Evaluation of Ophthalmic changes amongst the PLWH on HAART in a

tertiary care hospital of SURAT CITY

Dr. Vaibhavee V. NoticewalaDr. Manisha Shastri

Dr. Khushnood ShiekhDr. Pratik Shah

Ocular lesions in patients on highly active antiretroviral therapy (HAART) have shown changes in disease prevalence and pattern.

This study aims to present the clinical profile, systemic correlation, and visual outcome in PLWA in relation to HAART to document – (1) the association between Ophthalmic manifestations in PLWA and the CD4 count as well as the adherence to HAART (2) the Socio-Demographic Profile of the PLWA on HAART and its association with Demographic profile.

This study uses a prospective observational case series design.

Background:

Materials and method:•Study was conducted at Ophthalmology department, SMIMER, Surat . • Patients who have given their consent & were more than 18 years, having proper compliance for the HAART or recently change in regime of ART or having opportunistic infection . •Study was analyzed using chi square test.

187 patients were taken into study. Maximum patients are in 20-49 years of age. (mean age=35 ) Maximum number of patients involved are from lower socio-economical class. Among all patients 150 (80% )are from WHO stage-1 and 126( 67.4%) are on

recently started HAART treatment. 104 (56%) patients are on Zidovudine + Lamivudine + Nevirapine (Z-L-N) based

regime. Maximum improvement in CD4 count is in the range 0-250 & in the WHO stage-I

after the HAART in 141(75.4%). Prevalence of opportunistic infections such as pulmonary tuberculosis, followed by

the extra pulmonary tuberculosis is high in recently started HAART which is significantly associated with WHO stages III-IV and having correlation(p=0.001) with improvement of CD4 count in the range of 0-250 but not with the duration of HAART.

Although as the duration of HAART increases, occurrence of OIS decreases.

Discussion:

Most common symptom is diminished vision followed by watering. Study shows significant correlation(p=0.001) of the presence of cataract with age group (>40 yrs) but not with HAART regime.

To look for immune regeneration uveitis 7 eyes had irridocyclitis and two had choroiditis.

There is no significant correlation found among posterior segment lesion and different variables.

Findings of the present study are discussed with same of studies conducted by peer’s groups such as J Biswas et al (1990), Gharai S & Venkatesh P et al (2008) Dinesh k sahu et al (1999) etc.

Discussion:

WHO stage Male Female TotalI 101 49 150II 14 10 24III 6 4 10IV 3 0 3

Total 124 63

Duration of HAART Male Female Total

<3 month 46 16 623-6 months 44 20 64

6-12 months 22 19 22>12 months 12 8 20

Total 124 63 187

Improvement in CD4 count

WHO stageTotalI II III IV

<100 67 8 5 1 81101-250

48 10 2 0 60

251-500

25 4 2 2 33

>500 10 2 1 0 13Total 150 24 10 3 187

Z-L-N regime is the most common amongst 8 different HAART regimes and patients from WHO stage I had shown maximum improvement in their CD4 count in the range of 0-250.

There is significant statistical relation between the WHO staging and prevalence of opportunistic infections. Higher the WHO staging, more the prevalence of opportunistic infections.

The most common opportunistic infection is the Mycobacerial infection. Opportunistic infections were found more commonly among those who are on HAART since less than 6 months and who had improvement in CD4 in the range 0-250.

The most common examination finding was cataract which is responsible for the most common presenting symptom of diminished vision and significantly correlated with 30-49 yrs age group that concludes pre-mature cataract among these patients on HAART.

Study shows lower prevelance of manifestations in HIV in anterior and posterior segment in WHO stage I and the potential of exaggeration of uveitis with this HAART.

Regular follow up of patients with WHO stage I who are on HAART helps in early diagnosis as well as prevention in the progress of the disease.

Conclusion:

WHO STAGE

Opportunistic Infections Seen No OIs TotalTB EPTB PCP HZ CD CMV A Total

I 11 7 1 2 1 1 2 25 125 150II 6 1 1 0 0 0 0 8 16 24III 5 1 0 0 0 0 0 6 4 10IV 3 0 0 0 0 0 0 3 0 3

Total 25 9 2 2 1 1 2 42 145 187

Duration of HAART

Opportunistic Infections Seen No OIs TotalTB EPTB PCP HZ CD CMV A

< 3 months 11 1 0 0 1 0 2 47 623 – 6 months 9 4 2 2 0 0 0 47 64

6 - 12 months

5 4 0 0 0 1 0 31 41

>12 months 0 0 0 0 0 0 0 20 20Total 25 9 2 2 1 1 2 145 187

Improved CD4 Count

Opportunistic Infections Seen No OIs TotalTB EPTB PCP HZ CD CMV A

< 100 12 3 2 1 0 0 2 61 81101 – 250 8 5 0 1 1 0 0 45 60251 – 500 3 1 0 0 0 0 0 29 33

> 500 2 0 0 0 0 1 0 10 13Total 25 9 2 2 1 1 2 145 187