NRTIs and Ocular Risks: Uncovering the Link to Glaucoma

Nucleoside and nucleotide reverse transcriptase inhibitors, central to HIV management, are now linked to unexpected ocular risks—unpacking the connections and concerns for ocular health in patients undergoing antiretroviral therapy.

As the backbone of modern HIV regimens, NRTIs have transformed life expectancy, but recent real-world insights on NRTI-associated glaucoma risk reveal a 20–30% elevated incidence of primary open-angle glaucoma (POAG) among long-term users. The observed associations challenge the assumption of ocular safety in antiretroviral therapy, highlighting the need for proactive surveillance while acknowledging potential confounding factors.

This emerging evidence suggests that NRTIs in particular should be considered a potential risk factor for glaucoma in HIV patients, prompting ophthalmologists to integrate regular intraocular pressure assessments into patient protocols. Baseline optic nerve evaluations and periodic screenings can accelerate detection of early glaucomatous changes. 

Consider a 52-year-old patient on a tenofovir-based regimen who presented with mild visual field defects (loss of peripheral vision) and asymmetrical cup-to-disc ratios (differences in the optic nerve appearance) despite stable systemic control. Timely referral for slit-lamp gonioscopy (a method to examine the eye's front structures) and optical coherence tomography (imaging to view the retina) pinpointed early-stage primary open-angle glaucoma, enabling initiation of topical hypotensive therapy; medications like prostaglandin analogs and beta-blockers then stabilized intraocular pressure. This case illustrates how vigilant eye health monitoring in patients on NRTIs can avert advanced disease.

Balancing HIV medication effects with potential ocular side effects demands a multidisciplinary approach: primary care providers, infectious disease specialists and eye care professionals must collaborate to tailor follow-up intervals, educate patients on symptom recognition and discuss glaucoma prevention strategies. While an association with increased glaucoma risk due to NRTIs has been observed, the precise mechanism, including any direct effect on intraocular pressure, remains to be determined, underscoring the need for further research.

Key Takeaways:

• NRTIs have been linked to an increased risk of primary open-angle glaucoma, necessitating regular ocular assessments for patients.
• Healthcare providers must balance the benefits of HIV treatment with potential ocular side effects, underscoring the need for multidisciplinary approaches.
• Further research is essential to fully understand the mechanism through which NRTIs influence glaucoma risk, advocating for continued investigation.