1. Differential Diagnosis I:
HIV Retinopathy or CMV retinitis?
(CWS or CMV ?)

2. CWS
CWS
CMV retinitis

3. AIDS-related Eye pathology overview HIV/AIDS clinics / Wards / Workshops, approx 450 patients with eye disease (Myanmar, China, Russia, Cambodia, Laos, Thailand, Uganda, South Africa) “other” = the disease was very unusual, or not related to HIV (such as retinitis pigmentosa), or that no diagnosis was established
CMV
CWS TB
crypto
syph
toxo
ARN
“other”
50%
25%
10%
3-5% 1%
5-7%

4. HIV Retinopathy
A microvasculopathy that occurs in about 1/3 of patients with a CD4<50cells/µl.
Correlates to high HIV viral load.
Is a marker for those who are at high-risk for opportunistic infection, and may be present in addition to CMV or other OI’s
Rapidly resolves with ART
No symptoms
No treatment

5. HIV Retinopathy The most common eye complication of HIV/AIDS.
Characterized by cotton wool spots (CWS)
Sometimes with hemorrhages.
The primary entity that must be distinguished from CMV retinitis

6. Pattern Recognition
cotton wool spots (CWS) are generally small, less than ½ DD, with regular borders. (also occur in DM and HTN)
They are typically bright white, with no hint of yellow
They are commonly round or oval, or may look like a “twisted piece of cotton”
The “long axis” may sometimes be perpendicular to the NFL
They are superficial, may appear slightly “3 dimensional” and lie on top of the retinal blood vessels, often obscuring a portion of the vessel
As they fade they may exhibit a “granular” appearance
They occur in the “posterior pole” – usually within 4-5 “disc diameters” from the optic nerve

7. HIV Retinopathy

8. Retinal whitening in the peripheral retina is not a CWS
Retinal whitening in the peripheral retina is not a CWS. If the CD4 count is low suspect CMV retinitis
Vortex vein

10. Clinical Course CWS condense and fade, usually over 3-6 weeks
CMV retinitis advances

11. Cotton-Wool Spots condense and fade

12. CWS 2/6/09 and 2/27/09
Note granular appearance as CWS fades

13. CMV retinitis advances

14. Clinical Course
Following the clinical course is the key “test” to distinguish HIV Retinopathy (lesions condense and fade) from CMV retinitis (lesions advance)

17. Progression of small non-specific white spot into characteristic pattern of CMV retinitis

18. Pattern Recognition Dense opaque retinal whitening
Irregular border with small white satellite lesions
Centrifugal spread with Central clearing
Tends to follow vessels
Hemorrhage, but this is highly variable

19. Describe what you see & Give your diagnosis

24. Describe & dx please
What is this?