Ocular findings in systemic lupus erythematosus

Optical coherence tomography angiography findings of systemic lupus erythematosus patients and the effect of neuropsychiatric involvement on it

AIM

To investigate the radial peripapillary capillary plexus vessel density (RPCP-VD) and peripapillary retinal nerve fiber layer thickness (pRNFLT) of systemic lupus erythematosus (SLE) and neuropsychiatric SLE patients (NPSLE) using disc optical coherence tomography angiography (OCTA) and investigate the association between these parameters and SLE disease activity index (SLEDAI-2K).

METHODS

A total of 64 'right eyes (36 SLE patients, 28 healthy controls (HCs)) were included in this cross-sectional case-control study. Ten (27.7%) patients had neuropsychiatric involvement. RPCP-VD and pRNFLT of patients were evaluated in all peripapillary sectors. RPCP-VD and pRNFLT of NPSLE, non-NPSLE, and HCs were compared. The correlation between SLEDAI-2K and OCTA findings was evaluated.

RESULTS

SLE patients' RPCP-VDs were significantly lower compared with the HCs except for two sectors (p < .005). There was not a significant difference in pRNFLT of SLE patients and HCs. There was not a correlation between SLEDAI-2K and RPCP-VD in any subsectors but there was a significantly negative correlation between pRNFLT in tempo-inferior and inferior-temporal sectors. When compared with non-NPSLE-patients, NPSLE patients had significantly lower inferior-hemi (p = .001), inferior-nasal VDs (p = .003), and peripapillary (p = .012), superior-hemi (p = .038), inferior-hemi (p = .026), inferior-nasal (p = .002) and inferior-temporal (p = .012) pRNFLTs. A negative correlation was found between NPSLE and pRNFLT.

CONCLUSION

SLE patients may have early subclinical vascular involvement leading to decreased RPCP-VD. A negative correlation between the SLEDAI-2K and pRNFLT in the temporal subsectors of all SLE patients may show an association between the disease activity and temporal pRNFL thinning. The presence of neuropsychiatric involvement may also be associated with decreased RPCP-VD and pRNFLT.

Clinical and Immunological Profile of Pediatric-Onset Systemic Lupus Erythematosus in Eastern India: A Prospective Observational Study

BACKGROUND

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with a strong female predisposition. pSLE often results in a worse prognosis compared to adult SLE. Studies on pSLE from the Indian subcontinent are scarce.

OBJECTIVE

This study aims to describe the clinical manifestations, laboratory and serological parameters, management, and outcomes of pSLE patients from a premier tertiary care institute in Eastern India.

METHODS

This prospective observational study was conducted at Kalinga Institute of Medical Sciences, Bhubaneswar, from September 2020 to October 2023. Children aged 1-14 years fulfilling the Systemic Lupus International Collaborating Clinics criteria for SLE were included. A detailed history, clinical examination, and laboratory investigations were performed. Data on complications, treatment, and outcomes were collected. Statistical analysis was done using SPSS Statistics version 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.).

RESULTS

Out of 114,009 patients (outdoor and indoor), 40 were diagnosed with pSLE, resulting in an incidence of 0.35 per 1000 children. The female-to-male ratio was 7:1. The mean age of presentation was 11.67 ± 2.37 years. Among the predominant symptoms observed, mucocutaneous manifestations were seen in 39 (97.5%), followed by pallor in 36 (90%), and fever in 33 (82.5%). The most common organ system involved was mucocutaneous, observed in 39 (97.5%) patients, followed by hematological in 36 (90%) and renal in 19 (47.5%). Lupus nephritis was observed in 19 (47.5%) patients, with class IV being the most common. Anti-nuclear antibody and anti-double-stranded DNA were positive in 39 (97.5%) and 27 (68%) of children, respectively. Complete remission was achieved in 14 (35%), improvement in 16 (40%), and flare-ups in 3 (7.5%) patients.

CONCLUSION

pSLE is an uncommon but severe autoimmune disease with significant multi-system involvement. Early identification and prompt treatment are crucial to minimizing adverse outcomes. This study provides detailed insights into the clinical and immunological profile of pSLE in Eastern India, underscoring the need for larger multicentric studies with long-term follow-ups.

The eye in forensic practice: In the dead

Post-mortem examination of the eye provides valuable forensic information yet is often overlooked. This brief review focuses on determining the cause/manner of death and post-mortem interval. External eye findings like corneal haziness and tache noire, combined with post-mortem changes in the iris, lens, retina and vitreous humour, can help estimate time since death. Ocular biometrics (iris/retinal scans) may facilitate identification. Age-related ocular changes can provide insights. The eye offers clues into personality (corneal tattooing, trichotillomania) and cause of death (petechiae in strangulation, retinal haemorrhages in abusive head trauma). Ocular trauma and underlying eye disease may be evident. Toxicology of vitreous humour can detect drugs/poisons. As a window into systemic disease and age-related changes, the eye aids pathology interpretations and, accordingly, post-mortem examinations have value. Ocular findings should not be overlooked in forensic examinations as they provide distinct information in determining cause/manner of death and post-mortem interval.

Sight-Threatening Unilateral Posterior Scleritis With Positive Atypical p-ANCA As Early Manifestation of Lupus Spectrum Disease

Antinuclear cytoplasmic antibody (ANCA)-related scleritis is a potentially sight-threatening inflammatory condition that may occur as a primary vasculitis disorder or as a secondary vasculitis in a variety of inflammatory conditions. While ANCA has been classically associated with primary vasculitis diseases such as granulomatosis with polyangiitis (GPA), microscopic polyarteritis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA), it is interesting that in cases of lupus spectrum disease (LSD), both ANCA and atypical p-ANCA have been observed as secondary autoantibodies. Scleritis is a rare ocular manifestation of lupus disease with an incidence of around 1%. This paper describes a case of sight-threatening posterior scleritis with positive atypical p-ANCA as an early manifestation of LSD. LSD is an acknowledged condition but frequently presents a diagnostic challenge or delay due to its ambiguous symptoms which may not fully align with the classification criteria of established systemic lupus erythematosus (SLE). Nonetheless, this condition should not be underestimated due to its potential impact on major organ involvement and its tendency to progress to established SLE. The diagnosis of LSD heavily relies on clinician suspicion, considering factors such as symptoms present in at least one organ system, positivity of antinuclear antibody (ANA), and clinical suspicion of future SLE development. Early identification allows for early treatment which would benefit high-risk patients. A middle-aged Chinese lady presented with bilaterally asymmetrical eye redness and swelling, which was worse on the right side. Clinical examination revealed right eye proptosis, conjunctival injection, chemosis, scleral redness and binocular diplopia in all gazes. Right eye fundoscopic examination displayed extensive choroidal folds with a positive T-sign on the B-scan. Apart from ocular symptoms, there was no significant medical history related to autoimmune or connective tissue disorders. Her p-ANCA and c-ANCA results were negative, however atypical p-ANCA titer was positive with a high antinuclear antibody (ANA) titer of 1:1280 with a homogenous pattern. Additionally, she has a family history of systemic lupus erythematosus in her daughter. A diagnosis of right eye posterior scleritis secondary to underlying LSD was made. The scleritis was successfully treated with a combination of corticosteroid and systemic immunosuppressants and the patient was initiated on oral hydroxychloroquine to manage underlying LSD. We aim to highlight to clinicians the diagnostic challenges associated with scleritis in LSD and emphasize the importance of prompt and timely multidisciplinary management in minimizing patient mortality and morbidity, as reflected in this case. This case of a positive atypical p-ANCA scleritis in LSD serves as an excellent example of effective management.

Chorioretinal Findings in a Patient with New-Onset Systemic Lupus Erythematosus and Antiphospholipid Syndrome after Stillbirth Associated with Pre eclampsia

PURPOSE

To describe chorioretinal findings in a patient with new-onset systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) after a stillbirth associated with preeclampsia.

STUDY DESIGN

Case report.

RESULTS

We report a patient with new-onset SLE and APS after pregnancy, who had a history of preeclampsia and intrauterine death that presented with bilateral visual loss after a seizure. Clinical findings of a unilateral vaso-occlusive retinopathy and choroidopathy associated with intraocular inflammation, serous retinal detachment, and vasculitis are presented, which responded well to immunosuppressive therapy.

CONCLUSION

New-onset systemic lupus erythematosus (SLE) during or after pregnancy could occur, especially when complicated with preeclampsia, making it difficult to diagnose accurately. Pregnancy-induced hypertension retinopathy and choroidopathy, as well as chorioretinal manifestations of SLE and APS, can share similar ocular manifestations that can overlap and coexist in the same patient, and it is important to recognize them for an adequate management and follow-up.

Unveiling Ocular Manifestations in Systemic Lupus Erythematosus

Systemic Lupus Erythematosus (SLE) is a complex autoimmune disorder characterized by immune dysregulation and multi-organ involvement. In this concise brief review, we highlight key insights into Ocular Systemic Lupus Erythematosus (SLE), an intricate autoimmune disorder with diverse organ involvement. Emphasizing the formation of autoantibodies and immune complex deposition, we delve into the inflammation and damage affecting ocular structures. Clinical presentations, ranging from mild dry eye syndrome to severe conditions like retinal vasculitis, necessitate a comprehensive diagnostic approach, including clinical exams, serological testing, and imaging studies. Differential diagnosis involves distinguishing SLE-related ocular manifestations from other autoimmune and non-inflammatory ocular conditions. The multidisciplinary management approach, involving rheumatologists, ophthalmologists, and immunologists, tailors treatment based on ocular involvement severity, encompassing corticosteroids, immunosuppressive agents, and biologics. Follow-up is crucial for monitoring disease progression and treatment response. Future perspectives revolve around advancing molecular understanding, refining diagnostic tools, and exploring targeted therapies. Novel research areas include genetic factors, microbiome composition, and biotechnology for tailored and effective SLE ocular treatments.

An Orbital Pseudotumor Secondary to Systemic Lupus Erythematosus: A Case Report

Nonspecific orbital inflammation (NSOI), the primary cause of painful orbitopathy mostly in adults, can either manifest as localized or diffused. Periorbital edema or swelling is the most common sign followed by proptosis. NSOI or orbital pseudomotor secondary to systemic lupus erythematosus (SLE) is very uncommon in the Kingdom of Saudi Arabia. This is the first reported case from Saudi Arabia. The patient first presented to the outpatient department during her gestational period. Her chief complaint was right eye swelling and pain when she woke up in the morning. Her past medical history was positive for irritable bowel disease and SLE. A slit lamp examination revealed chemosis with conjunctival injections in the right eye and mild temporal chemosis in the left eye. Funduscopic examination after pupillary dilation revealed hyperemic discs with venous tortuosity more prominent in the right eye. Serum albumin level was low at 29 g/L. Orbital magnetic resonance imaging without contrast showed bilateral diffuse preseptal soft tissue swelling more prominent on the right side with diffuse bilateral congestion of intraorbital fat, including intraconal and extraconal fat. There was associated fat stranding around the optic nerves bilaterally. The bilateral extraocular muscles showed a diffusely increased T2 signal compatible with edema. The patient was given a bolus of intravenous methylprednisolone for three days. She had a satisfactory recovery. Early diagnosis is important to rule out other differential diagnoses, such as orbital cellulitis and lymphoma.

Ocular retinal findings in asymptomatic patients with antiphospholipid syndrome secondary to systemic lupus erythematosus

The objective is to perform a multimodal ophthalmological evaluation, including optical coherence angiography (OCTA), asymptomatic APS secondary to SLE (APS/SLE), and compare to SLE patients and control group (CG). We performed a complete structural/functional ophthalmological evaluation using OCTA/microperimetry exam in all participants. One hundred fifty eyes/75 asymptomatic subjects [APS/SLE (n = 25), SLE (n = 25), and CG (n = 25)] were included. Ophthalmologic abnormalities occurred in 9 (36%) APS/SLE, 11 (44%) SLE, and none of CG (p < 0.001). The most common retinal finding was Drusen-like deposits (DLDs) exclusively in APS/SLE and SLE (16% vs. 24%, p = 0.75) whereas severe changes occurred solely in APS/SLE [2 paracentral acute middle maculopathy (PAMM) and 1 homonymous quadrantanopsia]. A trend of higher frequency of antiphospholipid antibody (aPL) triple positivity (100% vs. 16%, p = 0.05) and higher mean values of adjusted Global Antiphospholipid Syndrome Score (aGAPSS) (14 ± 0 vs. 9.69 ± 3.44, p = 0.09) was observed in APS/SLE with PAMM vs. those without this complication. We identified that ophthalmologic retinal abnormalities occurred in more than 1/4 of asymptomatic APS/SLE and SLE. DLDs are the most frequent with similar frequencies in both conditions whereas PAMM occurred exclusively in APS/SLE patients. The possible association of the latter condition with aPL triple positivity and high aGAPSS suggests these two conditions may underlie the retinal maculopathy. Our findings in asymptomatic patients reinforce the need for early surveillance in these patients. Key Points • Retinal abnormalities occur in more than 1/4 of asymptomatic APS/SLE and SLE patients. • The occurrence of PAMM is possibly associated with APS and DLDs with SLE. • Presence of aPL triple positivity and high aGAPSS seem to be risk factors for PAMM.

Ocular Discoid Lupus Erythematosus: More Than what Meets The Eye

Lupus erythematosus is a spectrum that includes auto-immune disorders such as systemic lupus erythematosus (SLE), subacute cutaneous lupus erythematosus (SCLE), and chronic cutaneous lupus erythematosus (CCLE). Discoid lupus erythematosus (DLE) is the most common type of CCLE, and ocular DLE is a rather rare presentation. We report the case of a 42-year-old male patient who had been repeatedly mis-diagnosed and upon detailed dermatological workup was found to possess clinical, dermoscopic, and histopathological features of DLE. Our report focuses on the importance of dermoscopy as a useful point-of-care investigation to avoid delay, and thus related complications. It further suggests how fundus examination could prove helpful in identifying lupus-related fundus changes, and explores how to devise a suitable plan of treatment for such patients.

Posterior segment involvement in systemic lupus erythematosus - A series from South India

Purpose

To report the spectrum of posterior segment manifestations and visual outcomes in a large series of patients with systemic lupus erythematosus (SLE).

Methods

Retrospective study at a tertiary referral eye center in south India between 2016 and 2022.

Results

Charts of 109 patients diagnosed to have SLE were retrieved from our medical database. Only nine cases of SLE (8.25%) had posterior segment involvement. The male: female ratio was 1:8. The mean age was 28 years. Unilaterality was the most common presentation in eight cases (88.89%). Lupus nephritis was the most common systemic presentation in five cases (55.56%). Antiphospholipid antibodies (APLA) positivity was seen in two cases (22.22%). Ocular manifestations included microangiopathy (cotton wool spots) in one case, occlusive retinal vasculitis with cotton wool spots in four cases (five eyes), optic disc edema with combined venous and arterial occlusion (one case), central retinal vein occlusion with cotton wool spots and hemorrhages (one case), macular edema (four cases), posterior scleritis with optic disc edema and exudative retinal detachment in the posterior pole (one case), and tubercular choroidal granuloma (one case). Treatment included systemic steroids, hydroxychloroquine sulfate (HCQS), and immunosuppression in all cases, blood thinners in two cases, and laser photocoagulation in four cases. HCQS-related retinal toxicity was not seen in any of the 109 cases. Ocular manifestation was the initial presentation of SLE in one case. Visual outcome was poor in three cases.

Conclusion

Presence of posterior segment findings in cases with SLE may suggest a severe systemic disease. Early detection and aggressive treatment result in better visual outcomes. Ophthalmologists could play a vital role in guiding systemic therapy.

Analysis of Meibomian Glands in Juvenile Systemic Lupus Erythematosus Patients without Dry Eye Symptoms and Signs

PURPOSE

To evaluate meibomian gland loss and its possible association with disease duration and activity in Juvenile Systemic Lupus Erythematosus (JSLE) patients' without dry eye symptoms or signs.

STUDY DESIGN

Prospective clinical study.

METHODS

Ten eyes of 10 JSLE patients were evaluated using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and 14 eyes of 14 healthy controls were also enrolled. Ocular Surface Disease Index (OSDI) questionnaire and Schirmer I test were performed. Lid margin score, meibum quality and expressibility scores were evaluated. Noninvasive first breakup time (NIF-BUT) and noninvasive average breakup time (NIAvg-BUT), meibomian gland dropout area (MGDA) and meibography scores were evaluated using non-contact meibography (Sirius; CSO).

RESULTS

There was no significant difference between the JSLE patients and the healthy controls in the OSDI, NIF-BUT, NIAvg-BUT and Schirmer I tests. Also lid margin score, meibum quality and expressibility scores were not significantly different between the groups. However, JSLE patients had increased upper and lower lid MGDA and increased upper lid, lower lid and total meibography scores compared to the healthy subjects. Furthermore, the duration of JSLE showed a high positive correlation with upper and lower lid MGDA and meibography scores.

CONCLUSION

Meibomian gland loss could be observed in JSLE patients with no clinical signs and symptoms of dry eye. Considering the longer life expectancy of children, the positive correlation of disease duration with the meibomian gland reveals the importance of routine eye examinations from the diagnosis of the disease.

Subretinal fluid in a patient with systemic lupus erythematosus

A 28-year-old male patient presented to the outpatient department with visual disturbance in both eyes. The patient had a history of stage IV lupus nephritis that was diagnosed at the age of 14 years and had undergone hemodialysis at the age of 23 years. After he started hemodialysis, the systemic condition was well controlled, and systemic steroids were not used. His best-corrected visual acuity (BCVA) was 20/200 in the right eye and 20/100 in the left eye. Funduscopic examination revealed shallow subretinal fluid (SRF) and serous retinal detachment in both eyes. The first impression of this patient was central serous chorioretinopathy. However, the late phase of fluorescein angiography (FA) demonstrated multiple subretinal leakages, and the late phase of indocyanine green angiography showed choroidal vascular engorgement and multiple hyperfluorescent plaques in both eyes. Systemic lupus erythematosus showed moderate activity according to the results of the systemic evaluation. Based on the clinical examination, lupus choroidopathy was suspected in both eyes. Half-fluence photodynamic therapy (PDT) was administered to both eyes rather than systemic steroids because the patient was systemically stable. Three months after PDT, no SRF was observed in either eye. In addition, multiple subretinal leakages on FA were reduced compared to those before treatment. There was no recurrence of SRF for 4 years after PDT, and the final BCVA was 20/70 in the right eye and 20/40 in the left eye. During this time, numerous hypoautofluorescence spots appeared adjacent to the major retinal vessels in fundus autofluorescence.

Retinal changes in patients with idiopathic inflammatory myopathies: A case-control study in the MyoCite cohort

BACKGROUND

Retinal changes are the window to systemic vasculature. Therefore, we explored retinal changes in patients with Idiopathic inflammatory myopathies (IIM) as a surrogate for vascular health.

METHODS

Adult and Juvenile IIM patients (2017 ACR/EULAR criteria), visiting a tertiary care center in 2021 were enrolled for detailed ophthalmic examination in comparison with healthy controls (HC). Patients with conditions that precluded thorough posterior chamber examination were excluded. Scale variables are expressed as median (IQR). Multivariate analysis (binary logistic regression-BLR) was conducted, adjusting for age, gender, and comorbidities besides factors significant in univariate analysis.

RESULTS

43 patients with IIM [31 females; age 36 (23-45) years; disease duration 5.5 (2-12) months] were enrolled for participation. DM (44%) was the most common diagnosis. IIM patients exhibited frequent attenuation of retinal vessels (32.6 vs. 4.3%, p < 0.001), AV nicking (14 vs. 2.2%, p = 0.053), and vascular tortuosity (18.6 vs. 2.2%, p = 0.012), besides decreased visual acuity (53.5 vs. 10.9%, p<0.001) and immature cataracts (34.9 vs. 2.2%, p < 0.001). Attenuation of vessels [OR 10.9 (1.7-71), p = 0.004] emerged as significantly different from HC after adjusting for covariates in BLR. Notably, adults with IIM were more predisposed to retinal abnormalities [21 (57%) vs. 1 (16%), p = 0.068], especially attenuation of vessels [14(38%) vs. 0(0), p = 0.067] than jIIM. However, no difference was found in retinal features amongst the subtypes of adult IIM, nor did they correlate with MDAAT, MDI, or HAQ-DI.

CONCLUSION

Retinal microvasculopathy and diminution of vision occur in nearly one-thirds to half of the patients with IIM. Microvasculopathy occurs across subtypes of IIM, and more so in adults, calling for further investigation as a surrogate for damage assessment and potentially even systemic vascular health.

Bilateral Lupus Chorioretinopathy in a Patient With Active Systemic Lupus Erythematosus

Ocular involvement is commonly seen in systemic lupus erythematosus (SLE). However, chorioretinopathy is an easily missed ocular manifestation of SLE. Early recognition and a multidisciplinary treatment approach can play a key role in reducing the ocular and systemic morbidity seen with this condition. This case report describes a patient with active SLE who presented with bilateral lupus chorioretinopathy. The patient demonstrated a significant improvement in ocular symptoms once the systemic disease was controlled.

Ocular surface optimization before cataract surgery

The evolution of refractive cataract surgery has increased patient expectations for visual outcomes following cataract surgery. Precise biometry and keratometry are critical for accurate intraocular lens (IOL) selection and favorable surgical outcomes. In patients with the ocular surface disease and corneal pathologies, preoperative measurements can often be erroneous, leading to postoperative refractive surprises and dissatisfied patients. Conditions such as dry eye disease, epithelial basement membrane dystrophy, Salzmann's nodular dystrophy, and pterygia need to be addressed thoroughly before performing cataract surgery to optimize the ocular surface, obtain high-quality preoperative measurements, and ultimately determine the appropriate IOLs. In this review, the various ocular surface pathologies affecting cataract surgery outcomes and options for treatment are discussed and the importance of optimization of the ocular surface before cataract surgery is reviewed.

Acute choroidal involvement in lupus nephritis: A case report and review of literature

BACKGROUND

Systemic lupus erythematosus (SLE), characterized by the production of autoantibodies and widespread deposition of immune complexes, predominantly affects women of childbearing age. More than one-third of SLE patients present ocular manifestations. Choroidal disease is currently not completely understood, and its precise differentiation from central serous chorioretinopathy is rarely achieved. To date, no more than 60 patients with choroidal involvement have been reported.

CASE SUMMARY

A 37-year-old Chinese woman experienced decreased visual acuity bilaterally, accompanied by increasing periorbital swelling and severe conjunctival chemosis. Decreased breath sounds in both bases were detected via auscultation, as well as pitting edema in both ankles. SLE and lupus nephritis were diagnosed based on serositis, renal disorder, leukopenia and positive anti-Smith and anti-nuclear antibodies. Lupus choroidopathy was diagnosed based on ocular presentation and imaging. The patient was treated with systemic corticosteroids, spironolactone, hydroxychloroquine (HCQ), mycophenolate mofetil (MMF), and intravenous immunoglobulin. After 4 wk of hospitalization, the patient was discharged. Indocyanine green angiography showed no leakage from choroidal vessels, and ocular coherence tomography detected low amounts of subretinal fluid right before discharge. The patient was prescribed oral methylprednisolone, HCQ, and MMF. Two months after the first visit, ophthalmological examination revealed a visual acuity of 20/20 bilaterally, and SLE disease activity was well controlled; her symptoms disappeared completely.

CONCLUSION

Here we presented a case of lupus choroidopathy, successfully treated with systemic corticosteroids, and discussed previously reported cases, focusing on differential diagnosis with a central serous chorioretinopathy.

Orbital myositis in systemic lupus erythematosus: a case-based review

Ocular complications occur in up to one-third of patients with systemic lupus erythematosus (SLE). Among them, orbital myositis (OM) is considered a rare manifestation that affects the extraocular muscles and causes pain and restriction with eye movement. We report a case of OM in a 48-year-old female with SLE and secondary Sjogren's Syndrome, who presented headache, periorbital edema, and painful ocular movements in both eyes, with no other systemic manifestations. An orbital magnetic resonance image revealed thickening of the right medial rectus and left lateral rectus muscles. Laboratory tests were normal and there was no further disease activity. The patient was treated with prednisone 1 mg/Kg/day with a resolution of symptoms. We found 13 additional cases of OM from our literature review (11 SLE patients and 2 with discoid lupus erythematosus). There was a female predominance in these cases with a mean age of 43.6 years (SD ± 16.9). Their main clinical features included eye pain, swelling, proptosis, diplopia, and limitations in extraocular muscles, while in most of them, there was no other active systemic manifestation. Treatment with steroids led to the complete resolution of symptoms in most of these patients. The available evidence suggests that it is essential to have a high index of suspicion for OM in SLE patients even when there is no systemic disease activity so that proper treatment is initiated early.

The Application of Optical Coherence Tomography Angiography in a Patient with Systemic Lupus Erythematosus

A 15-year-old girl presented to the emergency department with a history of bilateral blurred vision for one day, with greater severity in the right eye. Fundus examinations revealed cotton wool spots, dot hemorrhage, and hard exudate. She underwent optical coherence tomography angiography (OCTA), which showed the presence of macula ischemia, decreased vascular density, mild retinal fluid, severe ischemia, some macular edema, and vascular sheathing, indicating active vasculitis in the right eye. Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect many organs in the body, including the eye. Ocular involvement is one of the most well-known features. Retinal vasculitis is a rare complication of SLE that is characterized by vascular sheathing that can progress to vaso-occlusion. We report the clinical features of SLE using OCTA.

Dry eye disease, a prominent manifestation of systemic autoimmune disorders

OBJECTIVES

Dry eye disease (DED) is arguably the most frequent ocular disease encountered in ophthalmic clinical practice. DED is frequently an underestimated condition causing a significant impact on visual function and quality of life. Many systemic autoimmune diseases (SAIDs) are related to moderate to severe DED. The main objective of this review is to enhance the awareness among ophthalmologists of the potential association of an underlying SAID in a high-risk patient with DED.

METHODS

An exhaustive literature search was performed in the National Library of Medicine's Pubmed, Scopus, Web of Science, and Google Scholar databases for all English language articles published until November 2021. The main keywords included "dry eye disease" associated with autoimmune, connective tissue, endocrine, gastrointestinal, hematopoietic, vascular, and pulmonary diseases. Case reports, series, letters to the editor, reviews, and original articles were included.

RESULTS

Although DED is frequently associated with SAIDs, its diagnosis is commonly delayed or missed, producing significant complications, including corneal ulceration, melting, scleritis, uveitis, and optic neuritis resulting in severe complications detrimental to visual function and quality of life. SAID should be suspected in a woman, 30 to 60 years old with a family history of autoimmunity, presenting with DED symptoms and extraocular manifestations including arthralgias, dry mouth, unexplained weight and hair loss, chronic fatigue, heat or cold intolerance, insomnia, and mood disorders.

CONCLUSIONS

Establishing the correct diagnosis and treatment of DED associated with SAIDs is crucial to avoid its significant burden and severe ocular complications.

Evaluation of subclinical retinal microvascular changes in systemic lupus erythematosus patients using optical coherence tomography angiography and its relationship with disease activity

Objective

This study aimed to investigate subclinical retinal microvascular changes with optical coherence tomography angiography (OCTA) in patients with systemic lupus erythematosus (SLE) and healthy controls (HCs), and to evaluate the relationship between OCTA findings and Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K).

Materials and Methods

In this study, 47 eyes of SLE and 41 eyes of healthy control (HC) were evaluated. The SLE patients were divided into two subgroups: low disease activity (LDA) (SLEDAI≤5) and high disease activity (HDA) (SLEDAI>6). The results of OCTA were compared between SLE patients and HCs as well as the SLE subgroups. The relationship between OCTA results and SLEDAI-2K was evaluated.

Results

There were no differences in foveal avascular zone (FAZ) areas between the SLE patients and HCs. Central foveal thickness (CFT) was lower in SLE patients ( p = .046). Superficial capillary plexus (SCP) vessel density (VD) in SLE patients was significantly lower only in the foveal area compared to that in HCs ( p = .006). Deep capillary plexus (DCP) VD in SLE patients was significantly lower in all areas except the temporal parafoveal area compared to that in the HCs. There was no statistically significant difference between SLE groups with LDA and HDA in FAZ or any of the other areas, including SCP and DCP. When the correlation between OCTA findings and SLEDAI-2K was examined, both SCP and DCP VD were found to be negatively correlated.

conclusions

It was observed that DCP VDs were affected in SLE patients with LDA, and SCP VDs were also affected in addition to DCP with HDA. This suggests that DCP may be the first capillary plexus to be comprised in SLE. VDs were negatively correlated with disease activity. It was concluded that OCTA can be a useful tool in assessing subclinical retinal microvascular pathology and disease activity in patients with SLE.

Pediatric uveitis: Role of the pediatrician

The challenges of childhood uveitis lie in the varied spectrum of its clinical presentation, the often asymptomatic nature of disease, and the evolving nature of the phenotype alongside normal physiological development. These issues can lead to delayed diagnosis which can cause significant morbidity and severe visual impairment. The most common ocular complications include cataracts, band keratopathy, glaucoma, and macular oedema, and the various associated systemic disorders can also result in extra-ophthalmic morbidity. Pediatricians have an important role to play. Their awareness of the various presentations and etiologies of uveitis in children afford the opportunity of prompt diagnosis before complications arise. Juvenile Idiopathic Arthritis (JIA) is one of the most common associated disorders seen in childhood uveitis, but there is a need to recognize other causes. In this review, different causes of uveitis are explored, including infections, autoimmune and autoinflammatory disease. As treatment is often informed by etiology, pediatricians can ensure early ophthalmological referral for children with inflammatory disease at risk of uveitis and can support management decisions for children with uveitis and possible underling multi-system inflammatory disease, thus reducing the risk of the development of irreversible sequelae.

Repository Corticotropin Injection (Acthar® Gel) for Refractory Severe Noninfectious Keratitis: Efficacy and Safety from a Phase 4, Multicenter, Open-Label Study

Introduction

Noninfectious keratitis is a painful corneal inflammation treated with topical cyclosporine and other immunosuppressants. Additional treatment options are needed for keratitis that does not improve with standard therapies. Repository corticotropin injection (RCI; Acthar^® Gel) is approved to treat severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa, including keratitis. This phase 4, multicenter, open-label study assessed the efficacy and safety of RCI for refractory severe noninfectious keratitis.

Methods

Patients were ≥ 18 years old with persistent severe keratitis despite treatment with topical immunosuppressants. Patients received 80 U of RCI subcutaneously twice weekly for 12 weeks followed by a 4-week taper. Assessments included all domains of the Impact of Dry Eye on Everyday Life (IDEEL) Questionnaire, Ocular Discomfort and 4-Symptom Questionnaire, and Visual Analog Scale (VAS). Corneal fluorescein and conjunctival lissamine green staining, Conjunctival Redness Scale, tear production (Schirmer’s test), visual acuity, slit lamp examination, and intraocular pressure were also assessed. Safety was evaluated via treatment-emergent adverse events. Analyses were performed using the modified intent-to-treat (mITT) population (patients who received ≥ 1 dose of RCI and contributed any post-baseline efficacy data).

Results

In the mITT population (N = 35), 50.0% (95% confidence interval, 33.2% to 66.8%) of patients experienced clinically important improvements in the symptom bother domain of the IDEEL Questionnaire at week 12 of RCI therapy. All domains of the IDEEL and the Ocular Discomfort and 4-Symptom Questionnaire showed improvements at week 12 of RCI treatment. The most pronounced improvements in the VAS at week 12 were for eye dryness and eye discomfort. Corneal staining, conjunctival staining, conjunctival redness, and tear production showed early improvements that were sustained through week 12. No new safety signals for RCI were identified.

Conclusions

RCI is safe and effective for refractory severe noninfectious keratitis that has not improved with other approved therapies.

Trial registration number

ClinicalTrials.gov NCT04169061.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-021-00400-y.

Increased Risk of Retinal Vasculitis in Patients With Systemic Lupus Erythematosus: A Nationwide Population-Based Cohort Study

Objectives: To evaluate the relationship between systemic lupus erythematosus (SLE) and the risk of retinal vasculitis (RV) using a population-based database.

Methods: Using the 1997–2013 Taiwanese National Health Insurance Database, we identified newly diagnosed SLE patients between 2001 and 2012 as the SLE group. We matched the SLE group with non-SLE individuals selected from a representative one million sample of the population in a 1:20 ratio for age, sex, and the year of the index date. After adjusting for potential confounders, including urbanization of the patient's residence, the level of the payroll-related insured amount, and selected comorbidities, we examined the association between SLE and the risk of RV using the Cox proportional hazard model shown as hazard ratios (HRs) with 95% confidence intervals (CIs). Sensitivity analyses were conducted using various definitions of RV.

Results: We included 11,586 patients with SLE and 231,720 matched non-SLE individuals. The mean age of the study participants was 36.7 ± 16.9 years, and the female-to-male ratio was 6.8:1. The incidence rates of RV were 56.39 cases per 100,000 person-years and 2.45 cases per 100,000 person-years, respectively. After adjusting for potential confounders, the incidence rate of RV in the SLE cohort was 22.99 times higher than that in the non-SLE cohort (56.39 vs. 2.45 per 100,000 person-years). The adjusted HR for RV in the SLE group was 23.61 (95% CI, 14.94–37.32). The results remained robust in the sensitivity analysis.

Conclusion: This nationwide population-based study revealed that SLE patients had a significantly higher risk of RV than non-SLE individuals.

Immunogenetics of the Ocular Anterior Segment: Lessons from Inherited Disorders

Autoimmune and autoinflammatory diseases cause morbidity in multiple organ systems including the ocular anterior segment. Genetic disorders of the innate and adaptive immune system present an avenue to study more common inflammatory disorders and host-pathogen interactions. Many of these Mendelian disorders have ophthalmic manifestations. In this review, we highlight the ophthalmic and molecular features of disorders of the innate immune system. A comprehensive literature review was performed using PubMed and the Online Mendelian Inheritance in Man databases spanning 1973-2020 with a focus on three specific categories of genetic disorders: RIG-I-like receptors and downstream signaling, inflammasomes, and RNA processing disorders. Tissue expression, clinical associations, and animal and functional studies were reviewed for each of these genes. These genes have broad roles in cellular physiology and may be implicated in more common conditions with interferon upregulation including systemic lupus erythematosus and type 1 diabetes. This review contributes to our understanding of rare inherited conditions with ocular involvement and has implications for further characterizing the effect of perturbations in integral molecular pathways.

Ophthalmic manifestations in patients with collagen vascular disorders: a hospital-based retrospective observational study

AIM

To study frequency and characteristics of ocular manifestations in Indian patients with collagen vascular disorders.

METHODS

The medical records of 73 patients (Males: Females 16:57) aged between 22 and 78 years (mean ± SD = 43.5 ± 12.9 years) with collagen vascular diseases were analyzed retrospectively for demography, subtypes of collagen vascular disease, and findings of complete ophthalmic examination.

RESULTS

Lupus erythematosus (LE) in 39(53.4%, (SLE 18, DLE 21), systemic sclerosis in 27(37%), dermatomyositis in 5(6.8%), and primary Sjögren's syndrome in 2(2.7%) patients, respectively, were observed. Only 35(47.9%) patients had ocular manifestations. In LE keratoconjunctivitis sicca (n = 6), keratitis (n = 5), severe blepharitis (n = 3), retinopathy (n = 2), and optic neuritis in one patient, respectively, were major ocular manifestations. Major abnormalities occurring in systemic sclerosis included restricted eyelid mobility of variable severity (n = 8), eyelid telangiectasia (n = 5), keratoconjunctivitis sicca (n = 6), cataract (n = 5), shallow fornices (n = 4), conjunctival surface disease (n = 4), and uveitis, keratitis, episcleritis in one patient each, respectively. One patient with dermatomyositis had heliotrope rash. Two patients with primary Sjögren's syndrome had keratoconjunctivitis sicca.

CONCLUSIONS

The study shows that LE frequently presented with keratoconjunctivitis sicca, retinopathy, and optic neuritis. Systemic sclerosis commonly develops eyelid immobility, blepharitis and telangiectasia, ocular surface disease and keratoconjunctivitis sicca, corneal abnormalities, and uveitis. A comprehensive ocular evaluation is imperative for early detection and management particularly of ocular surface disease, uveitis, and retinopathy to prevent potential sight-threatening complications. Limitations include retrospective study design and small number of patients for stratification.

Non-central serous chorioretinopathy in a patient with systemic lupus erythematosus and hydroxychloroquine retinopathy

Subretinal fluid accumulation in a patient with systemic lupus erythematosus (SLE) may represent a diagnostic challenge. We present a case of a 43-year-old man with baseline diagnosis of SLE and hydroxychloroquine-associated maculopathy who reported progressive vision loss on the right eye, associated with corticosteroids use for an arthritic crisis. Ophthalmological examination did not reveal any acute finding. On optical coherence tomography, subretinal fluid in the perifoveal area was visible on the right eye, with corresponding enlargement of the visual field defect. An increased choroidal thickness was also visible. Fluorescein angiography revealed, on the right eye, two pinpoint areas of leakage and indocyanine green angiography signs of choroidal vascular hyperpermeability. Considering a diagnosis of a non-central central serous chorioretinopathy, corticosteroids use was interrupted, with resolution of the subretinal fluid. This case illustrates the relevance of a multimodal imaging approach to guide the diagnosis of patient with an SLE with subretinal fluid.

Structural Retinal Assessment Using Optical Coherence Tomography and Fundus Fluorescein Angiography in Systemic Lupus Erythematosus Patients

BACKGROUND

Ocular manifestations in systemic lupus erythematosus (SLE) can be the presenting symptom of the disease or a sight-threatening complication.

OBJECTIVES

To detect different structural retinal changes in patients with SLE who had no ophthalmological symptoms and investigate the relationship between different retinal changes and the disease activity assessed by the Systemic Lupus Erythromatosus Disease Activity Index score.

STUDY DESIGN

A descriptive pilot study from January 2016 to January 2017.

METHODS

Fifty-two eyes of 26 patients diagnosed to have SLE were examined using visual acuity assessment, fundus examination, optical coherence tomography (OCT), and fundus fluorescein angiography (FFA).

RESULTS

Fundus fluorescein angiography showed different changes in the form of venular occlusion and optic nerve leakage. There were also degenerative changes in the form of alternating hyperfluorescent and hypofluorescent areas outside the arcades as well as peripapillary areas and capillary dropout. Optical coherence tomography detected signs of degenerative thinning, incomplete posterior vitreous detachment, and epiretinal membrane. A significant correlation was found between SLE activity and the changes detected by FFA (p = 0.017). However, there was no significant correlation between disease activity and changes detected by OCT. Optical coherence tomography changes were significantly correlated with the duration of hydroxychloroquine use of more than 5 years (p = 0.032). There was no correlation between FFA or OCT changes and proteinuria or antiphospholipid antibodies.

CONCLUSIONS

Fundus fluorescein angiography is more sensitive in detecting early subclinical retinal changes in patients with SLE, which correlates with disease activity, whereas OCT is more sensitive in detecting changes resulting from hydroxychloroquine use.

Plasmacytoid dendritic cells in the eye

Plasmacytoid dendritic cells (pDCs) are a unique subpopulation of immune cells, distinct from classical dendritic cells. pDCs are generated in the bone marrow and following development, they typically home to secondary lymphoid tissues. While peripheral tissues are generally devoid of pDCs during steady state, few tissues, including the lung, kidney, vagina, and in particular ocular tissues harbor resident pDCs. pDCs were originally appreciated for their potential to produce large quantities of type I interferons in viral immunity. Subsequent studies have now unraveled their pivotal role in mediating immune responses, in particular in the induction of tolerance. In this review, we summarize our current knowledge on pDCs in ocular tissues in both mice and humans, in particular in the cornea, limbus, conjunctiva, choroid, retina, and lacrimal gland. Further, we will review our current understanding on the significance of pDCs in ameliorating inflammatory responses during herpes simplex virus keratitis, sterile inflammation, and corneal transplantation. Moreover, we describe their novel and pivotal neuroprotective role, their key function in preserving corneal angiogenic privilege, as well as their potential application as a cell-based therapy for ocular diseases.

Orbital myositis in systemic lupus erythematosus: A case report and literature review

Orbital myositis is a rare manifestation of systemic lupus erythematosus (SLE). Herein, we report a case of orbital myositis in a patient with SLE, along with a literature review. A 45-year-old female patient presented with pain in the right eye, chemosis, proptosis, and limited abduction. Computed tomography of her orbits revealed thickening of her right lateral rectus muscle. She had no other systemic symptoms. There was no elevation in the biomarkers of inflammation or disease activity. She was treated with high-dose steroids, and her symptoms resolved rapidly. It is important to maintain a high index of suspicion for orbital myositis in patients with SLE even when there are no systemic disease activities, such that early treatment can be initiated. It is also important to rule out other mimickers such as orbital cellulitis and thyroid eye disease.

Ocular manifestations of rheumatic diseases

PURPOSE

Our aim was to summarize key aspects of the pathomechanism and the ocular involvements of rheumatic and systemic autoimmune diseases.

METHODS

Apart from a paper in French (Morax V, Ann Oculist 109:368-370, 1893), all papers referred to in this article were published in English. All the materials were peer-reviewed full-text papers, letters, reviews, or book chapters obtained through a literature search of the PubMed database using the keywords ocular manifestations; pathogenesis; systemic inflammatory rheumatic diseases; rheumatoid arthritis; osteoarthritis; fibromyalgia; systemic lupus erythematosus; seronegative spondyloarthritis; ankylosing spondylitis; reactive arthritis; enteropathic arthritis; psoriatic arthritis; systemic sclerosis; polymyalgia rheumatica and covering all years available. Some statements articulated in this paper reflect the clinical experience of the authors in their tertiary-referral center.

RESULTS

Ophthalmic disorders are categorized by anatomical subgroups in all rheumatic diseases. The most common ocular manifestations are diverse types of inflammations of different tissues and dry eye disease (DED).

CONCLUSION

The eye could be a responsive marker for the onset or aggravation of an immune reactivation in many rheumatic diseases, furthermore, ocular findings can antedate the diagnosis of the underlying rheumatic disease. By recognizing ocular manifestations of systemic rheumatic diseases it might be possible to avoid or at least delay many long term sequelae.

Macular edema associated with non-infectious uveitis: pathophysiology, etiology, prevalence, impact and management challenges

Macular edema (ME) is the most common sight-threatening complication in uveitis. The diagnostic and therapeutic management of the uveitic macular edema (UME) might be challenging due to the complex diagnostic workup and the difficulties physicians face to find the underlying cause, and due to its usually recurrent nature and the fact that it can be refractory to conventional treatment. Some of the mild cases can be treated with topical steroids, which can be combined with non-steroid anti-inflammatory drugs. However, immunomodulators such as methotrexate, tacrolimus, azathioprine, cyclosporine and mycophenolate mofetil together with anti-tumor necrosis factor-α (anti-TNF alpha) monoclonal antibodies such as adalimumab and infliximab, may be required to control the inflammation and the associated ME in refractory cases, or when an underlying disease is present. This review of the literature will focus mostly on the non-infectious UME.

Orbital Vasculitides-Differential Diagnosis

PURPOSE OF REVIEW

The orbit is subject to a variety of vascular insults that manifest with both specific and nonspecific patterns of vision compromise. The aim of the following review is to highlight the ophthalmic clinical features of systemic vasculitides that most frequently involve the orbit and differentiate them from the most common non-vasculitic orbital disorders.

RECENT FINDINGS

New studies continue to explore the autoimmune nature of vasculitic disease and seek to determine optimal use of newer therapies such as biologic agents. The pattern of ocular involvement in the context of clinical history allows the knowledgeable physician to distill a differential diagnosis into a specific or likely cause. Establishing a diagnosis in a timely fashion allows for a custom-tailored approach to therapy.

SLE dacryoadenitis

In systemic lupus erythematosus, ophthalmic manifestations are noted in up to one-third of patients. We describe a patient with an unusual initial presentation of this disorder.

Systemic lupus erythematosus and ocular involvement: an overview

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease of undefined etiology and with remarkably heterogeneous clinical features. Virtually any organ system can be affected, including the eye. SLE-related eye involvement can be diagnosed in approximately one-third of the patients and is usually indicative of disease activity. An early diagnosis and the adoption of suitable therapeutic measures are necessary to prevent sight-threatening consequences, especially in patients with juvenile SLE. Periocular lesions, such as eyelid involvement and orbital inflammation, are relatively rare and, in case of orbital masses, may require a biopsy control. Keratoconjunctivitis sicca or secondary Sjögren's syndrome is the most frequent ophthalmic manifestation of SLE. According to its variable severity, lubricating tear drops may be sufficient in mild cases, whereas cyclosporine-A ophthalmic solution, glucocorticoids (GCs), methotrexate, and/or other immunosuppressive drugs may be required in the more severe cases. Partial occlusion of the lacrimal punctum by thermal cautery is rarely applied. Although uncommon, episcleritis and scleritis can sometimes be detected as an initial finding of SLE and reveal themselves as moderate to intense ocular pain, redness, blurred vision, and lacrimation. Unilateral or more often bilateral retinopathy is responsible for visual loss of variable severity and is ascribed to vasculitis of the retinal capillaries and arterioles. In addition to the combined treatment suitable for all patients with active SLE, intravitreal bevacizumab should be considered in cases of severe vaso-occlusive retinopathy and laser photocoagulation in cases of neovascularization. Purtscher-like retinopathy is likely ascribable to the formation of microemboli that results in retinal vascular occlusion and microvascular infarcts. Choroidal disease is characterized by monolateral or bilateral blurred vision. Because of the choroidal effusion, retinal detachment and secondary angle-closure glaucoma may occur. Ischemic optic neuropathy is characterized by acute-onset and progressive binocular visual impairment as a consequence of occlusion of the small vessels of the optic nerves due to immune complex vasculitis. Intravenous GC boluses followed by oral GCs and/or, in case of recurrence, intravenous cyclophosphamide and/or rituximab are commonly employed. Neovascularization can be treated by intravitreal bevacizumab and progression of retinal ischemic areas by retinal laser photocoagulation. Ocular adverse events (AE) have been described following the long-term administration of one or more of the drugs presently used for the treatment of SLE patients. Posterior subcapsular cataracts and secondary open-angle glaucoma are common AE of the prolonged GC administration. The long-term administration of hydroxychloroquine (HCQ) sulfate is well known to be associated with AE, such as vortex keratopathy and in particular the often irreversible and sight-threatening maculopathy. Length of administration > 5 years, > 1000 g total HCQ consumption, > 6.5 mg/kg daily dosing, coexistence of renal disease, and preexisting maculopathy are all considered risk factors for HCQ-induced retinopathy. Ocular AE of additional immunosuppressive and biological agents are still poorly known, given the worldwide more limited experience with their long-term use. A thorough ophthalmological control is strongly recommended at closer intervals for all SLE patients, in step with the total length of exposure to the drugs and the cumulative dose administered.

Peripheral Ulcerative Keratitis Associated with Autoimmune Disease: Pathogenesis and Treatment

Peripheral ulcerative keratitis (PUK) is type of crescent-shaped inflammatory damage that occurs in the limbal region of the cornea. PUK is always combined with an epithelial defect and the destruction of the peripheral corneal stroma. PUK may have a connection to systemic conditions, such as long-standing rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Wegener granulomatosis (WG), relapsing polychondritis, classic polyarteritis nodosa and its variants, microscopic polyangiitis, and Churg-Strauss syndrome. However, the most common connection is with RA, which is also the focus of this review. The pathogenesis of PUK is still unclear. It is thought that circulating immune complexes and cytokines exert an important influence on the progression of this syndrome. Treatment is applied to inhibit certain aspects of PUK pathogenesis.

Uveitis in childhood-onset systemic lupus erythematosus patients: a multicenter survey

The aim of this study is to assess uveitis prevalence in a large cohort of childhood-onset systemic lupus erythematosus (cSLE) patients. A retrospective multicenter cohort study including 852 cSLE patients was performed in ten pediatric rheumatology centers (Brazilian cSLE group). An investigator meeting was held and all participants received database training. Uveitis was diagnosed through clinical assessment by the uveitis expert ophthalmologist of each center. Patients with and without uveitis were assessed for lupus clinical/laboratory features and treatments. Uveitis was observed in 7/852 cSLE patients (0.8%). Two of them had ocular complications: cataract and irreversible blindness in one patient and retinal ischemia with subsequent neovascularization and unilateral blindness in another. Uveitis was identified within the first 6 months of cSLE diagnosis in 6/7 patients (86%). Comparison of a subgroup of cSLE patients with (n = 7) and without uveitis (n = 73) and similar length of disease duration showed that patients with uveitis had increased SLEDAI-2K score (19 vs. 6; p < 0.01). In addition, fever (71 vs. 12%; p < 0.01), lymphadenopathy (29 vs. 1.4%; p = 0.02), arthritis (43 vs. 7%; p = 0.02), and use of intravenous methylprednisolone (71 vs. 22%; p = 0.01) were higher in cSLE patients with uveitis, as compared to those without this manifestation, respectively. Presence of fever was significantly associated with uveitis, independently of SLEDAI scores or use of intravenous methylprednisolone pulses, as shown by adjusted regression analysis (adjusted prevalence ratio 35.7, 95% CI 2.4-519.6; p < 0.01). Uveitis was a rare and initial manifestation of active cSLE patients. Early recognition is essential due to the possibility of irreversible blindness.