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Background: Retinal vascular occlusions are known causes of acute visual impairment. Prior studies have found an increased risk of retinal vascular occlusion among individuals with human immunodeficiency virus (HIV). However, these studies were conducted between 1983 and 1998, prior to the establishment of antiretroviral therapy (ART), which has since significantly improved HIV-related morbidity and mortality. While more recent case reports suggest a continued disease burden, no large-scale studies have examined this association in the ART era. We aim to determine the incidence and risk of retinal vascular occlusion, including retinal artery occlusion (RAO) and retinal vein occlusion (RVO), in HIV patients since widespread ART access.
Methods: We conducted a retrospective cohort analysis of healthcare data from May 2005 to May 2025 within the TriNetX global network. Adults ages 18 to 65 with HIV were compared to age-matched controls with dry eye syndrome. All patients were assessed by an ophthalmologist and excluded if they had prior history of retinal vascular occlusion. Propensity score matching (PSM) was used to balance demographics and comorbidities, including hypertension, diabetes mellitus, hyperlipidemia, and nicotine dependence. Incidence and relative risk (RR) of RAO and RVO were compared between cohorts. We calculated hazard ratios (HR) with 95% confidence intervals (CI) to stratify risk according to CD4 count (<100/µL vs. >100/µL) and viral load (< 200 copies/mL vs. > 200 copies/mL).
Results: After PSM, 26,736 patients were included in each cohort. HIV patients had an increased risk of RAO compared to controls (0.25% vs. 0.15%, RR=1.72, p<0.01); however, there was no significant difference in RVO outcomes (0.27% vs. 0.27%, RR=0.99, p=0.99). Among HIV patients, CD4 count <100/µL was associated with increased RAO risk (HR=1.83, p=0.02, 95% CI 1.11-2.99), but not RVO risk (HR=1.43, p=0.12, 95% CI 0.91-2.24). CD4 count >100/uL was not found to increase the risk of either RAO (HR=0.87, p=0.45, 95% CI 0.60-1.26) or RVO (HR=0.95, p=0.78, 95% CI 0.68-1.33). Viral load <200 copies/mL was not associated with a significant risk of RAO (HR=0.66, p=0.14, 95% CI 0.38-1.14) or RVO (HR=1.19, p=0.45, 95% CI 0.76-1.86).
Conclusion: HIV infection was associated with an increased risk of RAO, but not RVO, compared to controls. Given that the elevated RAO risk was concentrated among those with severe immunosuppression, these findings support early initiation of ART to mitigate HIV-associated RAO risk. Additionally, HIV screening may be warranted in atypical or unexplained cases of RAO.
