Vaso-occlusive retinopathy in the primary anti-phospholipid antibody syndrome

Clinical Features of Pregnancy-associated Retinal and Choroidal Diseases Causing Acute Visual Disturbance

PURPOSE

To report clinical features of patients with retinal and choroidal diseases presenting with acute visual disturbance during pregnancy.

METHODS

In this retrospective case series, patients who developed acute visual loss during pregnancy (including puerperium) and visited a tertiary hospital from July 2007 to June 2015, were recruited by searching electronic medical records. Patients were categorized according to the cause of visual loss. Clinical features and required diagnostic modalities were analyzed in the retinal and choroidal disease group.

RESULTS

Acute visual loss occurred in 147 patients; 49 (38.9%) were classified into the retinal and choroidal group. The diagnoses included central serous chorioretinopathy (22.4%), hypertensive retinopathy with or without pre-eclampsia (22.4%), retinal tear with or without retinal detachment (18.4%), diabetic retinopathy progression (10.2%), Vogt-Koyanagi-Harada disease (4.1%), retinal artery occlusion (4.1%), multiple evanescent white dot syndrome (4.1%), and others (14.3%). Visual symptoms first appeared at gestational age 25.9 ± 10.3 weeks. The initial best-corrected visual acuity (BCVA) was 0.27 ± 0.39 logarithm of the minimum angle of resolution (logMAR); the final BCVA after delivery improved to 0.13 ± 0.35 logMAR. Serious visual deterioration (BCVA worth than 20 / 200) developed in two patients. Differential diagnoses were established with characteristic fundus and spectral-domain optical coherence tomography findings in all cases.

CONCLUSIONS

In pregnant women with acute visual loss, retinal and choroidal diseases are common and could be vision threatening. Physicians should be aware of pregnancy-associated retinal and choroidal diseases and their clinical features. The differential diagnosis can be established with non-invasive techniques.

Pregnancy-associated retinal diseases and their management

Pregnancy-associated retinal diseases are conditions that may occur uniquely in pregnancy or, more commonly, general conditions that may worsen or alter during pregnancy as a result of hematologic, hormonal, metabolic, cardiovascular, and immunologic changes. Diabetic retinopathy (DR) is by far the most common retinal condition that is altered by pregnancy. However, there are currently no widely accepted, precise clinical guidelines regarding its management during pregnancy. At present it is not possible to predict who will regress and who will progress without treatment. Some of the variation in progression of DR in pregnancy may be a result of well-known risk factors such as hypertension or inadequate glycemic control prior to pregnancy. Other pregnancy-associated retinal diseases are relatively uncommon, and their treatments are poorly characterized. Pre-existing conditions include the white dot syndromes, such as punctuate inner choroidopathy and ocular histoplasmosis syndrome, as well as chorioretinal neovascularization from many other etiologies. Retinal and chorioretinal disorders that can arise during pregnancy include central serous chorioretinopathy and occlusive vasculopathy such as retinal artery occlusion (Purtschers-like retinopathy) and retinal vein occlusion. There remains a small group that appear to be unique to pregnancy, with pre-eclampsia- and eclampsia-associated retinopathy, disseminated intravascular coagulopathy, or amniotic fluid embolism being the best described. In angiogenic retinal diseases outside of pregnancy, the use of anti-vascular endothelial growth factor (anti-VEGF agents) has proven helpful. There are no safety data about the use of anti-VEGF agents during pregnancy, and conventionally the proposed interventions have been laser photocoagulation and systemic or intravitreal injections of steroids. Most of the literature on the treatment of pregnancy associated-chorioretinal neovascularization is anecdotal.

Serum antiphospholipid antibody levels in pseudoexfoliation

PURPOSE

To evaluate the levels of serum antiphospholipid antibodies in patients with pseudoexfoliation syndrome (PXS), pseudoexfoliation glaucoma (PXG), primary open-angle glaucoma, and healthy controls.

MATERIALS AND METHODS

This prospective study included 17 patients with PXS, 19 patients with pseudoexfoliation glaucoma, 15 patients with primary open-angle glaucoma, and 19 normal individuals. Venous blood samples were obtained in the morning after an overnight 8-hour fasting. Anticardiolipin antibodies, isotypes IgG and IgM were measured by means of an enzyme-linked immunosorbent assay. Lupus anticoagulant antibodies were measured by dilute Russell viper venom time screen test.

RESULTS

Mean±standard mean of error of anticardiolipin antibody IgG levels in patients with PXS and PEG were significantly higher than those of the controls (P<0.05). The mean lupus anticoagulant antibody levels of the controls were not statistically different from the levels of patients with PXS, pseudoexfoliation glaucoma, and primary open-angle glaucoma (P>0.05). The anticardiolipin antibody IgG concentrations above the cutoff value of 15 GPL/mL were found in 8 patients (21.05%) with pseudoexfoliation. There was no individual in the control group having anticardiolipin antibody IgG level above the cutoff value (P<0.05).

CONCLUSIONS

Elevated serum antiphospholipid antibodies, a risk factor for cardiovascular and cerebrovascular disease, is more common in patients with PXS and pseudoexfoliation glaucoma than in the healthy controls and in patients with primary open-angle glaucoma.

Prothrombin gene mutation G20210A, homocysteine, antiphospholipid antibodies and other hypercoagulable states in ocular thrombosis

The purpose of the present study was to determine whether using an extended panel of laboratory tests increases the detection of a hypercoagulable state in patients with ocular thromboses. Twenty consecutive patients with ocular thromboses (vein, artery, or choriocapillaris occlusions) underwent testing for activated protein C resistance/factor V Leiden, prothrombin G20210A, lupus anticoagulant, anticardiolipin antibodies, hyperhomocysteinemia, and deficiencies of protein C, protein S, and antithrombin. For each patient, we selected two age-matched and gender-matched individuals without ocular thromboses as controls. Sixteen of the 20 patients (80%) had one or more laboratory tests that supported a hypercoagulable condition. Prothrombin G20210A (P < 0.02) and hyperhomocysteinemia (P < 0.0006) were significantly more frequent in ocular thrombosis patients compared with controls. The most common condition was antiphospholipid antibody syndrome, present in 40% of patients (confirmed by repeat testing at least 6 weeks later), but this did not reach statistical significance compared with the controls. No patients with ocular thromboses had hereditary abnormalities of protein S, protein C, or antithrombin. In conclusion, an extended panel of laboratory tests improved the detection of a hypercoagulable state in ocular thromboses. Testing for homocysteine, antiphospholipid antibodies, and the prothrombin G20210A mutation should be considered in patients with ocular thromboses.

Review of severe vaso-occlusive retinopathy in systemic lupus erythematosus and the antiphospholipid syndrome: associations, visual outcomes, complications and treatment

PURPOSE

To discuss the pathogenesis of severe vaso-occlusive retinopathy in systemic lupus erythematosus (SLE), the association with antiphospholipid antibodies, and its implications for management and prognosis.

METHODS

An illustrative case history of a woman with SLE and severe vaso-occlusive retinopathy in the presence of antiphospholipid antibodies is presented. A literature review of previously reported cases and previously published data on the topic was performed and forms the basis for discussion.

RESULTS

This is a rare form of retinopathy in SLE as distinct from the more common, benign form, being classically a microangiopathy with diffuse capillary non-perfusion and small arterial or arteriolar occlusions in the retina. Poor visual outcomes with visual loss are reported in 80% of cases with neovascularization occurring in 40% of cases. It is associated with antiphospholipid antibodies, typically characterized by microthrombosis and immune complex mediated vasculopathy rather than a true vasculitis. There is a strong association between this severe form of retinopathy and central nervous system manifestations of SLE. Anticoagulation has a role in the secondary prevention of thrombosis in the presence of antiphospholipid antibodies, but the role of aspirin and immunosuppression is unclear in the treatment of this condition. Vigilant ophthalmic follow up and aggressive treatment of neovascularization and vitreous haemorrhage can prevent further visual loss. These points are highlighted in the brief case report presented.

CONCLUSION

Severe vaso-occlusive retinopathy is a rare form of retinopathy in SLE often associated with poor visual prognosis and neovascularization. It may be a manifestation of the antiphospholipid syndrome. Treatment is aimed at preventing further thrombosis and complications arising from neovascularization.

Oculorenal manifestations in systemic autoimmune diseases

Vasculitides form a heterogeneous group of diseases characterized by blood-vessel inflammation and necrosis. They have a wide spectrum of manifestations because of the involvement of arteries and other vessels of various sizes and locations. Early diagnosis and prompt treatment may decrease the morbidity and mortality associated with these disorders. Examination of the eye and kidney should be performed routinely in those diseases. This article reviews the major types of oculorenal manifestations in systemic autoimmune diseases.

Anticardiolipin antibodies in patients with retinal vein occlusion and no risk factors: a prospective study

BACKGROUND

Several reports have described the association between antiphospholipid antibodies (APAs) and retinal venous occlusive (RVO) disease. The purpose of this study was to look at the prevalence of these antibodies in patients with RVO disease and no conventional risk factors. We specifically examined how APAs may affect the course of this disease.

METHODS

Twenty-four patients with the diagnosis of RVO disease were screened prospectively for APAs. All were free from risk factors for retinal vein thrombosis and other immunologic conditions. Patients were observed for a period of 3 to 12 months.

RESULTS

Lupus anticoagulant was negative in all 24 patients. Ten (43%) of 24 patients had anticardiolipin antibodies (ACAs). All patients with ACAs were younger than 45 years of age, with an average age of 33 years. The average age of patients with no ACAs was 66 years. Comparison of the average age of the two groups showed a statistically significant difference. There was no statistical significance between the two groups for development of neovascular disease. Seropositive patients who developed neovascularization had elevated titers for an average of 11.8 weeks versus 3.3 weeks for those who did not have neovascularization. Neovascular complications generally began several weeks after the titers became negative.

CONCLUSION

There was a significant prevalence of ACAs in young patients with RVO disease and no associated systemic risk factors. Seropositive patients who developed neovascular disease had elevated titers for more than 6 weeks. However, the role of these transient ACAs in retinal vein occlusion is still not clear and merits further study.

Antiphospholipid antibody syndrome in a six-year-old female patient

PURPOSE

To report the first instance of primary antiphospholipid antibody (APA) syndrome in an otherwise healthy 6-year-old female patient with retinal venous thromboses.

DESIGN

Observational case report.

METHODS

A 6-year-old girl with poor vision in the left eye and preretinal hemorrhage underwent testing for infectious, autoimmune and embolic disease, diabetes, and hypertension. Testing for factor V Leiden and prothrombin G20210A mutations, homocysteine, anticardiolipin antibodies (ACAs), lupus anticoagulant, and functional assays for protein S, protein C, and antithrombin III were performed to detect a hypercoagulable state. No IRB approval was necessary.

RESULTS

Only a positive lupus anticoagulant and moderately elevated ACA IgG were found. The ACA IgG was moderately elevated on repeat testing 18 months later. Laser to nonperfused retina caused some regression of retinal neovascularization. Aspirin was recommended to reduce the risk of future thromboses.

CONCLUSIONS

Although uncommon, retinovascular thrombosis in children can occur in APA syndrome. Testing for ACA and lupus anticoagulant should be considered.

Primary anti-phospholipid antibody syndrome (APS): current concepts

Primary anti-phospholipid syndrome (APS) is a thrombophilic state characterized by recurrent arterial and venous thrombosis, recurrent pregnancy loss, and the presence of circulating anti-phospholipid antibodies that may be responsible for thrombophilia and pregnancy morbidity. Ophthalmologic features are present in 15-88% of the patients with primary APS, thus ophthalmologists are one of the first physicians to whom the patient will present. An accurate diagnosis may save the patient from recurrent, potentially life-threatening thrombosis. In the U.S.A., an estimated 35,000 new cases of APS-related venous thrombosis occur each year in a population that is several decades younger than the patient population typically affected by thrombosis. Clinical features, such as chorea, transverse myelitis, cardiac valvular lesions, and accelerated atherosclerosis, are hypothesized to be due to a direct tissue-antibody interaction and cannot be explained purely by thrombosis. The use of recently proposed, well-defined diagnostic criteria, and better standardization of laboratory assays for the anti-phospholipid antibodies should help enable epidemiological surveys to establish the prevalence of these antibodies in patients with thrombosis and in the general population. Diagnosis of APS should be considered in all patients with recurrent systemic or ocular thrombosis in the absence of known risk factors. Several well-designed prospective studies show an increased risk of thrombosis in the presence of medium to high antibody level. With ocular involvement in as many as 88% of APS patients, an ophthalmic assessment should be an integral part of the clinical work-up of any patient with suspected or confirmed APS. The presence of isolated ocular thrombophilia with persistently elevated anti-phospholipid antibodies or lupus coagulant should confirm the diagnosis of APS. Management of these patients must be a multi-disciplinary effort with either a rheumatologist or a hematologist having the overall responsibility for coordinating treatment and monitoring the patient's immune status and anticoagulation. Treatment of isolated ocular thrombophilia in the presence of moderate to high titers of antiphospholipid antibodies should be on the same principles as patients with APS to prevent recurrent ocular or cerebral thrombosis.

Primary antiphospholipid syndrome presenting with a branch retinal artery occlusion in a 15-year-old boy

Acute vascular events are rare in the pediatric population, but there is an association with the presence of antiphospholipid antibodies. When there is no other underlying medical disorder, this is referred to as primary antiphospholipid syndrome. We present a case of a 15-year-old boy who developed an acute superior branch retinal artery occlusion. Complete evaluation revealed significant elevations in antiphospholipid antibodies. To our knowledge, there are no cases in children of primary antiphospholipid syndrome presenting with this clinical manifestation.

Ocular features associated with anticardiolipin antibodies: a descriptive study

PURPOSE

To evaluate ocular features in patients presenting with inflammation in the presence of anticardiolipin antibodies.

METHODS

A descriptive study of 13 patients presenting with idiopathic ocular inflammation involving anterior and posterior segment was performed. Patients were followed for a mean follow-up of 22 months (range, 1 to 125). A comprehensive report of ocular involvement, including visual symptoms, visual acuity, clinical characteristics, funduscopic and fluorangiographic features, was reported. Systemic associated symptoms were analyzed. Laboratory investigations included anticardiolipin antibody titers and isotypes, presence of other autoantibodies, and markers of immune system activation.

RESULTS

The most common ocular symptom at presentation was blurred vision (eight patients) followed by redness and pain(three patients) and visual loss(two patients). Anterior segment abnormalities, including iritis (eight patients) scleritis (two patients) and filamentary keratitis (one patient), were present in 76% of patients, whereas the most represented feature of posterior involvement was retinal vasculitis (60%) followed by vitritis (38%), retinal detachment (15%), posterior scleritis (7%), and central retinal artery occlusion (7%). All patients had abnormal titers of anticardiolipin antibodies, predominantly IgG isotype; six had markers of immune system activation.

CONCLUSIONS

Although posterior pole disease is more commonly associated with anticardiolipin antibodies, the anterior segment can also be involved with a wide spectrum of features. Scleritis has never been previously described as associated with anticardiolipin antibodies. Systemic symptoms are frequently present in association with ocular disease.

Ocular involvement in primary antiphospholipid syndrome. Ocular involvement in primary APS

The purpose of this study is to evaluate the ocular findings in patients with the primary antiphospholipid syndrome (APS).

PATIENTS AND METHODS

Twenty-two patients (44 eyes) with primary APS (17 women, 5 men) were examined. All patients were younger than 50 years (median age; 37.5 years). In 18 patients, fundus flourescein angiography was performed in addition to the ophthalmologic examination.

RESULTS

Sixteen patients (72.7%) described visual symptoms. Anterior segment was normal in 19 patients (86.4%). Posterior segment abnormalities were observed in 15 patients (68.2%). Venous dilatation and tortuosity were the most common ocular findings. Retinal vascular occlusive disease was detected in 5 patients (22.7%). Flourescein angiography abnormalities were noted in 14 of the 18 patients (77.8%). The most common angiographic finding was pigment epithelial window defects.

CONCLUSIONS

Our results indicate that posterior eye segment involvement is relatively common in the primary APS. It also seems that the screening for APS is important in young patients with retinal vascular occlusion, especially in those without conventional risk factors.

Long-term follow-up of ischaemic retinopathy in the antiphospholipid syndrome with lupus-like disease

PURPOSE

Antiphospholipid syndrome (APS), as an acquired prothrombotic disorder, is increasingly being recognised as an important cause of systemic venous and arterial thrombosis. The defining feature of the condition is the presence of raised levels of antibodies to negatively charged phospholipids in the serum.

METHODS

We describe 2 cases of APS with ocular involvement and review the recent literature. Both patients experienced acute visual loss. It was the presenting symptom in one case--a finding that led to the diagnosis of the syndrome.

RESULTS

Management with anticoagulation therapy, in which the International Normalised Ratio (INR) has been maintained at or above 3, resulted in reperfusion of the ischaemic retina and stabilisation of the retinopathy in one patient, whilst in the other case, where the INR was less than 3, irreversible visual loss occurred.

CONCLUSION

Anticoagulation with warfarin appears to result in reperfusion of ischaemic retina with stabilisation of the neovascular process when the INR is greater than 3.

Antiphospholipid antibodies and retinal thrombosis in patients without risk factors: a prospective case-control study

PURPOSE

To determine the prevalence of antiphospholipid antibodies and other immunologic abnormalities in patients with occlusive retinal vascular events, exempt from conventional risk factors of retinal thrombosis.

METHODS

Forty patients with retinal vascular occlusion (26 with retinal vein occlusions, eight with arterial occlusions, two with combined venous and arterial occlusions, and four with venous occlusions plus vasculitis), free of main accepted risk factors for retinal thrombosis, were prospectively screened for antiphospholipid antibodies (anticardiolipin-antibodies and lupus anticoagulant) and other immunologic abnormalities. Fourteen patients were younger than 50 years. Prevalence and mean values of antiphospholipid antibodies (aPL) were compared with those in a homogeneous control group of 40 patients.

RESULTS

The prevalence of antiphospholipid antibodies in the study group was 22.5% (nine of 40). Comparison with control group prevalence (5% [two of 40]) showed a statistically significant difference (P = .04). Six patients in the study group disclosed positivity for IgG-anticardiolipin antibodies, one patient for IgM anticardiolipin antibodies, and two patients for both isotypes IgG and IgM anticardiolipin antibodies. The antibody assay for lupus anticoagulant was negative for all patients. Three patients were diagnosed as having primary antiphospholipid antibody syndrome and are undergoing systemic anticoagulant therapy. Relevant immunologic abnormalities were also found (27.5% with antinuclear antibodies, 35% with elevation of circulating immune complexes, 35% with complement deficiency, 30% with positive rheumatoid factor, and 17.5% with positive C-reactive protein). Thirteen patients (32.5%) had more than four parameters altered. No significant association was found between prevalence or mean values of anticardiolipin antibody and patients younger than 50 years.

CONCLUSIONS

The high prevalence of anticardiolipin antibodies in patients with vaso-occlusive retinopathy exempt from conventional risk factors, and the relevant diagnostic and therapeutic implications, lead us to recommend a systematic search for specific antiphospholipid antibodies in such patients.

Anticardiolipin antibodies and occlusive vascular disease of the eye: prospective study

There is a recognized association between the presence of anticardiolipin antibodies and vascular occlusive disease. The purpose of our study is to detect the presence of high titers of anticardiolipin antibodies (ACA) in the serum and to correlate the titers with the severity of the vascular disease in patients with occlusive ocular vascular disease. 82 patients were included in a prospective study; 25 patients with anterior ischaemic optic neuropathy, 36 with retinal vein occlusion and 21 with retinal artery occlusion. ACA (IgG and IgM isotypes) were measured by ELISA in the sera of all patients. The group of the patients (group A) was compared to an age-matched control group of 79 healthy individuals (group B). IgG isotype (but not IgM) titers of ACA were found significantly higher in group A (P < 0.001). In patients with titers of ACA (IgG isotype) > 100 units we noted a higher incidence of a more severe disease (recurrency, involvement of both eyes or extraocular manifestations) especially among those with anterior ischaemic optic neuropathy and secondarily in those with retinal artery occlusion. Our results suggest that the association between high titers of ACA and occlusive vascular disease of the eye concerns only the IgG isotype. In addition, the detection of high titers of IgG/AGA in patients could be a useful marker for disease severity and prognosis and this observation seems to be more explicit in cases with arterial occlusive disease than in cases with venous occlusive disease.

The clinico-ophthalmological spectrum of antiphospholipid syndrome

Antiphospholipid syndrome (APS) is a hypercoagulable disorder with highly variable symptomatology including ocular manifestations. Antiphospholipid antibodies (aPL) are the serologic markers of this clinical entity. Our aim was to note the main associated ocular features of APS and elucidate which pathogenic mechanisms may participate. Retinal vascular thrombosis and different neuro-ophthalmologic manifestations, such as optic neuropathy and amaurosis fugax, may be considered as the ocular hallmarks of this syndrome. Ocular features due to aPL-induced thrombosis should be treated with anticoagulant drugs. Conversely, for the treatment of ocular features due to immunological mechanisms such as vasculitis, immunosuppressive regimes seem to be more appropriate.

Primary antiphospholipid antibody syndrome and retinal occlusive vasculopathy

PURPOSE

To report a 31-year-old healthy patient with retinal venous occlusion in his left eye attributable to primary antiphospholipid antibody syndrome.

METHODS

The patient was examined clinically. Multiple serologic and clinical investigations were performed to determine the causative disease. He was closely followed up for more than 3 years.

RESULTS

The presence of lupus anticoagulant in our patient was indicated by a kaolin clotting time index of 27 (normal, <17) and confirmed by the demonstration of IgG antibodies against phospholipids. After long-term oral anticoagulant treatment for 2 years, lupus anticoagulant levels returned to normal, and therapy was stopped. No further thrombotic event occurred during follow-up.

CONCLUSIONS

In retinal vascular occlusions of unexplained origin, antiphospholipid antibodies may play an important role in the pathogenesis. Detecting these antibodies in the serum of patients with retinal vascular occlusion helps determine the appropriate treatment with long-term oral anticoagulants.

Antiphospholipid antibodies and retinal vascular disease

BACKGROUND

Antiphospholipid antibody retinopathy is a rare and poorly defined clinical entity in which the proper diagnosis has important ocular and systemic implications. The clinical course of five patients with antiphospholipid antibody retinopathy is described and the role of such antibodies in idiopathic retinal venous occlusive disease is investigated.

METHODS

Five case reports are presented highlighting the presentation, course, therapy, associations and outcomes of patients with antiphospholipid antibody retinopathy. In addition, twenty additional patients presenting with idiopathic retinal venous occlusive disease were tested for the presence of antiphospholipid antibodies.

RESULTS

All five patients with antiphospholipid antibody retinopathy had diffuse retinal vascular occlusion. All five patients presented with associated rheumatologic disease, including three with lupus or lupus-like disease. Antibodies to antiphospholipid were not detected in any of the twenty patients with idiopathic retinal venous occlusive disease. Prompt panretinal photocoagulation together with varying regimens of corticosteroids, immunosuppressives, or warfarin was partially successful in stabilizing the ocular and systemic disease.

CONCLUSION

The diagnosis of antiphospholipid antibody retinopathy should be suspected in patients with diffuse retinal vaso-occlusion, particularly when characterized by involvement of both arteries and veins, neovascularization at presentation, and symptoms of symptoms of systemic rheumatologic disease. Antiphospholipid antibodies do not appear to play an important role in idiopathic retinal vein occlusions.

Thrombophilic factors in ischaemic and non-ischaemic idiopathic retinal vasculitis

Two common causes of visual loss in idiopathic retinal vasculitis (RV) are retinal ischaemia and cystoid macular oedema. This study investigated whether thrombophilic factors are more prevalent in patients with ischaemic RV than non-ischaemic RV. Twenty patients with RV (10 ischaemic, 10 non-ischaemic) were prospectively recruited before starting systemic immunosuppression. Twenty-one different haemostatic parameters were tested. Seventeen patients had at least one haemostatic abnormality. Three patients had low Protein S, one had low Protein C. Three patients had positive anticardiolipin antibody titres, 1 had poor fibrinolytic activity, 3 had raised fibrinogen levels. Ten patients had raised lipoprotein (a) levels. Fibrinogen levels were higher in the smokers (p = 0.02). Although all von Willebrand's factor levels were within the normal range, they were higher in the ischaemic group (p = 0.008), in which smoking was more prevalent. This study has shown a high prevalence of thrombophilic abnormalities in RV patients, and implicates smoking in the aetiology of ischaemic RV.

Idiopathic recurrent branch retinal arterial occlusion. Natural history and laboratory evaluation

PURPOSE

To investigate the long-term visual and systemic prognosis of patients with idiopathic recurrent branch retinal artery occlusions, and to test recent hypotheses regarding possible causes of this syndrome.

METHODS

The authors retrospectively reviewed the medical and photographic records of 16 eligible patients. Each of 15 living patients was interviewed by one of the authors, then underwent follow-up ophthalmic examination, formal visual field testing, and a battery of clinical laboratory tests.

RESULTS

Over a mean follow-up of 9 years, only three eyes (9%) lost visual acuity from foveal ischemia, although nine eyes (28%) had central and/or extensive peripheral visual field loss at final examination. Ocular neovascular complications developed in eight eyes (25%). Eight patients (50%) had associated vestibuloauditory and/or transient sensorimotor symptoms, but serious permanent neurologic deficits or recurrent systemic thromboembolic events did not develop. Although most patients had one or more vaso-occlusive risk factors, extensive laboratory testing failed to define the etiology of the arterial occlusions.

CONCLUSIONS

On long-term follow-up, the visual, neurologic, and systemic prognosis for most patients with idiopathic recurrent branch retinal arterial occlusions remains favorable. Although it is probable that such patients are etiologically heterogeneous, the authors theorize that many have mild or partial manifestations of the microangiopathic syndrome of encephalopathy, hearing loss, and retinal arteriolar occlusions.

Coagulation abnormalities in ischaemic optic neuropathy

The aetiology of non-arteritic ischaemic optic neuropathy (ION) is multifactorial with local anatomical and systemic haemodynamic abnormalities both playing a role. A careful search for treatable vascular disease risk factors is required to allow rational therapy, to optimise the visual prognosis and to allow new insights into pathogenesis. We describe 7 cases in which there was an associated thrombophilic (prothrombotic) state; 4 had deficiencies of the physiological anticoagulants proteins C and S and antithrombin III and 2 had anti-phospholipid antibody (lupus anticoagulant) syndromes. A further patient had reduced levels of the physiological fibrinolytic agent tissue plasminogen activator (t-PA). In 5 patients other risk factors for small vessel occlusive disease were also present, and 4 had recurrent episodes of ION in the same eye. The visual prognosis in these patients may be improved by anticoagulation with warfarin.

Pathogenetic mechanisms in combined cilioretinal artery and retinal vein occlusion: a reappraisal

We examined nine patients who presented cilioretinal artery occlusion (CLRAO) associated with retinal vein occlusion (RVO). CLRAO was probably secondary to the raised intraluminal resistance consequent to the RVO in patients showing initially a delayed filling of the cilioretinal artery in fluorescein angiography. Interestingly, these patients presented an ophthalmoscopically more severe form of RVO and had systemic predisposing factors for a RVO. In patients presenting a physiological perfusion of the cilioretinal artery in fluorescein angiography, RVO was a self limited disease and etiologic factors were not found. This may suggest that in these patients the CLRAO probably occurred simultaneously with the RVO after a decrease in perfusion pressure in both retinal and cilioretinal arterial systems. In this combined vaso-occlusive retinopathy the vulnerability of cilioretinal arteries can be explained either by the absence of autoregulation or by their lower perfusion pressure gradient in comparison with retinal arteries.

Anticardiolipin antibodies in uveitis

Anticardiolipin antibodies (ACA) have been described in association with thrombosis and several vascular diseases and may be involved in retinal vasculitis. To investigate this question we tested sera from 86 patients with posterior uveitis and 100 healthy controls for the presence of anticardiolipin antibodies. The antibody was present in 15 patients: in 7 of the patients with acute retinal necrosis (n = 24), in 4 with idiopathic retinal vasculitis (n = 10), 3 with syphilis (n = 6) and in one SLE patient with retinal vasculitis. Ten patients had IgA-type anticardiolipin antibodies, 6 had IgM-type and 4 had IgG-type anticardiolipin antibodies. Anticardiolipin antibodies could not be detected in sera from uveitis patients with Behçet's disease (n = 10), sarcoid (n = 9), toxoplasmosis (n = 7), multiple sclerosis (n = 3) or Birdshot chorioretinopathy (n = 10). Ten of the healthy controls had cardiolipin antibodies of the IgM class. The exact role of these auto-antibodies in the pathogenesis of retinal vasculitis remains to be resolved.