EYE DISORDERS

VENEREAL EYE DISEASE

Venereal eye disease? Strangely enough, nearly all diseases which are considered to be sexually transmitted diseases can have significant ocular involvement. This can occur as a direct infection, as with gonorrhea or chlamydia, or as a secondary infection, as with AIDS. Therefore, it is important to inform your ophthalmologist of any sexually transmitted diseases which you may have been treated for if you are having an eye problem. These diseases include:

Herpes

Herpes is a virus which commonly causes sexually transmitted disease, usually in the form of genital ulcers. In women, active and potentially contagious ulcers may give no symptoms. Fever blisters are also caused by the herpes virus, although usually a different strain of the virus. Both strains can cause eye disease by direct infection. Once herpes causes an infection, the virus can become dormant in a nerve supplying sensation to the area infected. At a later time (sometimes years) a recurrent infection can then occur if the virus becomes reactivated.

Eye Involvement

Conjunctivitis

The first time that the herpes virus infects the eye, it can cause conjunctivitis, or "pink eye". Usually one eye would be involved, and it may be a mild or even unnoticed infection. Possible symptoms could include eye redness, watery discharge, blister formation on the eyelids, and a scratchy sensation. Once the infection runs its course, a reactivation could occur at a later date.

Corneal disease

The cornea can be affected usually as a reactivation of a prior ocular herpes infection. Usually, one eye is involved, but both could be. Genital herpes does not have to be active at the same time as the corneal infection. The cornea is the clear part of the eye through which we see. Symptoms could include eye redness, scratchy sensation, pain, sensitivity to light, and blurred vision. Herpes involving the cornea tends to leave scars, which could permanently affect the vision. Treatment is available in the form of antiviral eyedrops, and close follow-up with an ophthalmologist is advised to prevent visual loss.

Iritis

Iritis is inflammation within the eye, similar to how arthritis is imflammation within a joint. Herpes can cause iritis by itself, or in combination with a corneal infection. Symptoms of iritis usually can include sensitivity to light, aching, and blurred vision. Treatment is with anti-inflammatory eyedrops with or without antiviral eyedrops, and close follow-up by an ophthalmologist.

Syphillis

Syphillis is re-emerging as a common sexually transmitted disease, even though it is easily treated by penicillin. The organism causing this is a spirochete, or a sort of spiral shaped bacteria. When it is first acquired, an ulceration can occur at the genital area of contact (about 3 weeks after exposure), but this usually disappears without treatment. Women may not notice the ulceration if it is internal. The disease is contagious while this ulceration is present. The disease then goes through different stages, and can involve many different parts of the body, including the brain and eyes. Laboratory testing can confirm the active and inactive stages of the disease.

Eye Involvement

Corneal disease

The cornea, or clear part of the eye, can be involved in the early stages of syphillis by a condition called "interstitial keratitis". This can lead to scarring of the cornea and visual loss. Treatment is by treating the underlying disease (the syphillis itself).

Iritis

Syphillis may be a relatively common cause of intraocular inflammation, or iritis. Symptoms can include eye redness, pain, sensitivity to light, and floaters. Treatment is with ocular steroids, and by treating the underlying syphillis if it has not been treated.

Optic nerve involvement

In advanced and long term (years) untreated syphillis, the central nervous system can be involved (the brain and spinal cord). The optic nerve can also be affected, leading to inflammation or degeneration of the nerve. The main symptoms could be a loss of vision and blind spots in the peripheral vision. Treatment is by intravenous penicillin for at least 10 days.

Other ocular structures

Syphillis can involve nearly every part of the eye, including the retina, the gland that produces tears, and the muscles that control eye movement. Changes in the pupil shape can also occur.

Acquired Immune Deficiency Syndrome (AIDS or HIV)

The HIV virus does not usually cause eye disease in and of itself. However, the way that the immune system becomes suppressed in AIDS can lead to unusual eye conditions that normally would not affect a person with a normal immune system. These conditions can affect nearly every part of the eye, orbit, and entire visual system. Some of the more common problems are discussed here:

Manifestations of AIDS affecting the external part of the eye

Dry Eye

Patients with AIDS are more prone to developing a dry eye problem due to inflammatory disease affecting the tear glands themselves.

Kaposi's sarcoma

Kaposi's sarcoma is a malignancy which can affect up to 30% of patients with AIDS. This can involve the eyelids also, as a violet colored, flat or nodular growth. This can also involve the conjunctiva, or lining over the white part of the eye. Different treatment options are available for this disorder.

Molluscum Contagiosum

This disorder can occur in non-AIDS patients as small flesh-colored nodular growths on the skin which tend to spread. In AIDS, there tend to be much larger and more numerous growths, and these often will recur after excision. The growths are caused by a virus, which can cause eye irritation if located at the edge of the eyelid.

Corneal infection

There is a risk of spontaneous corneal infection in patients with AIDS, especially when associated with IV drug abuse. Unusual causes of infection, such as fungus infections, and more difficult to treat infections may be encountered. There may be greater risk of reactivation of viral infections affecting the cornea such as herpes virus and shingles (reactivation of the chicken-pox virus, or zoster).

Internal ocular complications of AIDS

AIDS retinopathy

This is a finding that can be seen in the retina of patients with AIDS, but usually does not indicate infection of the retina. Small white patches can be seen scattered in the retina, called "cotton wool spots". Usually these have no visual consequence, and similar findings can be seen in the retina with other vascular diseases such as diabetes.

CMV retinitis

Cytomegalo virus (CMV) infection of the retina can cause significant visual loss in AIDS patients. This virus is usually acquired during life as a flu-like illness, and then becomes dormant. However, with AIDS it can reactivate in numerous locations in the body. With retinal infection, symptoms can include seeing floaters, developing a blind spot in part of the vision, or experiencing loss of vision. Any AIDS patient with these symptoms should be seen rapidly by an ophthalmologist. The condition can be treated by IV anti-viral medication, and by other means. There may be a chance of retinal detachment with this condition as well.

Toxoplasmosis retinits

Toxoplasmosis is a parasite that most people are exposed to at some point in their lives, but it usually does not cause disease. Cat feces and raw or undercooked meat are common sources. Once in the body, the organism becomes dormant and encysted. In AIDS, it can become reactivated in the eye and brain. With a retinal infection, symptoms usually include severe floaters and blurred vision due to inflammatory debris being liberated into the fluid filled center of the eye. The eye may become red and painful due to inflammation. Pain is not usually experienced with CMV retinitis. The vision can be permanently affected by this condition. Treatment is with certain oral antibiotics, but toxoplasmosis may recur.

Viral diseases

Herpes and Shingles (chicken-pox virus) may both cause retinal infection. Antiviral medication may treat the condition. Fungal infections and syphillis can also affect the retina.

AIDS related disorders affecting the orbit and optic nerves

Orbital diseases

The orbit (or the boney socket that holds the eye, muscles, and nerves) can be affected by AIDS. Disease of the orbit usually causes eye protrusion, lid swelling, double vision, blurred vision, and possibly pain. Non-infectious causes can include cancer such as lymphoma. Inflammation of the orbital contents (pseudo-tumor) can simulate a growth or infection behind the eye. Infectious causes can include aspergillosis (a fungus) spread from the sinuses.

Optic nerve disorders

Swelling of the optic nerve (papilledema) can be causes by infections involving the brain such as toxoplasmosis or lymphoma. An actual infection of the optic nerve by cryptococcus (a fungus) can cause swelling of the nerve leaving the eye with a sudden loss of vision (often in both eyes). Syphillis can also cause infection of the optic nerves.

Importance of Early Detection of Ocular Problems from AIDS

From the above discussion, it may seem that there are a hopeless number of possible ocular problems related to AIDS. Fortunately, however, nearly all of the listed conditions are treatable, especially if caught in the early stages. It is important for any person with AIDS who develops a red eye, blurred vision, floaters, a painful eye, or double vision to seek medical attention immediately. Sometimes an ocular condition can signal an infection in the brain or elsewhere in the body, so immediate treatment can benefit more than just the vision.

Ocular infection with Gonorrhea

Gonorrhea is a common sexually transmitted bacterial disease and can also be present as a urinary tract infection. Serious gonorrhea infections can cause complications involving the joints, heart, skin, liver, brain (meningitis), and eye. Ocular infection with gonorrhea is usually by direct hand to eye spread. A rapid infection of the lining over the eye and inside of the eyelids can ensue (conjunctivitis), with severe pus-like discharge. The cornea can be directly involved (corneal ulcer), and spread even into the eye is possible.

Treatment of the condition is by appropriate antibiotics, usually given IV or IM (injection into a muscle). Irrigation of the eye itself can help, as can local antibiotics onto the eye. Usually, testing for other venereal diseases such as syphillis and chlamydia are performed, and sexual contacts may need treatment as well.

Ocular infection with Chlamydia

Chlamydia is an organism similar to a bacteria which frequently causes urinary tract disease and genital disease (often without symptoms in women). Ocular spread occurs in about 1 in 300 cases of genital disease. A conjunctivitis (pink eye) results, often starting in one eye. Symptoms are similar to the typical viral conjunctivitis which adults can get, including a red, itchy eye with mucoid or watery discharge. The cornea can be irritated in some cases leading to a scratchy sensation. The infection is often long-lasting (more than 2 weeks), and does not respond to eye antibiotics alone.

Treatment is with oral antibiotics, once the disease is suspected. This will also treat any urinary or genital infection as well. The duration of treatment is usually 3 weeks, and sexual contacts should be tested and treated as well.

Ocular infestation with lice

Oddly enough, the species of lice which can reside on the eyelashes is the same as that found in the pubic region, the "crab louse" (Phthirus pubis). Thus, this can be considered a venereal disease, and is usually acquired from sexual contacts. The common head or body louse usually does not invade the area around the eyes. Red itchy eyes and eyelids are common symptoms, and there may be a history of lice elsewhere on the body. The creature can be seen under magnification at the base of the eyelashes, and "nits", or small white eggs, can also be seen. Treatment is by physically removing any lice seen, and be applying an ointment to the eyelids and lashes for 10 days to smother any remaining lice. Other areas with hair should be washed with a shampoo designed to kill lice (available over the counter). These shampoos should not be used around the eyes. All clothes, bedsheets, etc. of all family members and sexual contacts should be washed and dried at the highest possible temperatures.