If you’re living with HIV or AIDS and have been told you need cataract surgery, you’re probably wondering what this means for your eye health—and your overall health too. The good news is, things have changed significantly over the past couple of decades. What used to be a high-risk scenario is now far more manageable, thanks to antiretroviral therapy (ART), improved surgical techniques, and a deeper understanding of HIV-associated eye conditions.
Back in the 1980s and 1990s, patients with advanced HIV had a much higher chance of developing ocular complications like CMV retinitis or HIV-associated uveitis. These weren’t just incidental issues—they significantly impacted cataract surgery planning, outcomes, and post-op recovery. Fast forward to today, and while some challenges remain, cataract surgery can be safely and effectively performed in most HIV-positive patients.
In this article, we’ll walk through what’s changed, what to watch out for, and how the surgical approach is now tailored to your specific needs. Whether you’ve had CMV retinitis in the past, struggle with recurrent uveitis, or are concerned about opportunistic infections, this guide is here to help.
The Legacy of CMV Retinitis: Why It Still Matters
Cytomegalovirus (CMV) retinitis used to be one of the most feared ocular complications in patients with AIDS. Before ART became widely available, it was the leading cause of visual loss in people with AIDS. The retina would become inflamed and necrotic, leaving behind areas of scarring and thinning—particularly in the periphery but sometimes near the macula or optic disc.
If you’ve previously had CMV retinitis, that history matters. Even if your viral load is undetectable now and your CD4 count is strong, those retinal scars don’t go away. During cataract surgery, the surgeon must carefully assess whether your visual potential is limited by this prior damage. OCT scans and fundus photography are essential to set realistic expectations before going into surgery.
Another consideration is whether there are active or reactivated areas of retinitis. Although this is now rare, it can still occur—especially in those who have interrupted or poor adherence to ART. Reactivation risk may influence surgical timing, with some surgeons opting to delay surgery until full ocular stability is confirmed.
HIV-Associated Uveitis: Inflammation That Lingers
HIV-positive individuals may experience various forms of uveitis—not necessarily from opportunistic infections, but as a direct effect of immune dysregulation. These inflammatory episodes often fluctuate and can lead to posterior synechiae, iris atrophy, and pupil distortion, all of which make cataract surgery more technically challenging.
Steroid use is often necessary to control inflammation, but this in turn can promote cataract development. It’s a tricky cycle: inflammation leads to steroid use, which leads to cataracts, which are harder to operate on in inflamed eyes.
Today’s approach involves tight control of inflammation before surgery. This often means a course of systemic or periocular corticosteroids to quieten the eye, sometimes with adjunctive immunomodulatory therapy if needed. Surgeons will typically aim for at least 3 months of inflammation-free status before proceeding.
Intraoperatively, iris hooks, pupil expanders, and viscoelastic devices are often used to manage small pupils and synechiae. Postoperative care then includes a tailored tapering of steroids and close monitoring for recurrence of inflammation.
CD4 Count and Viral Load: Still Important Benchmarks
Your CD4 count and viral load are still central to surgical planning. While cataract surgery is now commonly performed even in HIV-positive individuals, very low CD4 counts (typically below 50 cells/mm³) are still considered high-risk. This is because the immune system is significantly compromised, increasing the risk of infection and poor wound healing.
A well-controlled viral load combined with a CD4 count above 200 is generally considered a green light for surgery. That said, each case is individual. Even in patients with lower CD4 counts, some surgeons will proceed with added perioperative precautions if the cataract is severely limiting vision or function.
Preoperative blood work, anaesthetic fitness checks, and coordination with your HIV specialist all come into play. Surgeons may also prophylactically cover patients with antibiotics or antivirals depending on their prior ocular and systemic history.
Opportunistic Infections After Surgery: Is the Risk Still There?
The short answer is: yes, but it’s much lower than before. The longer answer depends on your immune status, ART compliance, and any prior ocular infections. CMV, toxoplasmosis, herpes viruses, and fungal infections were once a looming threat in the early postoperative period. Now, with improved prophylaxis and immune recovery, these are less common—but not entirely gone.
If you’ve ever had ocular toxoplasmosis or CMV, your ophthalmologist will be particularly vigilant after surgery. This might mean more frequent follow-ups, targeted retinal imaging, or even prophylactic antiviral therapy.
One area that has received renewed attention is immune reconstitution inflammatory syndrome (IRIS). In some cases, starting ART can trigger a rebound immune response, paradoxically worsening inflammation. This can complicate the early postoperative course, so timing surgery relative to ART initiation or recent changes in therapy is important.
Visual Outcomes: What Can You Expect?
Cataract surgery in HIV-positive patients used to be associated with poorer outcomes due to coexisting retinal disease and inflammation. But studies from the ART era have shown a marked improvement in visual recovery. If your retina is relatively healthy, and there’s no ongoing inflammation, your chances of getting a good visual result are excellent.
The most common limiting factors now are pre-existing damage from CMV retinitis, optic nerve atrophy, or longstanding cystoid macular oedema. OCT scans before surgery can help set realistic goals. Many patients who’ve lived with blurred or hazy vision due to cataracts now report dramatic improvements in quality of life after surgery.
As always, good outcomes depend on good follow-up. Attending postoperative appointments and adhering to the drop regimen (anti-inflammatory and antibiotic) is key to making sure everything heals properly.
Intraoperative Considerations: Anything Special?
Yes—there are a few added complexities. First, HIV-positive patients, especially those with uveitis or CMV history, often present with dense cataracts, small pupils, or posterior synechiae. This can make surgery more demanding, and it’s essential that you’re under the care of an experienced anterior segment surgeon.
Second, some surgeons prefer using scleral tunnels or limbal incisions instead of clear corneal incisions in high-risk patients to reduce infection risk. There’s also a preference for foldable IOLs made from hydrophobic acrylic, as these seem to induce less inflammation.
Finally, longer surgeries in complex cases may necessitate adjustments in anaesthesia and postoperative care. Surgeons will weigh the use of topical versus sub-Tenon anaesthesia depending on ocular history and overall health.
The Role of Antiretrovirals in Recovery
Antiretroviral therapy (ART) doesn’t just manage your HIV—it plays an important role in how your eye heals. Patients who are well-controlled on ART have dramatically lower rates of postoperative complications compared to those with uncontrolled viral loads.
That said, some ART drugs can have ocular side effects themselves. Didanosine, for instance, has been linked to optic neuropathy and retinal pigment epitheliopathy. While these are rare today due to newer regimens, they’re worth discussing with both your HIV physician and your eye surgeon.
There’s also a theoretical concern that ART might influence ocular wound healing or inflammatory response, though the evidence remains limited. In practice, the benefits of ART far outweigh any surgical risks.
Communication Is Key: Your HIV Specialist and Eye Surgeon Must Talk
This isn’t the kind of surgery you want to go into with piecemeal care. Ideally, your HIV specialist and cataract surgeon should be in regular communication, particularly if your disease is advanced or you’ve had ocular complications in the past.
Together, they’ll make decisions around:
- Timing of surgery relative to ART adjustments
- Whether to start prophylactic antivirals
- Managing systemic corticosteroids
- Monitoring CD4 and viral load trends before and after surgery
Having a coordinated care team is one of the best predictors of a smooth surgical journey.
What About the Lens Choice?
In most HIV-positive patients, standard monofocal intraocular lenses (IOLs) are the go-to choice. These offer excellent visual outcomes and are less likely to provoke inflammation.
Multifocal or extended depth of focus lenses are generally avoided in patients with a history of uveitis, CMV retinitis, or macular pathology. That’s because even minor contrast loss or glare can significantly affect quality of vision when the retina is compromised.
Your surgeon will guide you based on your ocular history and lifestyle goals, but in most cases, simplicity equals success.
Frequently Asked Questions
- Can I still have cataract surgery if I have a low CD4 count?
Yes, but it depends on just how low it is and how well your overall health is managed. Most surgeons prefer your CD4 count to be above 200 cells/mm³ before proceeding, as this reduces the risk of infection and poor healing. If your count is lower, your ophthalmologist will work closely with your HIV specialist to weigh the risks and possibly delay surgery until your immune system is more stable. - Will my HIV medication affect cataract surgery or healing?
Your antiretroviral therapy (ART) usually helps, rather than hinders, your recovery. Being on ART improves your immune response and lowers the chance of complications. That said, a few older ART drugs have been linked to eye issues, so your doctors will review your regimen to make sure everything is appropriate before surgery. - I’ve had CMV retinitis in the past—will this affect my results?
It might, depending on how much damage the CMV left behind in your retina. Scarring near the macula or optic nerve can limit how clearly you see, even if the cataract is removed perfectly. Your surgeon will likely carry out OCT scans beforehand to assess how much visual improvement you can realistically expect. - Is there a risk the surgery could cause a flare-up of HIV-related eye inflammation?
Yes, but this is manageable. If you’ve had uveitis before, your surgeon will typically give you steroid treatment to quiet the eye before operating. Post-op inflammation is common, but it’s usually mild and controlled with drops. What matters is that your eye is quiet and stable before the operation. - Could I get an eye infection after surgery because of my HIV status?
The risk is there, but it’s much lower than it used to be—especially if your HIV is well-controlled. Surgeons often prescribe antibiotic drops after the procedure, and in some high-risk patients, they may give oral antivirals or antibiotics too. Close monitoring in the weeks after surgery helps catch and treat any issues early. - Do I need to stop taking my HIV meds before or after surgery?
In almost all cases, no. You should continue your ART exactly as prescribed unless your HIV physician tells you otherwise. Stopping suddenly can lead to viral rebound and weaken your immune system, which is the last thing you want before a procedure. Always inform both your surgeon and HIV doctor about every medication you’re taking. - Will I still need glasses after cataract surgery?
That depends on the type of lens you have implanted and your eye health. If your retina is healthy and your surgeon uses a monofocal lens set for distance, you may only need reading glasses. But if you’ve had retinal disease or macular damage, your visual outcome may be limited—and glasses might still be needed to optimise whatever clarity you can achieve. - Can I have surgery on both eyes at the same time?
Probably not. For patients with a complex medical history, including HIV, most surgeons prefer to operate on one eye first and wait until it has fully healed before doing the second. This gives time to spot any issues early and reduces the risk of bilateral complications. - How soon can I go back to work or daily activities after surgery?
If everything goes smoothly, most people can return to light tasks within a few days and resume normal routines within two weeks. However, if your case is complicated by inflammation or a history of eye disease, recovery might take longer. Your surgeon will give personalised advice based on how things look after the procedure. - Where can I go for cataract surgery if I have HIV and need specialist care?
It’s important to choose a clinic or hospital with experience in managing complex cataract cases and comorbid conditions like HIV. At London Cataract Centre, we regularly work with patients who have underlying conditions such as HIV or AIDS, and we coordinate closely with their broader medical teams to ensure safe, effective outcomes.
Final Thoughts: You Can Still See Clearly
The days when cataract surgery was too risky or unrewarding for patients with HIV or AIDS are largely behind us. With well-managed antiretroviral therapy, advances in surgical technology, and a deeper understanding of HIV-related eye disease, outcomes are better than ever.
Still, it’s important to individualise your care. No two patients are the same, and factors like your CD4 count, viral load, ocular history, and medication use will all shape your surgical plan.
If you’re considering cataract surgery and live with HIV, don’t hesitate to bring your questions to both your ophthalmologist and your HIV physician. The collaborative care model is what ensures the best outcomes.
References
- Jabs, D.A., Van Natta, M.L., Thorne, J.E., Weinberg, D.V., Meredith, T.A., Kuppermann, B.D. & Sepkowitz, K. (2004) Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: 1. Retinitis progression, Ophthalmology, 111(12), pp.2224–2231. doi: 10.1016/j.ophtha.2004.05.031. Available at: https://pubmed.ncbi.nlm.nih.gov/15582078/ (Accessed: 19 June 2025).
- Jabs, D.A., Van Natta, M.L., Thorne, J.E. et al. (2010) Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: five-year outcomes, Ophthalmology, 117(11), pp.2152–2161.e1–e2. doi: 10.1016/j.ophtha.2010.03.031. Available at: https://pubmed.ncbi.nlm.nih.gov/20673591/ (Accessed: 19 June 2025).
- Kempen, J.H., Min, Y.-I., Freeman, W.R., Holland, G.N., Dieterich, D.T. & Jabs, D.A. (2014) Risk of cataract among subjects with AIDS free of ocular opportunistic infections, Ophthalmology, 121(12), pp.2317–2324. Available at: https://jhuccs1.us/soca/lsoca/open/LSOCA%20publications%20list.pdf (Accessed: 19 June 2025).
- Nwosu, S.N.N., Okpala, N.E., Nnubia, C.A. & Akudinobi, C.U. (2020) Outcome of cataract surgery in HIV‑positive patients at the Guinness Eye Center Onitsha, Orient Journal of Surgical Sciences, 1(1), pp.10–13. Available at: https://www.ajol.info/index.php/ojss/article/view/238599 (Accessed: 19 June 2025).
- Israel, A. et al. (2023) Cataract surgery outcomes in HIV‑positive patients at a tertiary care centre, Investigative Ophthalmology & Visual Science. Available at: https://iovs.arvojournals.org/article.aspx?articleid=2766745 (Accessed: 19 June 2025).