lymphoma has declined by greater than 50% in the HAART era [106, 107]. However, the overall prevalence of intraocular lymphoma may be on the rise. In one large retrospective study, the proportion of intraocular lymphoma as an AIDSdefining illness rose from 4.4% to 6.3% following the advent of HAART [108].

In non-Hodgkin’s lymphoma with CNS involvement, symptoms include floaters and vision loss; non-Hodgkin’s lymphoma usually shows lesions in the retina, in the subretinal pigment epithelial space, and optic nerve, whereas the ocular manifestations of systemic lymphoma typically affect the uveal tract due to invasion through the choroidal circulation. Vitritis is common in both categories. Deep retinal lesions typically associated with CNS lymphoma in AIDS patients are of a creamy white appearance, may have associated retinal hemorrhages, and can be large with well-defined edges (lesions can be confused with atypical CMV) (Fig. 1.19). Uveal manifestations of lymphoma in these patients include serous retinal detachments and alterations of retinal pigment epithelium.

Brain MRI and analysis of cerebrospinal fluid for cytology are mandatory in all patients suspected of having intraocular or CNS disease [109]. Treatment at this time includes chemotherapy and radiation that are based on the stage and extent of disease, but the longterm prognosis is poor.

Controversies and Perspectives

•The next era will be one that improves our understanding of disease processes, refines treatments, and returns to the study of HIVrelated eye disease.

•Retinal and optic nerve damage that occurs in the absence of clinically apparent infections needs additional study. Of particular importance is whether damage progresses despite HAART and immune recovery.

•Better long-term strategies for the management of CMV retinitis and its complications are required. Issues include not only treatment but also prevention and visual rehabilitation. Strategies appropriate for the developing world must be considered.

•A still better understanding of CMV retinitis is needed, especially with regard to risk factors for its development and recurrence. Studies of human genes that regulate the immune response to specific infections hold promise in this area. Additional studies of CMV immunity may lead to tests that are useful for predicting those at highest risk.

•The basis for alterations in vision that have been documented in the absence of clinical lesions (abnormal color vision, reduced contrast sensitivity, and visual field changes) should be explored further.

•Study of the retinal vasculature also may provide insights into other nonocular disorders

associated with HIV disease. Renal disease and cardiovascular disease have become important in the HAART era and may share disease mechanisms with the microvasculopathy of HIV disease.

Focal Points

•AIDS is a condition characterized by severely compromised cell-mediated immunity, predisposing patients to opportunistic infections and neoplasms.

•Approximately about 0.8% of the world’s population is infected with HIV. Of these patients, more than 90% are unaware that they are infected and up to 70% have ocular complications related to HIV/AIDS.

•Proper diagnosis of ocular complications by HIV is critical because failure to diagnosis can lead to severe and permanent vision loss, because specific therapy is available for many of the more common disorders, and because ocular disease may be the initial manifestation of an underlying disseminated infection.

•HIV retinopathy is the most common retinal manifestation. It is characterized by the formation of cotton-wool spots, hemorrhages, and microaneurysms, and it is typically asymptomatic.

•Important ocular infections seen in patients with HIV/AIDS include CMV retinitis, the most common, VZV herpetic retinitis, toxoplasmic retinochoroiditis, syphilis, Pneumocystis carinii choroiditis (PCC), Mycobacterium tuberculosis, and cryptococcal choroiditis.

•Noninfectious causes of uveitis observed in patients with HIV/AIDS include neoplastic disease, drug-induced uveitis, and immune recovery uveitis (IRU).

•HAART has had a substantial impact on HIV in wealthy countries, including immune reconstitution for many patients with resultant improved survival and declines in opportunistic infections. However, HIV/AIDS remains a leading cause of death in developing countries, particularly sub-Saharan Africa.

Acknowledgment Supported in part by the Fundacion Arevalo-Coutinho para la Investigación en Oftalmología (FACO), Caracas, Venezuela.

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J.F. Arévalo, M.D., F.A.C.S. ( )

Chief of Vitreoretinal Division, The King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia

Professor of Ophthalmology, Wilmer Eye Institute, The Johns Hopkins University, Baltimore, MD, USA e-mail: arevalojf@jhmi.edu

R.A. Garcia, M.D.

Retina and Vitreous Department, Clínica Oftalmológica El Viñedo, Av. Andres Eloy Blanco con calle 139. El Viñedo, Valencia, Carabobo 2001, Venezuela

e-mail: rafagarcia77@yahoo.com

L.S. Tata, M.D.

Vitreoretinal Service, Clínica Oftalmológica El Viñedo, Av. Andrés E. Blanco c/calle 13, Valencia, Carabobo 2010, Venezuela

e-mail: luismiguelsuarez@gmail.com

C.A. de Amorim Garcia, M.D., Ph.D. Department of Ophthalmology, Federal University

of Rio Grande de Norte, Rua Ceara Mirim 316, Tirol, Natal, Rio Grande do Norte 590202-240, Brazil e-mail: prontoc.de.olhos@digi.com.br

F. Orefice

Department of Oftalmologia, Hospital São Geraldo,

HC/UFMG, Rua Espirito Santo 1634/102 CEP 30160-031,

Belo Horizonte, Minas Gerais 30160-031, Brazil

e-mail: F.Orefice@terra.com.br

A.L.L. Curi, M.D., Ph.D.

Fundação Oswaldo Cruz - Fiocruz, Instituto de Pesquisa Clínica Evandro Chagas – IPEC, Centro Hospitalar,

Av. Brazil 4365 Manguinhos, Rio de Janeiro 21040900, Brazil

e-mail: andre.curi@ipec.fiocruz.br

E.T. Cunningham Jr., M.D., Ph.D., M.P.H.

The Uveitis Service, Department of Ophthalmology,

California Pacific Medical Center,

San Francisco, CA, USA

e-mail: Emmett_cunningham@yahoo.com