIV viral load, HAART use, CMV lesion location and size, and retinitis activity. Conclusions Cytomegalovirus retinitis was associated with a substantial risk of incident VF loss, but the incidence is approximately 6-fold lower than that observed in the pre-HAART era. Those who have HAART-induced immune recovery have approximately 40% lower risk of VF loss for both outcomes after controlling for confounding. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

To report the prevalence of ocular complications of AIDS in the era of highly active antiretroviral therapy (HAART).Cohort study.Patients with AIDS, 13 years or older.History, eye examination, and laboratory testing at enrollment.Frequency of ocular complications at enrollment.As of March 31, 2003, 1632 participants with AIDS were enrolled. The cohort had a history of severe immune deficiency, as evidenced by a median nadir CD4+ T-cell count of 30 cells per microliter. At enrollment, the median CD4+ T-cell count was 164 cells per microliter. CD4+ T-cell counts were50 in 24.1% butor =100 in 63.6% andor =200 in 43.0%. Cytomegalovirus (CMV) retinitis was present in 22.1%, whereas other ocular opportunistic infections each were present inor =0.6%. The incidence of CMV retinitis estimated from retrospective data was 5.60/100 person-years. Of the 360 patients with CMV retinitis, 22.5% were newly diagnosed at enrollment, and the remainder had more long-standing CMV retinitis (median, 2.8 years).Although there is the possibility of oversampling patients with AIDS and ocular complications (as compared with a random sample), which would lead to increased estimates of prevalent and incident ocular morbidities, these data still suggest a substantial decline in the incidence of CMV retinitis from the pre-HAART era. Nevertheless, new cases of CMV retinitis continue to occur, and there is a population of patients with long-standing retinitis who will require management.

To report the clinical features on eye examination of patients with AIDS in the era of highly active antiretroviral therapy (HAART).Cohort study.Patients with AIDS, ageor = 13 years.Ophthalmologic examination, contrast sensitivity, visual fields, and laboratory testing at enrollment.Eye examination findings at enrollment.As of March 31, 2003, 1632 participants with AIDS were enrolled. Evidence of intraocular inflammation was substantially more common among patients with cytomegalovirus (CMV) retinitis or other major ocular complications than among those without, as were the complications of infection and inflammation, including cataracts, pseudophakia, macular edema, and epiretinal membrane. Among patients with CMV retinitis, macular edema and epiretinal membrane formation were most common among patients with long-standing retinitis and immune recovery. Patients with newly diagnosed retinitis had eye examination findings similar to those reported in the pre-HAART era. Visual impairment (20/40) in the better-seeing eye was present in 9.2% of patients with CMV retinitis, 41.4% of patients with other major ocular complications (primarily ocular opportunistic infections), and only 0.6% of patients with no major ocular complication (P.0001). Although patients without major ocular complications generally had good visual acuity, approximately 9.8% of eyes and 6.6% of participants had contrast sensitivity loss sufficient to impair reading speed.In the HAART era, CMV retinitis and other ocular opportunistic infections are associated with intraocular inflammation, structural ocular complications, and visual impairment. Patients with newly diagnosed CMV retinitis have eye examination findings similar to those seen in the pre-HAART era.

To evaluate risk factors for mortality among patients with AIDS in the era of highly active antiretroviral therapy (HAART), particularly the effect of cytomegalovirus (CMV).Prospective cohort study of patients with AIDS, conducted from 1998 through 2003.One thousand five hundred eighty-three patients with AIDS, of whom 374 had CMV retinitis.Patients were contacted every 3 months, with examinations at least every 6 months, in which standardized data were collected on AIDS history and treatment, eye examinations, and hematologic, virologic, and immunologic laboratory data.Mortality.The overall mortality rate was 0.07 deaths/person-year. In a multivariate analysis, the following baseline risk factors were associated with an increased mortality: higher human immunodeficiency virus (HIV) viral load (relative risk [RR] = 4.6 for HIV viral load100,000 copies/ml vs.400 copies/ml; P0.0001), lower CD4+ T-cell count at enrollment (RR = 3.8 for CD4+ T cell count 0-49 cells/microl vs.or = 200 cells/microl; P0.0001), CMV viral loador = 400 copies/ml (RR = 1.9; P = 0.002), lower hemoglobin (RR = 1.7 for hemoglobin10 g/dl; P = 0.009), a history of cryptococcal meningitis (RR = 1.7; P = 0.02), CMV retinitis (RR = 1.6; P = 0.0002), and Karnofsky scoreor = 80 (RR = 1.4; P = 0.008).In the era of HAART, CMV disease as manifested by CMV retinitis and a detectable CMV viral load were associated with an increased risk for mortality, even after adjusting for demographic, treatment, immunologic, and HIV virologic factors.

To describe the course of cytomegalovirus (CMV) retinitis in patients with AIDS in the era of highly active antiretroviral therapy (HAART).Multicenter, prospective, observational study.Two hundred seventy-one patients with AIDS and CMV retinitis.Follow-up every 3 months with medical history, ophthalmologic examination, laboratory testing, and fundus photographs.Second (contralateral) eye involvement among patients with unilateral disease and retinal detachment (RD).The overall rate of second eye involvement among patients with unilateral CMV retinitis was 0.07 per person-year (PY); among those with CD4+ T-cell counts of50/microl it was 0.34/PY, compared with 0.02/PY among those with CD4+ T-cell counts ofor =200/microl (P0.0001). Risk factors for contralateral eye involvement included low CD4+ T-cell count and detectable CMV load. The overall rate of RD was 0.06/PY; among those with CD4+ T-cell counts of50/microl it was 0.30/PY, compared with 0.02/PY among those with CD4+ T-cell counts ofor =200/microl (P0.0001). Risk factors for RD included a low CD4+ T-cell count and larger area of CMV retinitis.Compared with the rates reported in the pre-HAART era of second eye involvement (approximately 0.40/PY) and RD (approximately 0.50/PY), the rates of these events were reduced among patients in the HAART era. However, among patients with CD4+ T-cell counts of50/microl, the rates were more similar to those from the pre-HAART era.

To describe the course of cytomegalovirus (CMV) retinitis in patients with AIDS in the era of highly active antiretroviral therapy (HAART).Multicenter, prospective, observational study.Two hundred seventy-one patients with AIDS and CMV retinitis.Follow-up every 3 months with medical history, ophthalmologic examination, laboratory testing, and fundus photographs. Photographs were evaluated for relapse of the retinitis (progression) by graders at a centralized reading center.Retinitis progression (movement of the border of a CMV lesionor =750 microm over aor =750-microm front or occurrence of a new lesion one-quarter disc area or more in size).The overall rate of retinitis progression was 0.10/person-year (PY); among those with CD4+ T-cell counts of50/microl, it was 0.58/PY, compared to 0.02/PY among those with CD4+ T-cell counts ofor =200/microl (P0.0001). In the multivariate analysis, significant risk factors for retinitis progression included a low CD4+ T-cell count, positive CMV load, longer time from AIDS diagnosis, and low Karnofsky score.Compared with the rate of retinitis progression (approximately 3.0/PY) reported in the pre-HAART era, the rate of retinitis progression was reduced among patients in the HAART era, even among those with low CD4+ T-cell counts, who might be expected to behave most like patients from the pre-HAART era. However, these events also occurred among patients with high CD4+ T-cell counts and presumed immune recovery. Continued ophthalmologic follow-up of patients with immune recovery is recommended to detect early retinitis progression.

To describe the 5-year outcomes of patients with cytomegalovirus (CMV) retinitis and AIDS in the era of highly active antiretroviral therapy (HAART).Prospective, multicenter, observational study.A total of 503 patients with AIDS and CMV retinitis.Follow-up every 3 months with medical history, ophthalmologic examination, laboratory testing, and retinal photographs. Participants were classified as having previously diagnosed CMV retinitis and immune recovery (CD4+ T cells ≥ 100 cells/μl), previously diagnosed retinitis and immune compromise, and newly diagnosed CMV retinitis (diagnosis45 days before enrollment).Mortality, retinitis progression (movement of the border of a CMV lesion ≥ ½ disc diameter or occurrence of a new lesion), retinal detachment, immune recovery uveitis (IRU), and visual loss (20/40 and ≥ 20/200).Overall mortality was 9.8 deaths/100 person-years (PY). Rates varied by group at enrollment from 3.0/100 PY for those with previously diagnosed retinitis and immune recovery to 26.1/100 PY for those with newly diagnosed retinitis. The rate of retinitis progression was 7.0/100 PY and varied from 1.4/100 PY for those with previously diagnosed retinitis and immune recovery to 28.0/100 PY for those with newly diagnosed retinitis. The rate of retinal detachment was 2.3/100 eye-years (EY) and varied from 1.2/100 EY for those with previously diagnosed retinitis and immune recovery to 4.9/100 EY for those with newly diagnosed retinitis. The rate of IRU was 1.7/100 PY and varied from 1.3/100 PY for those with previously diagnosed retinitis and immune recovery at enrollment to 3.6/100 PY for those with newly diagnosed retinitis who subsequently experienced immune recovery. The rates of visual loss to20/40 and to ≤ 20/200 were 7.9/100 EY and 3.4/100 EY, respectively; they varied from 6.1/100 EY and 2.7/100 EY for those with previously diagnosed retinitis and immune recovery to 11.8/100 EY and 5.1/100 EY for those with newly diagnosed retinitis. Although the event rates tended to decline with time, in general, at no time did they reach zero.Despite the availability of HAART, patients with AIDS and CMV retinitis remain at increased risk for mortality, retinitis progression, complications of the retinitis, and visual loss over a 5-year period.Proprietary or commercial disclosure may be found after the references.