Imaging of Long-term Retinal Damage after Resolved Cotton Wool Spots

Purpose: Patients infected with the human immunodeficiency virus (HIV) develop noninfectious retinopathy characterized by retinal cotton wool spots (CWS) and microvascular abnormalities. Ophthalmoscopically, CWS fade with time. We hypothesized that structural changes should be permanent and possibly visible well after ophthalmoscopic resolution. We used simultaneous spectral domain optical coherence tomography (SD-OCT)/scanning laser ophthalmoscope (SLO) to allow colocalization of the lesions and determine the extent and location of residual damage after ophthalmoscopic resolution of the lesions. Design: Retrospective, noninterventional case series. Participants: Eight eyes of 7 HIV patients with 19 resolved retinal CWS. Methods: Nineteen retinal CWS were imaged between 2 and 16 years (median, 7.84) after the acute lesions using simultaneous SD-OCT and SLO examinations. The areas of the previous CWS were scanned by overlaying the color retinal image over the SLO image and scanning at high resolution in the horizontal plane through the resolved lesion. Each CWS lesion had a control area taken from the same eye within 2 disc diameters of the lesion. The thickness of each of the retinal layers was compared between lesions and control areas using a paired t-test with multitest correction. Main Outcome Measures: Thickness of the retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), inner plexiform layer (IPL), inner nuclear layer (INL), outer plexiform layer (OPL), and outer nuclear layer (ONL). Results: The greatest loss of thickness was seen in the retinal GCL with a 43% reduction in thickness. There was a statistically significant thinning of the RNFL, GCL, IPL, INL, and OPL. The median thickness differences ranged from 5 to 7 microns. This difference was highly significant. Another striking finding was the displacement of the ONL toward the retinal surface resulting in an apparent increase in thickness of the ONL by >15% (median difference, 12 microns). Conclusions: Our data, using ultrahigh resolution and high-speed SD-OCT/SLO, show and quantify the presence of permanent retinal destruction associated with retinal CWS in HIV disease.