Cytomegalovirus retinitis in pre-HAART AIDS patients in China.

Editor, Despite increasing public awareness and concern of HIV/AIDS in China, there has been only a paucity of data on HIV/AIDS-related retinal diseases for China. We therefore conducted this study to assess the prevalence of cytomegalovirus retinitis (CMVR) in AIDS patients in China examined and treated before the highly active anti-retrovirus therapy (HAART) was introduced. The retrospective study included patients suffering from AIDS, who were consecutively treated in the period from 2009 to 2011 in a tertiary hospital specialized for infectious diseases and who had not undergone HAART therapy. The ethics committee of the Beijing Di Tan Hospital approved the study. After obtaining a detailed medical history, all patients underwent a medical examination including blood cell analysis and biochemical blood examination. A comprehensive ocular examination was carried out. The diagnosis of AIDS was based on the 1993 Centres for Disease Control and Prevention case surveillance definition of AIDS. CMVR was characterized by a necrotizing retinitis at the posterior pole of the eye (Jensen et al. 1984; Sanders et al. 1993; Seregard 1994). Microvascular retinopathy was defined by cotton wool spots or retinal haemorrhage or microaneurysm. Optic neuropathy was characterized by haemorrhages, oedema or pallor of the optic nerve head (Kallenbach & Frederiksen 2008). The study included 173 consecutive patients with a mean age of 39.5 ± 11.5 (range; 8–79 years). The infection route was through sexual contacts [heterosexual: 52 (29.9%); homosexual: 31 (17.8%); bisexual: 1], transfusion of infected blood products [34 (19.5%) patients], injection of narcotic drugs [3 (1.7%) patients], mother to baby transmission (one patient) and unknown [51 (29.3%) patients]. Prevalence of CMVR detected in 45 eyes of 35 (20.2%) patients was significantly associated with a CD4+ T cell count <50 cells/μl (Table 1). Microvascular retinopathy was present in 57 (32.9%) patients (cotton wool spots: 23.7%; retinal haemorrhages: 11.6%). An optic neuropathy was detected in 23 (13.3%) patients, with optic disc pallor being the main type (50%), followed by CMVR involving the optic nerve head (30%). Visual impairment present in 10 (5.8%) patients was due to CMVR (n = 3 patients), optic neuropathy (n = 3), uveitis (n = 1), cataract (n = 1) and unknown reasons (n = 2). Blindness present in 3 (1.8%) patients was caused by CMVR at the posterior pole (n = 2) and optic neuropathy (n = 1). The prevalence of fundus lesions in our study population was lower than in populations included in previous investigations from Western countries before the HAART era, but it was higher than in previous reports from mainland China (Wang et al. 2012). Wang et al. (2012) reported recently that in 718 HIV/AIDS patients from Eastern China, CMVR was the most common ocular complications, with a prevalence of 10.6%. Based on the optic disc morphology, the prevalence of optic neuropathy was 13% in our study. We might have underestimated the frequency of optic neuropathy because we did not perform perimetry nor did we measure the thickness of the retinal nerve fiber layer. Main limitations of our study were that it was a retrospective hospital-based study with a relatively small number of patients and a potential selection bias; and that the diagnosis of CMVR was made based on the ophthalmoscopic appearance of retina and not biochemical examinations of aqueous humour samples. In conclusion, before introduction of HAART therapy into China, a CMVR was detected in about 20% of patients with AIDS, while 33% of the AIDS patients showed a microvascular retinopathy and 13% of the patients had optic neuropathy. These figures may serve as baseline values to assess the effect of HAART after its clinical introduction in China.