HIV Infections of the Eyelid, Tear Duct and Conjunctiva

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Photograph © Kyle May

Known as the ocular adnexa, this section of the ocular anatomy provides protection and lubrication to the eye itself and includes the eyelid, tear ducts and conjunctiva (white of the eyes). 

In people with HIV, the most common infections to present within these areas include

Microvascular changes—evidenced by micro-aneurysms and the dilation of veins and arteries—are also known to occur in about 70% to 80% of patients with HIV and may be directly related to the HIV infection itself.

Herpes Zoster

Herpes zoster (HSV) is caused by the local reactivation of the varicella zoster virus (VZV), which travels along a nerve route within in a specific dermatome (i.e., the area of skin supplied by a single nerve). When reactivated on the ophthalmic portion of the so-called trigeminal nerve, it can present with intense pain and small, fluid-filled rash that can often erupt and crust over. The localized infection is then referred to as Herpes zoster ophthalmicus (HZO).

HZO presents in approximately 10% of people with HIV, primarily in those with CD4 counts below 200 cells/mL. Advancing age (60 years or older) can also be a contributing factor to the condition, as well as psychological distress.

Oral acyclovir is the standard course of therapy for HZO, with oral or intravenous steroids regularly prescribed should there be evidence of ocular involvement (e.g., the optic nerve and the eye itself).  Early diagnosis and treatment is key to avoiding damage to the cornea, retina, choroid or optic nerves.

There is a VZV vaccine, which was recommended for use in adults 50 years of age or older by the U.S. Food and Drug Administration (FDA) in 2011. While no formal recommendations have been issued for its use in older adults with HIV, growing opinion tends to support its use in immune competent patients with sustained viral control.

Kaposi Sarcoma

Kaposi sarcoma (KS) is a painless, red-to-purplish skin tumor that is most often associated with severe immune suppression. Caused by the human herpes virus 8 (HHV8), it can present in and around the eyelids of around 20% of cases, often with localized inflammation.

While the incidence of KS has diminished greatly with the advent of combination antiretroviral therapy (cART), it is still can still occur in those with low CD4 counts, particularly if viral suppression is not sustained. With the initiation of cART, shrinkage of the lesions will often occur within a relatively short period of time, disappearing as immune function is restored.

Ocular presentation of KS tumors is extremely rare, although red eyes, dry eyes, photophobia (intolerance of light) and blurred vision are known to occur as a result of tumors around the more sensitive areas of the eyelids and tear ducts.

Molluscum Contagiosum

Molluscum contagiosum is a highly contagious skin infection caused by the molluscum contagiosum virus (MSV). It is spread from person to person by casual contact and cause painless, dome-shaped, fluid-filled lesions on the skin, as well as mucous membranes. The lesions have a hard white core and are usually the same color as a person’s skin, albeit with a waxy appearance.

Molluscum contagiosum most frequently occurs in young children and people with severe immune suppression.  It can present on any of the skin, including around the eye and the eyelid itself. Ocular involvement is seen to be rare. In healthy individuals, the infections are often self-limiting, rectifying themselves

MSV infections tend to be more severe in immune-compromised individuals with HIV. Treatment options are limited and can include topical creams and over-the-counter wart medications for the gradual removal of smaller lesions, or the use of liquid nitrogen or laser therapy for those wanting rapid removal. There is no vaccine for MSV.

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Article Sources

  • Benson, C.; Hua, L.; Andersen, J.; et al. "ZOSTAVAX is generally safe and immunogenic in HIV+ adults virologically suppressed on ART: results of phase 2, randomized, double-blind, placebo-controlled trial." 19th Conference on Retroviruses and Opportunistic Infections (CROI); Seattle, Washington; March 5-8, 2012; abstract 96.
  • Centers for Disease Control and Prevention (CDC). "Clinical Information: Molluscum Contagiosum." Atlanta, Georgia.
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  • U.S. Department of Health and Human Services (DHHS). "Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents: Non-CMV Herpes - Varicella Zoster Virus." Rockville, Maryland.
  • U.S. Food and Drug Administration (FDA). "FDA Approves Zostavax vaccine to prevent shingles in individuals 50 to 59 years of age." Silver Springs, Maryland; a press release issued May 24, 2011.