Ocular disease in patients with HIV infection

Sophia L Zagora1, Angie N Pinto2,3, Peter J McCluskey 1.

1 Save Sight Institute, University of Sydney, Australia

2 Royal Prince Alfred Hospital, Sydney, Australia

3 Kirby Institute, UNSW, Sydney, Australia

Last reviewed: August 2019


 HIV infection and particularly HIV-induced immunodeficiency and its treatment may be complicated by a large number of ocular complications, especially opportunistic infections and cancers (Table 1). While ocular disease is encountered infrequently in HIV patients receiving antiretroviral therapy (ART), it is still an important consideration in HIV-infected patients who are not receiving ART or remain immunodeficient on ART. The occurrence and type of ocular disease can be predicted to a large degree by the CD4+ T cell count (Table 2). A fundal examination should be a routine part of the examination of HIV patients presenting with severe immunodeficiency. The management of eye disease should always be coordinated between an Ophthalmologist with experience in the ocular complications of HIV infection and a physician experienced in managing HIV-infected patients.

Table 1. Ophthalmic complications of HIV infection1

Red flags






Blisters; Pain; Decrease in vision

Herpes zoster ophthalmicus

Molluscum contagiousum

Preseptal cellulitis

Kaposi’s sarcoma

Squamous cell carcinoma

Conjunctival microvasculopathy

Viral swab:  HSV PCR

Bacterial swab: MCS


Pain; Redness; Swelling

Orbital cellulitis

Non-Hodgkin’s lymphoma

Bacterial swab: MCS

Anterior segment

Pain; Decrease in vision

Viral keratitis (VZV, HSV)

Bacterial keratitis (S. aureus; S. epidermis, P. aeruginosa)

Protozoan keratitis (microsporidia)


Conjunctival microvasculopathy

Allergic eye disease

Vortex keratopathy

Dry eye Disease  Meibomian gland dysfunction

Uveitis (HLA B27- related)

Viral swab:  HSV, VZV PCR
Bacterial swab: MCS

Smear: wet prep for free living amoeba

Tissue or fluid3: Amoeba PCR,

Serum T. pallidum antibodies

Posterior segment

Decrease in vision; Floaters

CMV retinitis

VZV retinitis (PORN/ARN)

HSV retinitis

Toxoplasma retinitis

Syphilis uveitis

Pneumocystis choroiditis

Cryptococcal choroiditis

TB-related uveitis

Ocular CNS Non-Hodgkin’s lymphoma

Retinal microvasculopathy

Ischaemic maculopathy

Immune recovery uveitis

Drug induced uveitis (Rifabutin)

Detection of DNA in blood, vitreous fluid or tissue by PCR: CMV, VZV, HSV, Pneumocystis, Toxoplasma, M. tuberculosis

Serology: Toxoplasma, T. pallidum, CMV antibodies;

Cryptococcal antigen


Decrease in vision; Pain

Cerebral toxoplasmosis

Cryptococcal meningitis



VZV encephalitis/radiculitis

TB related neurological disorders

Ocular CNS Non-Hodgkin’s lymphoma

Optic neuritis

Optic atrophy

Ocular motility disorders

Brain imaging: CT, MRI

CSF examination:

- Opening pressure, protein, glucose, culture (bacterial, fungal, mycobacterial)

- DNA by PCR: HSV, VZV, CMV, JC virus, Mtb, T. pallidum, Toxoplasma

- Serology: T. pallidum, CrAg

1) {ref}Denniston AKO, PL M. OXford Handbook of Ophthalmology. 3rd edition ed. United Kingdom: Oxford University Press; 2014{/ref}

2) Eyebrow, eyelids and lacrimal apparatus

3) Investigations include an anterior chamber tap (in young patients) and /or vitreous tap with PCR to identify underlying pathogen.

 Abbreviations: MCS - microscopy, culture, sensitivity; PCR - polymerase chain reaction; PORN - progressive outer retinal necrosis; ARN - acute retinal necrosis; PML - Progressive multifocal leukoencephalopathy; HSV – herpes simplex virus; VZV – varicella zoster virus; CMV - cytomegalovirus

Table 2. Typical occurrence of ocular disease at different CD4+ T cell counts

CD4+ T cell count (cells/mm3)

Ocular disease


Herpes Zoster Ophthlamicus




Kaposi’s sarcoma





Varicella Zoster Virus retinitis


Cytomegalovirus retinitis

  1. {ref}Denniston AKO, PL M. OXford Handbook of Ophthalmology. 3rd edition ed. United Kingdom: Oxford University Press; 2014{/ref}