Primary vascular occlusion in IRVAN (idiopathic retinal vasculitis, aneurysms, neuroretinitis) syndrome

Comprehensive overview of IRVAN syndrome: a structured review of Case Reports and Case Series

Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome is a rare spectrum of retinal vasculitis, aneurysms, and neuroretinitis affecting young individuals in their third decade. Most of our current knowledge is based on case reports, case series, and a handful of collaborative studies. There is much diversity in treatment approaches and outcomes in the reported literature. We have aggregated published case reports and case series into quantitative and narrative synthesis to draw evidence-based conclusions toward clinical features, atypical and rare findings, systemic associations, disease course, and treatment outcomes. The analysis suggested the disease mostly affects young individuals with a female predilection. Anterior chamber and vitreous inflammation are common than previously believed. The most prevalent pattern of retinal vasculitis in IRVAN eyes is mixed vasculitis, followed by arteritis and phlebitis. Most eyes at the time of presentation have capillary nonperfusion and require treatment. Most eyes retain good visual acuity; however, treatment is required to maintain visual function. Intravitreal antivascular endothelial growth factors administered as an adjunct to retinal laser photocoagulation are more likely to improve visual outcomes. Besides, we have discussed the different hypotheses on the etiopathogenesis of the disease and stronger evidence suggests an inflammatory origin of the disease.

Multimodal imaging in IRVAN syndrome presenting with Branch Retinal Artery Occlusion

PURPOSE

To describe multimodal imaging findings in a patient with idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome presenting with branch retinal artery occlusion (BRAO).

CASE DESCRIPTION

A 33-year-old woman presented with acute BRAO in the right eye. A diagnosis of underlying IRVAN syndrome was made based on the presence of arteriolar aneurysms on the optic disc and along major arterioles and faint retinal hard exudates in both eyes. Eight months later, best-corrected visual acuity was 20/25 in the right eye and 20/20 in the left eye. The hard exudates had increased, and there were extensive areas of peripheral retinal capillary nonperfusion without new vessels. Optical coherence tomography (OCT) showed a localized retinal thinning corresponding to the prior BRAO. Fundus autofluorescence showed nodulo-linear periarterial hypoautofluorescence. OCT angiography (OCTA) showed localized ischemic changes, mainly involving the deep capillary plexus, corresponding to the area of resolved BRAO. It also clearly delineated the optic disc aneurysms. The patient received bilateral scatter laser photocoagulation directed to areas of peripheral capillary nonperfusion. Over a 6-month follow-up period, visual acuity remained unchanged, and there was no evidence of disease progression.

CONCLUSION

Multimodal imaging, including fundus autofluorescence, OCT, and OCTA can provide additional valuable information in the evaluation of IRVAN syndrome complicated with BRAO.

Long-term outcomes in a series of idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome

OBJECTIVE

Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome is a rare entity with a potentially poor visual prognosis. Our objective is to review the clinical presentation and long-term outcomes of patients with IRVAN syndrome.

DESIGN

This is a retrospective case series.

METHODS

We reviewed the charts of all the patients diagnosed with IRVAN syndrome at our tertiary care centre from 2002 to 2015.

RESULTS

We included the long-term clinical outcomes of 7 eyes (5 patients) diagnosed with IRVAN syndrome. After a mean follow-up of 84.9 months, best-corrected visual acuity was 20/40 or better in the majority of eyes (70%). Four (57.1%) patients had systemic conditions, namely, multiple sclerosis, ischemic stroke, and positive antiphospholipid titres. All eyes were treated with laser photocoagulation. Four (40%) eyes received adjunctive intravitreal bevacizumab injections.

CONCLUSION

IRVAN is an important diagnosis for clinicians to recognize. When treated in a timely manner, long-term visual outcomes can be favourable.

Idiopathic Retinal Vasculitis, Aneurysms, and Neuroretinitis Syndrome Presenting With Branch Retinal Artery Occlusion

Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) is a rare syndrome affecting the retinal and optic disc vasculature. Diffuse retinal ischemia, macular edema, and neovascularization may lead to bilateral vision loss. The authors report a case of a 36-year-old woman presenting with branch retinal artery occlusion (BRAO) in her right eye who was subsequently diagnosed with IRVAN syndrome. She was treated with panretinal photocoagulation for peripheral retinal ischemia and pars plana vitrectomy for vitreous hemorrhage. She later developed a BRAO in her left eye. This case demonstrates that BRAO may be a presenting feature of IRVAN syndrome. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:948-951.].

Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome: clinical perspectives

Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome typically affects young, healthy individuals. Despite the dramatic fundus appearance seen in this syndrome, these patients are usually asymptomatic. The syndrome includes peculiar vascular abnormalities in the form of multiple aneurysmal dilatations seen along retinal arterioles and optic nerve-head arterioles, which are best appreciated on fluorescein angiography. Neuroretinitis and retinal vasculitis are seen in all patients, and manifested by staining of the optic nerve head and diffuse leakage from vessels, mainly arterioles, on fluorescein angiography. The devastating vision-threatening outcomes of this syndrome include exudative retinopathy and extensive peripheral retinal nonperfusion areas, which can eventually lead to neovascularization. This review summarizes current knowledge on the variable clinical aspects of this disease, highlighting diagnostic and treatment strategies.

Single Bilateral Dexamethasone Implant in Addition to Panretinal Photocoagulation and Oral Azathioprine Treatment in IRVAN Syndrome

The idiopathic retinal vasculitis, aneurysms and neuroretinitis (IRVAN) syndrome is a disease characterized by multiple retinal macroaneurysms, neuroretinitis and peripheral capillary nonperfusion. Visual loss may result from either ischemia-related complications or macular involvement. Treatment is not always rewarding. We report a case with stage 2 IRVAN syndrome who was successfully treated with a single bilateral intravitreal dexamethasone implant in addition to panretinal photocoagulation and systemic azathioprine treatment.

Management of IRVAN syndrome with observation

A 7-year-old girl with IRVAN (idiopathic retinal vasculitis, aneurysms, and neuroretinitis) syndrome was monitored for 9 years. The patient had symmetric multiple aneurysmal dilations, retinal vasculitis, and severe hard exudation in the macula bilaterally. Long-term visual acuity in her untreated right eye was 20/25. In the left eye, treated with laser panretinal photocoagulation and intravitreal vascular endothelial growth factor inhibitor therapy, visual acuity decreased to 20/200 from macular hard exudates and central fibrovascular tissue. Observation is a consideration in IRVAN syndrome if the vision remains good with hard exudation.

Branch retinal artery occlusion associated with posterior uveitis

BACKGROUND

The purpose of this study is to report the clinical features and visual outcome of branch retinal artery occlusion (BRAO) associated with posterior uveitis. This is a retrospective study including the 18 eyes of 18 patients. All patients underwent a complete ophthalmic evaluation. Fundus photography, fluorescein angiography, and visual field testing were performed in all cases.

RESULTS

Diseases associated with BRAO included active ocular toxoplasmosis in 7 patients, rickettsiosis in 4, Behçet's uveitis in 2, West Nile virus infection in 1, idiopathic retinal vasculitis in 1, Crohn's disease in 1, ocular tuberculosis in 1, and idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome in 1 patient. The mean initial visual acuity was 20/50. BRAO involved the first order retinal artery in 33.3% of the eyes, the second order retinal artery in 33.3%, an arteriole in 27.8%, and a cilioretinal artery in 5.5%. The macula was involved in 44.4% of the eyes and an acute focus of retinitis or retinochoroiditis was associated to BRAO in 55.5%. Repermeabilization of the occluded artery occurred in all patients with permanent scotomas in the corresponding visual field. The mean visual acuity at last visit was 20/32.

CONCLUSIONS

BRAO, with subsequent visual impairment, may occur in the eyes with posterior uveitis. Physicians should be aware of such vision-threatening complication of infectious and inflammatory eye diseases.

Primary branch retinal artery occlusion in idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome associated with hyperhomocysteinemia

PURPOSE

The purpose of this study was to report primary branch retinal artery occlusion in a case with idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome.

METHODS

Review of medical case records, color fundus photographs, and fundus fluorescein angiography of a 23-year-old man diagnosed with idiopathic retinal vasculitis, aneurysms, and neuroretinitis.

PATIENT

A 23-year-old man presented with sudden painless decreased vision in right eye since 1 day. Ocular examination revealed a best-corrected visual acuity of counting fingers 1 feet in the right eye and 20/20 in the left eye, relative afferent pupillary defect in the right eye, 1+ vitreous cells in both eyes, optic disk neovascularization with massive peripapillary and perivascular lipid exudation, and occluded smaller vessels in both eyes. In addition, there was an area of retinal opacification in the posterior pole along the inferotemporal arcade in the right eye. The patient underwent color fundus photography, fluorescein angiography, and a detailed systemic workup.

RESULTS

Fundus fluorescein angiographic features were suggestive of idiopathic retinal vasculitis, aneurysms, and neuroretinitis in both eyes with branch retinal artery occlusion in the right eye. Detailed systemic workup revealed raised serum homocysteine levels. The patient underwent scatter retinal photocoagulation in both eyes and also was started on folic acid and pyridoxine supplementation. At 1 year of follow-up, the best-corrected visual acuity in the right eye improved to 20/60. Posterior segment examination showed reduced exudation, resolution of optic disk neovascularization in both eyes, and clearing of retinal opacification in the right eye. Also, the levels of serum homocysteine decreased over 1 year.

CONCLUSION

Primary branch retinal artery occlusion can be an atypical presentation of idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome. Such a case should be thoroughly investigated for underlying hypercoagulable state. Also, a careful long-term follow-up is required for these patients to prevent any neovascularization sequelae.

Visual acuity recovery in a case of idiopathic retinal vasculitis aneurysms and neuroretinitis

PURPOSE

To describe the visual recovery after intravitreal injections of the antivascular endothelial growth factor, bevacizumab, in a case of vaso obliteration from idiopathic retinal vasculitis, aneurysm, and neuroretinitis (IRVAN). The name IRVAN was given to the condition to highlight the key findings present in the disease. IRVAN is a severe, sight threatening condition that can lead to peripheral capillary non-perfusion and vision loss from the ischemic sequelae of vascular occlusion. Panretinal photocoagulation (PRP) is the current standard of care for IRVAN but visual outcome is poor if PRP is initiated after neovascularization develops. Intravitreal bevacizumab has success at treating neovascularization from other ischemic retinopathies and inflammatory retinal conditions that have similar characteristics to IRVAN.

CASE REPORT

This case report describes a patient with decreased vision in the OS. The patient presented with best-corrected visual acuity of 20/20 in the OD and count fingers at 4 ft in the OS. Evaluation revealed findings consistent with an advanced stage of IRVAN. Anterior and posterior neovascularization had developed from extensive capillary non-perfusion in both retinas. A dense vitreous hemorrhage blocked vision OS. Bilateral intravitreal injections of bevacizumab and extensive PRP were given in the area of retinal ischemia for treatment. After 4 months, the patient's vision had improved from count fingers in the OS to 20/40.

CONCLUSIONS

IRVAN has favorable outcomes when treated with a combination of PRP and intravitreal injections of antivascular endothelial growth factor. This case demonstrates the effectiveness of this combination treatment in a case of IRVAN with both posterior and anterior neovascularization.