Unexplained inflammation could indicate HIV infection

ATLANTA – HIV can present in any part of the eye, according to a presenter here at SECO. “Anytime you see unexplained inflammation, HIV infection needs to be a consideration,” PRIMARY CARE OPTOMETRY NEWS Editorial Board Member Leo P. Semes, OD, told attendees at a continuing education session on AIDS and infection control.

Adnexal manifestations include herpes zoster, Kaposi’s sarcoma, molluscum contagiosum and conjunctival microvasculopathy, which is seen in 70% to 80% of HIV-infected patients, he said.

Anterior segment manifestations include keratoconjunctivitis sicca, infectious keratitis and iridocyclitis.

In the retina, clinicians may see microvasculopathy, infectious retinitis, infectious choroiditis and immune recovery uveitis/vitritis.

Orbital manifestations are uncommon, but may include lymphoma and orbital cellulitis, Dr. Semes said. Ten percent to 15% of HIV-infected patients will experience neuro-ophthalmic manifestations such as papilledema, cranial nerve palsies, ocular motility disorders and visual field defects.

Dr. Semes recommended the use of OraQuick for HIV suspects. He said it is a rapid in-office HIV test that can be done with a cheek swab or finger stick.

“This is a relatively good test,” he said. “Sensitivity is 99.3% and specificity is 99.9%. If there’s a suspicion and you run this test and it’s negative, it’s unlikely that the patient has HIV. You get results in 20 to 40 minutes.”

Optometrists can prevent HIV transmission in the office by sterilizing equipment.

“Items considered ‘critical’ were purchased sterile and must be sterilized between patients because they’ll enter sterile tissue or the vascular system,” Dr. Semes said. Critical items include surgical instruments, needles, implants and cannulae, he said.

“Semi-critical” devices come in contact with mucous membranes or nonintact skin and require high-level disinfection. These may include thermometers, tonometer tips, gonioscopy lenses and PMMA contact lenses, Dr. Semes said.

“Noncritical devices, including phoropters and the head rest on slit lamps, come in contact with intact skin and can be cleaned with low-level disinfection, such as an alcohol wipe,” he said.

Dr. Semes offered some practical recommendations. “We soak our tonometer heads and gonio prisms in hydrogen peroxide,” he said. “We use alcohol for the handle. If items are amenable to the autoclave, that’s our highest level of disinfection.

“An Alger brush will require prior cleaning and then have to undergo sterilization if you’re going to be the safest with it,” he continued. “Glutaraldehyde is very corrosive. If you have it in your office, you’re supposed to follow OSHA guidelines about how it’s stored, who handles it, how you clean up a spill … it gets complicated.”

Dr. Semes recommended referencing the Healthcare Infection Control Practices Advisory Committee’s Guideline for Disinfection and Sterilization in Healthcare Facilities.

“The good news is that universal precautions are not required for tears,” Dr. Semes said. “Maybe you want to make sure if you have a cut on your finger or any other open skin that you are protected. Considering wearing gloves if you come in contact with tears, saliva, sputum, sweat, vomitus, nasal secretions, urine, feces, etc.

“If you are exposed, there is a post-exposure protocol: a 4-week course of zidovudine and lamivudine,” he continued. “The expanded regimen adds indinavir or melfinavir. Then you follow up with appropriate testing.”