Etiological Paradigm Shift, Sentinel Ocular Presentations, and Visual Recovery Dynamics in HIV-Associated Uveitis: A Retrospective Cohort Study at an Academic Referral Center in West Sumatra, Indonesia

Abstract

Background: Uveitis frequently serves as the critical sentinel clinical manifestation unmasking occult Human Immunodeficiency Virus (HIV) infection. In the contemporary combination antiretroviral therapy (cART) era, shifting epidemiology has transformed opportunistic intraocular infections.

Objective: To evaluate the sociodemographic profile, CD4+ immunological status, anatomical phenotypes (SUN criteria), infectious etiologies, and visual acuity outcomes in HIV-infected patients presenting with active uveitis.

Methods: A retrospective cohort study was conducted at Universitas Andalas Hospital, Padang, Indonesia (February 2023–August 2026), reviewing consecutive HIV patients presenting with active uveitis. Ophthalmic assessments included best-corrected visual acuity (LogMAR), slit-lamp biomicroscopy, funduscopy, ultrasonography, and serology. Visual changes post-targeted therapy were analyzed using the Wilcoxon signed-rank test.

Result: Seventeen patients (34 eyes) were enrolled, demonstrating striking male predominance (94.1%) with a mean age of 33.1 ± 7.6 years. Crucially, 82.4% (n = 14) were newly diagnosed with HIV at ocular presentation. Panuveitis was the predominant phenotype (70.6%), presenting bilaterally in 52.9%. Ocular syphilis (Treponema pallidum) emerged as the leading etiology (82.4%), followed by cytomegalovirus retinitis (11.8%). Post-therapy, the legal blindness rate (< 20/400) halved from 35.3% to 17.6%. Mean visual acuity improved from LogMAR 1.00 ± 0.91 to 0.74 ± 0.87 (p = 0.055). Overall, 41.2% of eyes improved, 50.0% remained stable, and 8.8% deteriorated due to irreversible macular scarring.

Conclusion: Severe uveitis, particularly syphilitic panuveitis, represents an indispensable sentinel marker for occult HIV in young males. Routine reflex dual-screening for HIV and syphilis is strongly recommended in atypical uveitis, as prompt targeted therapy achieves substantial functional visual salvage.