LASIK Surgery in HIV Positive Patients
When HIV was first recognized by the Center for Disease Control 30 years ago, it was considered a lethal disease. Since that time, advances in research, and the development of highly active anti-retroviral therapy (HAART) have resulted in the transition of HIV from a deadly illness to a chronic disease. The World Health Organization estimates that advances in HIV treatment have added 14.4 million life years to patients with HIV worldwide.
As HIV/AIDS patients live significantly longer lives, more patients are requesting LASIK refractive surgery to address visual acuity issues. The United States FDA recommendations list HIV infection as a relative contraindication for LASIK surgery; however a number of practitioners believe that LASIK can be safely and effectively performed in HIV positive patients, so long as patients are appropriately selected, and practitioners adhere diligently to universal precautions.
The most recent WHO data estimates the global prevalence of HIV/AIDS at 33.4 million people, with the United States representing approximately 1.5 million of those cases. Globally, the disease burden is highest in Africa and Southeast Asia, where access to HAART is limited.
In the United States, Western Europe and Canada, the disease is most prevalent in minority populations. African Americans represent 45% of all newly reported cases of HIV infection in the US. The majority of these patients theoretically have access to HAART, however there is evidence that a significant minority either remains unable to access treatment, or has opted out of treatment. A recent study of HIV positive patients in Washington, DC found that while 89% of the patients met criteria for HAART treatment, only 52% were receiving treatment at the time of study.
There is no epidemiological data available on the number of HIV positive patients who receive refractive surgery annually. In a mailed survey of refractive surgeons, Aref et al found 54.2% reported having performed LASIK on an HIV positive patient, while 42.4% states they had not performed LASIK on this patient population, however the number of cases performed was not reported.
Ocular Complications of HIV
Historically, HIV infection was associated with a wide variety of ocular complications. Prior to widespread implementation of HAART, 50-75% of the HIV/AIDS population experienced significant ocular complications at some point during their lifetime.
The most common eye condition associated with HIV infection is CMV retinitis, which generally occurrs in AIDS patients with a CD4 T lymphocyte count of less than 50/mm3. In the pre-HAART era, 21-44% of AIDS patients developed this complication. The vast majority of reported cases were due to reactivation of latent infection. CMV retinitis initially manifests as blurred or lost central vision, scotomas, floaters, or photopsia; and can progress rapidly to serious visual impairment depending on the area of the retina involved.
It is rare for CMV to affect the anterior segment of the eye.
HIV positive patients have a 15-25% greater risk of developing zoster during their lifetime versus the general population, and are also significantly more likely to experience ocular involvement , termed herpes zoster ophthalmicus (HZO). In this patient population, HZO is often more severe, harder to treat, has an extended disease duration and can lead to viremia.
Corneal complications are common in HZO, and occur in approximately 65% of cases. The earliest manifestation of corneal involvement is punctate epithelial keratitis, which often progresses into dendritic lesions. Left untreated, progressive corneal involvement can lead to vision loss.
Herpes Simplex Virus
Herpes simplex keratitis is the most common cause of chronic ocular infections in the United States, with an estimated annual incidence of 20.7 cases per 100,000 individuals. There is no strong evidence to indicate that immunosuppression or HIV infection is a risk factor for developing HSV keratitis, however given the high prevalence of HSV co-infection among HIV positive patients, a significant percentage of HIV positive patients are affected by HSV keratitis each year.
It is believed that infection with HIV does not put an individual at higher risk for developing bacterial eye infections. However, some HIV associated eye conditions, specifically those resulting in eyelid abnormalities such as molluscum contagiosum and Kaposi sarcoma (both of which are more common in HIV/AIDS patients) can increase the risk of infection, as can keratoconjunctivitis sicca, which is also more prevalent in the HIV positive population.
Impact of HAART
Since the advent of HAART, the reported incidence of CMV retinitis has dropped by 80%. Currently, CMV retinitis only occurs in patients with advanced AIDS who have either failed, declined or were unable to access HAART.
The introduction of HAART has also significantly reduced the cases of zoster in HIV positive patients. In the pre-HAART era, incidence was 17 cases per 100 patients; since HAART, the reported incidence is down to 5 cases for every 100 patients . This has led to a significant drop in the number of reported cases of HZO in HIV positive patients.
LASIK in Patients With HIV/AIDS
There is very little data available on the safety and efficacy of LASIK in HIV positive patients. Currently, the US FDA considers HIV positivity a relative contraindication to refractive surgery, and the American Academy of Ophthalmology has no official opinion.
There are two primary concerns that led to the US FDA issuing their recommendation: the risk of infection in immunosuppressed patients, and the risk of viral transmission via the laser.
Risk of Transmission
Anecdotal reports from refractive surgeons seem to indicate a significant majority feel confident there is minimal risk for viral transmission via the laser equipment. There are no reports in the literature of HIV infection transmission due to LASIK surgery that might contradict this opinion. Despite this belief, a recent study on the practices of refractive surgeons indicates most surgeons (72.7%) who preform LASIK surgery on HIV positive patients do take additional precautions. Precautions included unilateral surgery, scheduling the patient for the last surgery of the day, wearing double gloves and immediate postoperative evacuation the laser plume.
LASIK in Patients HIV Positive Patients
There is limited literature evaluating the safety and efficacy of LASIK in patients with HIV positivity but without evidence of AIDS. Anecdotal reports from refractive surgeons indicate the majority believe LASIK can be safely performed in these patients without significant increased risk for infection. Aref et al found that 58% of US practitioners believe HIV positive patients without any AIDS defining characteristics were acceptable candidates for LASIK, while only 14% believed it was an absolute contraindication to surgery.
There is one case report of post-LASIK bilateral bacterial keratitis in an HIV positive patient. Additionally, Aref et al found 3.4% of survey responders (2 providers) reported postoperative keratitis in HIV positive patients, although the total number of cases was not reported. One survey responder reported an incidence of delayed wound healing and dry-eye.
A prospective observational cohort study was conducted and published recently. Amongst the U.S. Military HIV Natural History Study database which comprises of HIV+ service members and beneficiaries, participants who underwent LASIK/PRK and other refractive surgeries were identified. 79 out of a total of 2073 participants underwent refractive surgery with 53 undergoing PRK, 23 LASIK, 2 Radial keratotomy and 1 astigmatic correction. Complications were reported in 6 patients ranging 8 to 217 days post op; 5 of whom had undergone PRK and one RK. None of the patients undergoing LASIK had a complication. Out of the 6 patients with complications, 3 developed central corneal ulcers, one marginal corneal ulcer, one perforated ulcer and one unspecified keratitis. Type of surgery and prior history of AIDS were identified as risk factors for complications following refractive surgery in HIV+ patients in univariate analysis. However, no risk factors were identified in logistic regression analysis. Four of 6 patients with complications had viral load of >400 copies/ml and 3 out of 6 patients were on HAART at the time of surgery. None of the patients had CD4 counts <200/mm3. 
There are no reports of HZO, HSV keratitis or CMV retinitis following LASIK in this patient population.
LASIK in Patients With AIDS
There are no studies on the safety and efficacy of LASIK surgery in patients with HIV positivity who meet the defining criteria for AIDS (presence of an AIDS defining symptom or CD 4 T lymphocyte count less than 200/mm3). In the observational study conducted on HIV+ patients undergoing refractive surgery, none of the patients who had complications had CD4 count<200/mm3 at the time of the surgery although prior history of AIDS was identified as a risk factor for complications in univariate analysis.
Aref et al found that refractive surgeons are much less likely to perform elective LASIK on this patient population than on those with HIV positivity without evidence of immunosuppression. Only 12.5% of responders believe AIDS patients are acceptable candidates for refractive surgery, while the vast majority (88%) believes it to be a relative or absolute contraindication.
There is a lack of clinical research on this issue, which means the decision on whether to perform LASIK on HIV/AIDS patients varies by practitioner, and is often made on a case-by-case basis. Given these limitations, it is difficult to find broad recommendations; however there seems to be some consensus among practitioners, who agree with the following:
- Elective LASIK surgery should not performed on any patient with evidence of HIV/AIDS related ocular pathology or a history of any recurring ocular infection such as HZO, HSV keratitis or CMV retinitis.
- Elective LASIK surgery should be avoided in patients with HIV positivity and evidence of immunosuppression (AIDS defining condition or CD 4 T lymphocyte count below 200/mm3).
- Current viral load should be taken into account. Surgery should be deferred if viral load is >10,000 copies/ml at the time of planned surgery. 
- Elective LASIK surgery can generally be safely performed in HIV positive patients without evidence of immunosuppression, who do not have history of recurring ocular or eyelid infection.
- HIV positive patients considered for LASIK should be on HAART and compliant with treatment.
- Refractive surgeons should take care when performing LASIK surgery on HIV positive patients to strictly adhere to universal precautions.
- It is not unreasonable for the physician to take extra precautions when performing LASIK on HIV positive patients, such as avoiding bilateral surgery, scheduling the patient for the last case of the day, or evacuating the laser plume immediately after surgery, although there is no evidence of the efficacy of these measures.
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