VS206C: Anatomy and Physiology of the Eye
CASE 6: NON-COMPLIANCE (IMMUNOLOGY CASE 3)
Craig, a 35-year old male, presents complaining of red, itchy and watery eyes. These symptoms have been occurring
daily for the past 6 days.
A detailed history reveals that Craig moved to the Bay Area from New York 18 months ago in October, 2010. He
works in San Francisco, but lives in the Oakland Hills. He notes that his eye problems seem worse late in the
evenings and in the early morning. On further questioning he reveals that for the past 4 months, a small area of his
left eye has been bright red. He had not been particularly worried about the redness since that eye had not been
uncomfortable until this last week, and he attributes the problem to job fatigue. On further questioning Craig
comments that his vision has changed somewhat over the last 12 months, and feels this indicates that his glasses need
to be updated.
When asked about his general health, Craig states that he was diagnosed as being HIV+ 13 years ago. He didn’t
begin treatment until about a year after diagnosis, and at that point was taking three medications whose names he
can’t recall. He admits to not having been very good with compliance some of the time because of the complexity
and cost of the treatment. He is currently taking Atripla, but again has had difficulty with compliance due to the cost
of the medication and problems with obtaining insurance coverage.
Vision with his 4-year old glasses for high hyperopia is measured as 20/40 OD, 20/30 OS. Refraction shows that he
has become more hyperopic (+0.75 OU).
Biomicroscopy results: Bilateral conjunctival hyperemia, mild chemosis, and the lower palpebral conjunctivae show
a mild papillary reaction. The temporal third of the lower fornix of the left eye is blood red. The underlying sclera is
not at all visible in this area, and the central portion looks slightly raised.
Ophthalmoscopy: A few cotton wool spots are observed OU. In addition, there are 3 small creamy white round
lesions, 2 in the left eye and 1 in the right. These range from 1/8 to 1/4 disc diameters in size. The one that is in the
left eye is 1/8 away from the macula. Furthermore, in the left eye there is also an oval shaped sharply demarcated
white lesion 2 disc diameters in size inferior nasal to the optic nerve head.
A diagnosis of HIV retinopathy with secondary opportunistic infection by Candida albicans is made. Infection with
Toxoplasma gondii is also suspected. Craig is referred for treatment and a thorough workup of his general condition.
He is prescribed Pataday for what is presumed to be allergic conjunctivitis.
Non-Compliance Part 1 - Most important topics to cover
Immunity to fungi, protozoa and other parasites
The role of CD4+ cells and NK cells
Tumor immunology
Type 1 hypersensitivity
Guiding questions
Immunology (These are the most important questions)
What is the pathogenesis of AIDS? What does it do to the immune system?
Toxoplasma gondii is a protozoa. How would you expect a normal immune system to deal with it?
Candida albicans is a fungi. How would the normal immune system normally deal with it?
Why are patients infected with HIV prone to these infections more than they are to most bacterial infections?
How do these pathogens get into the eye? Are they there anyway, or do they gain access due to immune
compromise?
How would the immune system deal with a large parasite, for example one that is larger then 1 mm in size?
How does the immune system normally deal with tumor cells?
Why are AIDS patients predisposed to tumors?
How can someone with this type of immunodeficiency have a hypersensitivity reaction? Can they have all 4 types of
hypersensitivity?
©Copyright 1998 by the School of Optometry, University of California, Berkeley. Written by S. Fleiszig, OD, PhD.
Clinical
Apart from cotton wool spots, what other signs might you look for in HIV retinopathy?
Should Craig be treated for Toxoplasmosis?
Why is his vision reduced with his glasses?
How would you treat the Kaposi's sarcoma?
Would you expect to find Kaposi's sarcoma elsewhere?
Would you expect Craig to have other non-ocular signs of HIV infection?
Why hasn't Craig had allergic conjunctivitis before? (Clue: consider lifestyle issues; i.e. why didn't he have allergies
in New York, and why not 1 year ago when he was already in the Bay Area?)
Why are the allergies worse in the evening?
References
The references are listed by subject rather than by book. Copies of most of the references listed below are on reserve.
HIV
Immunodeficiency:
- Sunshine, Coico (2 copies on reserve)
Acquired Immunodeficiency Syndrome – General
- Roitt’s Essential Immunology. (1 copy on reserve)
- http://www.merck.com/mmpe/sec14/ch192/ch192a.html
Acquired Immunodeficiency Syndrome - Ocular
- Alexander. Primary Care of the Posterior Segment (1 copy on reserve)
- Pepose: Ocular Infection and Immunity. (1 copy on reserve)
The Immune Response to Fungi and Protozoa
- Roitt’s Essential Immunology. (1 copy on reserve)
- Mim's Pathogenesis of Infectious Disease (2001): (1 copy on reserve)
- Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases (2000). “Natural Killer Cells”: (3
copies on reserve in folders: VS206C No. 6)
Ocular Toxoplasmosis
- Kanski Clinical Ophthalmology. (2 copies on reserve)
- Alexander. Primary Care of the Posterior Segment (1 copy on reserve)
- Albert. Principles and Practice of Ophthalmology: Basic science (1 copy on reserve)
- Pepose. Ocular Infection and Immunity. (1 copy on reserve)
Ocular Candida albicans
- Pepose. Ocular Infection and Immunity. (1 copy on reserve)
- Albert. Principles and Practice of Ophthalmology: Basic science (1 copy on reserve)
Tumor Immunology
General
- Sunshine, Coico (2 copies on reserve)
- Roitt’s Essential Immunology. (1 copy on reserve)
Ocular
- Pepose: Ocular Infection and Immunity. (1 copy on reserve)
Non-pigmented conjunctival tumors
- Kanski: Clinical Ophthalmology. (see section on Kaposi's sarcoma) (1 copy on reserve)
Type 1 hypersensitivity
General Immunology
- Sunshine, Coico (1 copy on reserve)
- Roitt’s Essential Immunology. (1 copy on reserve)
Allergic conjunctivitis
- Pepose: Ocular Infection and Immunity. (1 copy on reserve)
©Copyright 1998 by the School of Optometry, University of California, Berkeley. Written by S. Fleiszig, OD, PhD.
Non-Compliance - Part 2
Follow-up
Craig returns three weeks later to pick up his new glasses. He comments that the drops that he was given helped the
allergies. He is no longer using them.
A letter sent from his physician states that Craig was treated with intravenous Amphotericin B for Candidiasis, which
has supposedly subsided. The suspected Toxoplasmosis infection/scar was diagnosed as a coloboma based on its
appearance, the lack of other signs, and the fact that he has no serum antibody against the protozoa. He had been
diagnosed with Acquired Immmune Deficiency Syndrome (AIDS) based on a CD4+ cell count of 190 cells/µl. He is
now undergoing drug resistance testing. Various medical specialists have diagnosed a number of the other usual
complications of this disease.
Biomicroscopy: Both eyes look quiet except for the Kaposi's sarcoma of the left eye, which has not increased in size.
Ophthalmoscopy: Similar to the last visit, except that the 3 active Candidiasis lesions now appear as hypopigmented
scars with central hyperpigmentation.
Guiding questions
What is a coloboma? How does this occur? Why was there confusion about the etiology of the coloboma?
What can result from poor compliance with HIV treatment regimens?
©Copyright 1998 by the School of Optometry, University of California, Berkeley. Written by S. Fleiszig, OD, PhD.