Two Case Reports of HIV Related Optic Neuropathy

Special Article - Ophthalmology: Clinical Cases and Images

Austin J Clin Ophthalmol. 2015;2(4): 1055.

Two Case Reports of HIV Related Optic Neuropathy

Elferink S¹*, Witmer AN² and Meenken C¹

1Department of Ophthalmology, VU Medical Center, Amsterdam, Netherlands

2Department of Ophthalmology, Onze Lieve Vrouwe Gasthuis Hospital, Amsterdam, Netherlands

*Corresponding author: Sjoerd Elferink, Department of Ophthalmology, VU Medical Center, Amsterdam, Netherlands

Received: May 01, 2015; Accepted: August 17, 2015; Published: August 27, 2015


To report the importance of considering a primary Human Immunodeficiency Virus (HIV) infection in patients with unexplained optic neuropathy. Two separate patients are discussed in this article. The first patient was evaluated because of a decreased visual acuity in both eyes. Investigation showed bilateral optic disc edema. Further analysis with MRI and a lumbar puncture could not confirm a diagnosis. On a routine screening several months later the patient was tested positive for HIV and a re-evaluation of the Cerebrospinal Fluid (CSF) showed a high viral load. After treatment with antiretroviral therapy the papillary edema disappeared but visual acuity did not improve.

The other patient presented with unilateral complaints. Upon evaluation, a decreased visual acuity and unilateral optic disc edema was found. Further analysis showed visual field loss in both eyes. A CT scan showed no abnormalities. The patient was recently diagnosed with HIV, for which treatment was not yet started. Analysis of the lumbar puncture showed a high viral load. Visual acuity increased after antiretroviral treatment was started.

Keywords: Optic neuropathy; HIV; Cerebrospinal fluid; Viral load


An important but rare cause of optic neuropathy is infection with HIV. More known ocular complications of HIV infection are HIV retinopathy and complications due to an opportunistic infection, such as Cytomegalovirus (CMV) retinitis. The occurrence of these complications is declining compared to the pre-antiretroviral therapy era but is still significant [1]. Optic neuropathy associated with HIV infection is described only in a few case reports in the literature and the pathophysiology is yet unknown. Especially when the diagnosis of HIV is not yet established, this diagnosis is easily missed and can have serious consequences for the patient.

Optic neuropathy refers to damage of the optic nerve. It is typically associated with visual field loss, dyschromatopsia and is often accompanied by a Relative Afferent Pupillary Defect (RAPD) if the neuropathy is unilateral. In several etiologies, it is associated with optic disc edema. Optic neuropathy has a broad differential diagnosis: it may be caused by ischemia, infectious or inflammatory causes, compressive/infiltrative lesions, toxic etiologies, trauma, hereditary causes or glaucoma [2].

We report on two HIV-positive patients with bilateral optic neuropathy and no signs of an opportunistic infection.

Case 1

An otherwise healthy 55-year-old male patient was referred to the outpatient clinic with a decline in vision in the left eye with a scotoma inferiorly since three weeks. His ocular history showed a moderate myopia in both eyes. Best Corrected Visual Acuity (BCVA) was 0.9 in the right eye and 0.4 in the left eye. No RAPD was present at presentation. Slit lamp biomicroscopy revealed no abnormalities, specifically no signs of uveitis. Fundoscopy revealed disc edema in both eyes (Figure 1a and 1b), most prominent in the left eye. No retinal hemorrhages or exsudates were present. Patient was then referred to the Department of Neurology for evaluation of intracranial pathology. Magnetic Resonance Imaging (MRI) of the brain and myelum showed no abnormalities. Lumbar puncture showed 10 cells with normal total protein count and glucose; opening pressure was within normal limits. Serology in the cerebral spinal fluid was negative for syphilis, Cryptococcus Neoformans and BorreliaBurgdorferi. Laboratory and radiologic examination revealed no active infectious parameters, nor active sarcoidosis.