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A, B) Retinal pigment epithelium mottling around the macular and para-macular area in fundus photo C, D) Dark patches at the macular region in fundus autofluorescence (FAF) E, F) Hyperfluorescence observed at macula and surrounding macular region in fundus fluorescein angiography (FFA) Peripheral retina was normal. The 30-2 Humphery visual fields (HVF) (HFAII 750, Carl Zeiss, Germany) showed central and paracentral field defects in both eyes (Figure 2). Multifocal electroretinogram (MfERG) (Veris FMS II, Electro-Diagnostic Imaging, CA, USA) showed reduced N1 and P1 amplitudes in foveal, parafoveal, and perifoveal ring responses (Figure 3). The maximum reduction of amplitudes was seen in the parafoveal responses even as the foveal peak was maintained. Spectral domain optical coherence tomography (SD-OCT) (Spectralis OCT, Heidelberg Engineering, Franklin, USA) revealed an almost complete loss of the ellipsoid layer and external limiting membrane especially in the parafoveal area with a small island of preserved photoreceptors at the fovea. The inner retinal layers were unaffected (Figure 4).
Source publication
Efavirenz (EFV), a non-nucleoside reverse transcriptase inhibitor, is commonly used to treat HIV-infected individuals. We report a case of painless, progressive and bilateral blurring of vision in an HIV-positive 54-year-old lady within months of treatment with anti-retro viral therapy including Efavirenz. On presentation, her visual acuity was 6/1...
Contexts in source publication
Context 1
... optic disc and retinal vessels were normal. Fundus photo (FF 450Plus with Visupac, Zeiss, USA) showed RPE mottling around the macular and para-macular area ( Figure 1A, B). Fundus autofluorescence (FAF) (FF 450Plus with Visupac, Zeiss, USA) revealed discrete dark patches at the macula in both eyes corresponding to the area of RPE mottling suggestive of RPE atrophy ( Figure 1C, D). ...
Context 2
... photo (FF 450Plus with Visupac, Zeiss, USA) showed RPE mottling around the macular and para-macular area ( Figure 1A, B). Fundus autofluorescence (FAF) (FF 450Plus with Visupac, Zeiss, USA) revealed discrete dark patches at the macula in both eyes corresponding to the area of RPE mottling suggestive of RPE atrophy ( Figure 1C, D). Fundus fluorescein angiography (FFA) (FF 450Plus with Visupac, Zeiss, USA) showed hyperfluorescence at the macula and the surrounding macular region in both eyes ( Figure 1E, F). ...
Context 3
... autofluorescence (FAF) (FF 450Plus with Visupac, Zeiss, USA) revealed discrete dark patches at the macula in both eyes corresponding to the area of RPE mottling suggestive of RPE atrophy ( Figure 1C, D). Fundus fluorescein angiography (FFA) (FF 450Plus with Visupac, Zeiss, USA) showed hyperfluorescence at the macula and the surrounding macular region in both eyes ( Figure 1E, F). ...
Context 4
... optic disc and retinal vessels were normal. Fundus photo (FF 450Plus with Visupac, Zeiss, USA) showed RPE mottling around the macular and para-macular area ( Figure 1A, B). Fundus autofluorescence (FAF) (FF 450Plus with Visupac, Zeiss, USA) revealed discrete dark patches at the macula in both eyes corresponding to the area of RPE mottling suggestive of RPE atrophy ( Figure 1C, D). ...
Context 5
... photo (FF 450Plus with Visupac, Zeiss, USA) showed RPE mottling around the macular and para-macular area ( Figure 1A, B). Fundus autofluorescence (FAF) (FF 450Plus with Visupac, Zeiss, USA) revealed discrete dark patches at the macula in both eyes corresponding to the area of RPE mottling suggestive of RPE atrophy ( Figure 1C, D). Fundus fluorescein angiography (FFA) (FF 450Plus with Visupac, Zeiss, USA) showed hyperfluorescence at the macula and the surrounding macular region in both eyes ( Figure 1E, F). ...
Context 6
... autofluorescence (FAF) (FF 450Plus with Visupac, Zeiss, USA) revealed discrete dark patches at the macula in both eyes corresponding to the area of RPE mottling suggestive of RPE atrophy ( Figure 1C, D). Fundus fluorescein angiography (FFA) (FF 450Plus with Visupac, Zeiss, USA) showed hyperfluorescence at the macula and the surrounding macular region in both eyes ( Figure 1E, F). ...
Citations
... 3 Retinal toxicity due to other ART drugs such as Didanosine (DDL), Clofazimine and Ritonavir have been reported to cause damage to the retinal pigment epithelium (RPE). 4 One-third of patients with AIDS developed CMV retinitis, accounting for more than 90% of cases of HIVrelated blindness. Untreated, CMV retinitis is progressive and will destroy the entire retina in 4-6 months. ...
We report a case of middle aged immunocompromised female with cytomegalovirus retinitis presenting with green reflex in pupillary y area of Right eye, her chief complaints were diminished vision in both eyes since one month, she was on HART for 3 years, discontinued for one and half year and again started after the advice of physician, apart from history, systemic and ocular examination done in detailed. BCVA, slit lamp examination, indirect ophthalmoscopy, FFA, B Scan and documentation done, Right eye was observed to note the further changes in fundus where as Left eye was treated with intra vitreal injection Ganciclovir to preserve the vison. Patient treated with intra vitreal Ganciclovir 500 micro grams, twice weekly with interval of 3days for three weeks, once the activity is decreased, injections were given weekly once, same dose continued for three more weeks and advised to follow every month to observe the fundus changes in left eye. Every visit patient was examined in detail, BCVA, anterior segment, fundus and also OCT in left eye to see the central macular thickness. Documentation done in every visit, macular changes after intra vitreal injection was documented by taking both horizontal and vertical OCT.
... There have also been reports of maculopathy linked to ritonavir and efavirenz. [55][56] Ethambutol, linezolid, and the relatively new medication combination of elvitegravir/cobicistat have all been linked to reports of optic neuropathy. [57] 2. Choroiditis 2.1 Pneumocystis P. carinii can cause conjunctivitis, orbital masses, optic neuropathy, and choroiditis in the eyes. ...
To describe the various types of ocular posterior segment and neuro-ophthalmic manifestation associated with
Human Immuno-deficiency virus (HIV) infection. And also describe the management or preventive measures associated with it. In
all cases of ocular disease due to HIV, there is only one reason i.e. immune system.
A Descriptive study was done to review the articles available on PubMed, Google Scholar, Medline, Publon, Orcid, Healthstar,
Science Open, Cochrane Library, Paperity and others related to the ocular complications associated with HIV infections. Peer-
reviewed articles/ studies were referred to ascertain the available screening tests, preventive measures, hygiene, neuro-ophthalmic
manifestation and management options for HIV patients. Some authors suggest that ocular posterior segment & neuro-ophthalmic
manifestation due to HIV infection is not recovered, but few authors suggest that it can be recovered with the help of highly active
antiretroviral therapy (HAART) in combination with some preventive measures and hygiene.
The Eye-care professional’s responsibility is to spread awareness about the complications related to the eye and their management
or preventive measures. Ocular complications are very diverse and relatively frequent in the case of HIV infection. Commonly it is
associated with a concurrent diagnosis of depression, anxiety, panic, attack and psychiatric disorders, etc. There are various
management or preventive measures like regular eye examinations, follow-up of the HIV patients, following the preventive
measures strategies, taking therapy properly, preventing to spread of the infection, etc.
... One publication reported few cases of maculopathy secondary to efavirenz treatment. Despite the fact of its toxic effect on the retinal pigment epithelium, efavirenz retinopathy usually affects the parafoveal region [14]. Tenofovir, a NRTI, is another antiretroviral drug. ...
Objective: This article aims to describe a unique case of didanosine-induced retinal degeneration that was discovered 11 years after the drug withdrawal. Case report: The patient is a 42-year-old woman with a medical history of HIV and hepatitis C virus since 2004. She has been prescribed antiretroviral therapy since then. For the first seven years (2004–2011), the patient was prescribed a combination therapy consisting of didanosine, efavirenz, and lamivudine. The protocol was changed to atripla (efavirenz, emtricitabine, and tenofovir) from 2011 to 2021. Recently (October 2021–January 2021), the patient was prescribed eviplera (rilpivirin, emtricitabine, and tenofovir). In addition, her past medical history revealed Gougerot-Sjogren syndrome and rheumatoid arthritis. She was prescribed hydroxychloroquine (HCQ) (2009–2021) at a dose of 400 mg daily. She had no vision complaint. Results: During her routine HCQ screening at the eye clinic, University Hospital Bretonneau, Tours, France, the widefield colour fundus photograph showed well-defined symmetric mid-peripheral areas of chorioretinal atrophy sparing the posterior pole of both eyes. Furthermore, the widefield fundus autofluorescence illustrated mid-peripheral round well-demarcation hypoautofluorescent areas of chorioretinal atrophy of both eyes. Conversely, the macular optical coherence tomography (OCT) was normal. Many of her drugs are known to be associated with retinopathy such as HCQ, tenofovir, efavirenz, and didanosine. Because our data corroborate peripheral retinal damage rather than posterior pole damage, this case report is compatible with didanosine-induced retinopathy rather than HCQ, efavirenz, or tenofovir retinal toxicity. Conclusions: All HIV patients who are presently or were previously on didanosine therapy should have their fundus examined utilising widefield fundus autofluorescence and photography.
... Similar findings were reported in a patient who had been on ritonavir for over 10 years [71]. There has also been a recent case of macular toxicity reported in a HIV-positive patient who was on efavirenz for 9 months, presenting with bilateral central and paracentral visual field defects, RPE mottling, loss of the outer retinal layers, and reduced macular responses on multifocal electroretinogram [72]. These reports of ART-associated retinopathy are quite uncommon, and one would think that the benefits of continuing the ART regimen would outweigh these potential side effects. ...
Purpose of Review
This review aims to provide an update on the clinical presentations and diagnostic findings of drug-induced retinal toxicities.
Recent Findings
Several newly FDA-approved medications have been associated with acute retinal toxicities, including brolucizumab, MEK inhibitors, ulixertinib, and FGFR inhibitors. Additionally, as previously believed-to-be well-tolerated medications, such as pentosan sulfate sodium, anti-retroviral therapies, and certain intraoperative ocular medications, are used more frequently or for longer periods of time, associated toxic retinopathies and inflammatory reactions have been reported. Finally, advances in ocular imaging have revealed novel findings in hydroxychloroquine and tamoxifen maculopathies.
Summary
Discovery of new medications, increased frequency of use, and longer-term use have led to increased reports of retinal toxicities. Advances in retinal imaging have allowed for earlier detection of subclinical changes associated with these medications, which may help prevent progression of disease. However, more research is needed to determine the point at which vision loss becomes irreversible. Risks and benefits must be assessed prior to discontinuation of the offending, but potentially lifesaving, therapy.
... Ritonavir and Efavirenz-associated maculopathy have also been reported. [85,86] Optic neuropathy has been reported with ethambutol, linezolid, and the relatively novel drug combination of elvitegravir/cobicistat. [80] All these adverse effects are rare, and hence are not a blanket contraindication to use of these drugs, but might limit therapy in cases where ocular complications occur. ...
Intraocular inflammation in patients with human immunodeficiency virus (HIV) infection is commonly due to infectious uveitis. Ocular lesions due to opportunistic infections (OI) are the most common and have been described extensively in the pre highly active antiretroviral therapy (HAART) era. Many eye lesions were classified as acquired immunodeficiency syndrome (AIDS) defining illnesses. HAART-associated improvement in immunity of the individual has changed the pattern of incidence of these hitherto reported known lesions leading to a marked reduction in the occurrence of ocular OI. Newer ocular lesions and newer ocular manifestations of known agents have been noted. Immune recovery uveitis (IRU), the new menace, which occurs as part of immune recovery inflammatory syndrome (IRIS) in the eye, can present with significant ocular inflammation and can pose a diagnostic and therapeutic challenge. Balancing the treatment of inflammation with the risk of reactivation of OI is a task by itself. Ocular involvement in the HAART era can be due to the adverse effects of some systemic drugs used in the management of HIV/AIDS. Drug-associated retinal toxicity and other ocular side effects are being increasingly reported. In this review, we discuss the ocular manifestations in HIV patients and its varied presentations following the introduction of HAART, drug-associated lesions, and the current treatment guidelines.
Ocular lesions in patients with human immunodeficiency virus (HIV) are commonly due to underlying opportunistic infections. With highly active antiretroviral therapy (HAART), infectious lesions have reduced and noninfectious ocular manifestations including drug-related side effects have been noted. While retinal toxicity has been noted with few other HAART drugs, there are not many on the same with Efavirenz usage. We report a series of five patients with possible efavirenz-related retinal toxicity, visual function abnormalities, and its management. Efavirenz was replaced with alternate anti-retroviral drug. Reversal of ocular side effects were noted subjectively in the form of symptom amelioration of the patients. Objectively, it could be documented with electroretinogram changes and other visual function tests reverting back to normal after change in HAART regime. Early identification of this uncommon side effect in select patients can prevent irreversible vision loss due to efavirenz-associated retinal toxicity.
