Retinal and Choroidal Thickness in Adult Patients with Familial Mediterranean Fever

Familial Mediterranean Fever-Associated Retinal Vasculitis: A Rare Manifestation Successfully Managed with IL-1 Pathway Inhibitors

PURPOSE

To investigate the rare manifestation of retinal vasculitis in Familial Mediterranean fever (FMF) and its correlation with specific gene mutations, particularly the MEFV gene, with a focus on the severity of phenotypes and systemic vasculitis.

METHODS

A case report of a 45-year-old Armenian patient with FMF history and dual mutations (M680I and M694V) was analyzed. Clinical assessments, including ocular examinations, were conducted at various stages of the disease. Treatment modalities, including prednisone, Anakinra, and Canakinumab, were administered and their effectiveness was assessed.

RESULTS

The patient presented with bilateral ocular pain and decreased vision, exhibiting acute anterior uveitis, perivascular hemorrhages resembling Roth spots, and subsequent features of persistent vascular sheathing and cotton-wool spots. Dual mutations, especially M694V, were associated with a severe phenotype and systemic vasculitis. Treatment with prednisone induced remission, and IL-1 pathway inhibition with Anakinra and Canakinumab successfully managed relapses.

CONCLUSION

This case underscores the rarity of retinal vasculitis in FMF, particularly involving arteries, and highlights the correlation between specific gene mutations (M680I, M694V) and disease severity. The successful management with IL-1 pathway inhibitors suggests a potential therapeutic approach. Increased clinical awareness, further research, and reporting are crucial for optimizing the understanding and treatment of FMF-related ocular manifestations.

Update on ocular manifestations of the main monogenic and polygenic autoinflammatory diseases

Autoinflammatory diseases include disorders with a genetic cause and also complex syndromes associated to polygenic or multifactorial factors. Eye involvement is present in many of them, with different extent and severity. The present review covers ophthalmological lesions in the most prevalent monogenic autoinflammatory diseases, including FMF (familial Mediterranean fever), TRAPS (TNF receptor-associated periodic syndrome), CAPS (cryopyrin-associated periodic syndromes), Blau syndrome, DADA2 (deficiency of adenosine deaminase 2), DITRA (deficiency of the interleukin-36 receptor antagonist), other monogenic disorders, including several ubiquitinopathies, interferonopathies, and the recently described ROSAH (retinal dystrophy, optic nerve edema, splenomegaly, anhidrosis, and headache) syndrome, and VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. Among polygenic autoinflammatory diseases, ocular manifestations have been reviewed in Behçet's disease, PFAPA (periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis) syndrome, Still's disease and autoinflammatory bone diseases, which encompass CRMO (chronic recurrent multifocal osteomyelitis) and SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome.

Choroidal vascularity index in adult patients with familial meditteranean fever

PURPOSE

This study aimed to evaluate choroidal vascular status by the choroidal vascularity index (CVI) in adult patients with familial Mediterranean fever (FMF) in remission period.

MATERIALS-METHODS

86 patients diagnosed with FMF and 54 healthy controls were recruited in this study. Retinal, ganglion cell complex and peripapillary retinal nerve fibre layer thicknesses were obtained using Spectralis domain-optical coherence (SD-OCT) tomography. Choroid images were obtained with the enhanced depth imaging mode of SD-OCT, and binarization was applied to the images using ImageJ software. CVI was described as the proportion of the luminal area to the total choroidal area. Blood-derived inflammation markers were calculated by the complete blood count.

RESULTS

The subfoveal choroidal thickness and nasal and temporal directions from fovea centralis at 500 μm, 1000 μm and 1500 μm were reduced in patients with FMF in comparison to healthy controls (p<0.001, each comparison). CVI was significantly decreased in patients with FMF compared to controls (62.28±2.2 and 64.79±4.3, p<0.001).

CONCLUSION

We concluded that the choroidal vasculature structure may be affected prior to retinal changes in patients with FMF.

Familial Mediterranean fever associated frosted branch angiitis, retinal vasculitis and vascular occlusion

OBJECTIVES

To analyse the entity of retinal vasculitis, including frosted branch angiitis (FBA), or retina vascular occlusion in patients with familial Mediterranean fever (FMF).

METHODS

Retrospective collaborative case series using invitation by email to uveitis specialists around the Mediterranean basin. This series was combined with a literature review. Exclusion criteria included infectious diseases, Behçet's disease or other autoimmune diseases.

RESULTS

A total of 16 patients (21 eyes) had FMF and retinal vasculitis (FBA 11 patients, mild retinal vasculitis 5 patients). The mean age at onset of vasculitis was 29.5 ± 13.4 (range 9-62) with a female to male ratio of 9 to 7. In 19 eyes treated with various forms of corticosteroid and/or immunosuppression, the mean initial spectacle-corrected visual acuity improved from 6/194 to 6/10.5 at the last mean follow-up of 29.0 ± 34.9 months (p < 0.001). The most common FEVR mutations were M680I and M694V. In addition, retinal vascular occlusions included one case of central retinal artery occlusion and one case of branch retinal artery occlusion.

CONCLUSION

FBA and milder forms of retinal vasculitis are associated with FMF. Therapy involves an increase in colchicine dosage in early cases, a long period of oral corticosteroid, intravitreal dexamethasone implant or periocular corticosteroid in select cases, and combination therapy with systemic immunosuppression in severe cases. FMF needs to be included in the differential diagnosis of retinal vasculitis.

Retrobulbar Ocular Blood Flow and Choroidal Vascular Changes in Patients Recovering from COVID-19 Infection

Background

To evaluate the effects of COVID-19 infection on the ocular vascular structure including choroidal thickness and retrobulbar blood flow values in comparison with healthy subjects.

Methods

Ninety eyes of 90 patients were included in this study. Participants were divided into Group 1 (n = 30) with mild COVID-19 infection, Group 2 (n = 31) with moderate disease, and Group 3 with age- and sex-matched healthy subjects (n = 29). Choroidal thickness was measured at the subfoveal area and at 500-µm intervals nasal and temporal to the fovea up to a distance of 1500 µm, using the enhanced depth imaging (EDI) technique of spectral coherence tomography (SD-OCT). The peak systolic velocity (PSV), end diastolic velocity (EDV), resistive index (RI), and pulsatility index (PI) values of the central retinal artery (CRA) and ophthalmic artery (OA) were evaluated with color Doppler ultrasonography (CDU).

Results

The choroidal thickness was significantly thinner in Group 1 and Group 2 than in Group 3 at all measurement points (p <0.001). This difference was not present between Group 1 and Group 2 who had COVID-19 disease of different severity (p>0.05).Among the retrobulbar blood flow parameters, OA PSV value was significantly lower in Group 1 and Group 2 compared to Group 3 (p = 0.025, p = 0.016, respectively). However, the CRA PSV and EDV and OA EDV values, and the CRA and OA PI and RI values were not statistically different between the groups (p> 0.05).

Conclusion

COVID-19 infection may predispose patients to ocular vascular pathologies by affecting both choroidal and retrobulbar blood flow.

Ocular blood flow and retinal, choroidal, and retinal nerve fiber layer thickness in children with familial Mediterranean fever with at least five attacks

PURPOSE

This study aimed to evaluate ocular blood flow and, retinal, choroidal and retinal nerve fiber layer thickness in children with familial Mediterranean fever (FMF) with patients who had at least five attacks.

METHODS

Fifty-six patients with FMF and 56 healthy subjects were enrolled in the study. Each participant's choroidal thickness (CT) and retinal thickness (RT) measurements were performed in the foveola and at horizontal nasal and temporal quadrants within 500-μm intervals up to 1.500 μm from the foveola using spectral-domain optical coherence tomography as well as the retinal nerve fiber layer thickness (RNFLT). Disc boundaries were determined manually by identifying seven points on the inner edge of the scleral ring. Following complete ophthalmological evaluation, peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistivity index (RI) values in the central retinal artery (CRA), ophthalmic artery (OA), and nasal posterior ciliary artery (NPCA) were measured using color Doppler ultrasonography (CDU) in the left eyes of the patients diagnosed with FMF and the controls. The results were subsequently compared.

RESULTS

No statistically significant differences were observed between the groups in terms of all RNFLT quadrant and RT measurements. All CT measurements were thinner in patients with FMF than in the controls (For Central and Temporal_1500 p = 0.01; For Temporal_500, Nasal 500 and Nasal_1000 p < 0.001; Temporal_1000 p = 0.002) except than the Nasal_1500 point. For nasal_1500 p = 0.121). The PSV and EDV values in the OA, CRA, and NPCA were significantly lower in patients with FMF compared to healthy controls (p < 0.001 for all). In contrast, the RI values of all arteries were significantly higher than in the control group (Regarding OA, CRA and NPCA RI, p = 0.003, p = 0.039, and p = 0.039, respectively).

CONCLUSIONS

The results of this study support the idea that chronic inflammation and frequent attacks in FMF may have an effect on decreased ocular blood flow and choroidal thinning.

Ocular involvement in monogenic autoinflammatory disease

OBJECTIVE

Monogenic Autoinflammatory diseases (AIDs) are a broad spectrum of rare hereditary diseases whose ocular involvement has not been well characterized yet. This systematic review aims to provide an overview of the current knowledge about ocular findings in AIDs.

METHODS

A systematic literature review was conducted using 2 electronic databases, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A combination of AIDs and ophthalmology-related search terms were used. All articles were screened by 2 independent reviewers for title, abstract and full text level. We included solely studies that investigated ocular findings in AIDs.

RESULTS

198 papers of 4268 records were retained. Data about 1353 patients with a diagnosis of autoinflammatory disease and ocular involvement were collected (680 CAPS, 211 FMF, 138 TRAPS, 238 Blau, 32 MKD, 21 SIFD, 7 Aicardi Goutières, 3 CANDLE, 8 DADA2, 9 HA20, 6 APLAID). Conjunctivitis was significantly more frequent in CAPS (p < 0.00001), uveitis in Blau, MKD, HA20 and CANDLE (p < 0.00001), papillitis/papilledema in CAPS (p < 0.00001), optic neuritis in Aicardi and DADA2 (p < 0.008), retinal vasculitis in FMF (p < 0.00001), progressive reduction in choroidal thickness in FMF and DADA2 (p < 0.00001), periorbital oedema in TRAPS (p < 0.00001) and retinitis in SIFD (p < 0.00001). Among AIDs with uveitis, granulomatous inflammation was more common in Blau syndrome (p < 0.00001).

CONCLUSION

This systematic literature review characterized the ocular involvement of several AIDs, and the present data may encourage to consider a timely ophthalmological screening program for these rare diseases.

Optical coherence tomography-angiographic vascular densities in Familial Mediterranean Fever (FMF) Patients with M694V Mutations

Familial Mediterranean fever (FMF) is a hereditary auto-inflammatory disease with accompanying findings of amyloidosis and vasculitis. M694V is one of the most common mutations associated with amyloidosis. This study compared the macular optical coherence tomography angiography measurements in FMF patients who were genetically verified to carry the M694V mutation of the MEFV gene to those in healthy controls. The vessel densities (VDs) of superficial (SVP) and deep vascular plexus (DVP) of the retina, and choriocapillaris, foveal avascular zone (FAZ) perimetry, foveal VD 300µ around the FAZ (FD-300), acirculatory index (AI) and non-flow area were measured with  optical coherence tomography angiography (OCT-A). The FMF and control groups were matched for age and gender. Compound heterozygous pathogenic variants were excluded. Thirty-eight FMF patients with M694V mutations (28 heterozygous and 10 homozygous) and 40 healthy controls were included. The two groups were similar with the regard to age and gender (P=0.88 and P=0.49, respectively). None of the investigated parameters, including the vessel densities of the SVP and DVP, and choriocapillaris, FAZ perimetry, FD-300, AI, and non-flow area showed a statistically significant difference between the FMF and control groups. The macular vessel density measurements and FAZ parameters of FMF patients with M694V mutations do not differ from age- and sex-matched healthy controls.

Choroidal vascularity index as a biomarker of systemic inflammation in childhood Polyarteritis Nodosa and adenosine deaminase-2 deficiency

BACKGROUND/PURPOSE

To assess EDI-OCT (enhanced depth imaging optical coherence tomography) of choroid for inflammatory signs in children with polyarteritis nodosa (PAN) and adenosine deaminase-2 deficiency (DADA-2).

METHODS

In this cross-sectional study conducted between June 2017 and September 2018, we evaluated children diagnosed with PAN (n = 11) and DADA-2 (n = 4) and an age- and sex-matched control group (n = 15). Demographic and laboratory data were retrospectively analyzed from patient charts. Disease activity was assessed using the pediatric vasculitis activity score (PVAS). Choroidal images were obtained with spectral domain-OCT to measure choroidal thickness (ChT) at 5 points (750 and 1500 μm from the foveal center in the temporal and nasal quadrants and beneath the fovea), and to calculate the total subfoveal choroidal area (TCA), luminal area (LA), stromal area (SA), and the choroidal vascularity index (CVI).

RESULTS

The median (min-max) age was 8 (4-16) years in PAN patients, 6 (5-16) years in DADA-2 patients and 8 (8-10) years in control group at the OCT visit (p = 0.214). The ChT at 3 points and the TCA, LA, and SA were higher in children with both PAN and DADA-2 patients compared to those of the control group (p < 0.0001, p = 0.049, p = 0.007, p = 0.007, p = 0.006, p = 0.033, respectively). The CVI was similar in both groups. No association was observed between the OCT findings, PVAS, and the erythrocyte sedimentation rate, and serum leukocyte and C-reactive protein levels.

CONCLUSION

Similar CVI scores were obtained from PAN and DADA2 patients under treatment and from healthy controls. Increased subfoveal ChT without any other signs of ocular involvement may suggest choroidal thickening as a sign of mild subclinical inflammation.

Posterior Segment Ocular Parameters in Children with Familial Mediterranean Fever

Purpose: To measure and compare posterior ocular layers in remission period in children with familial Mediterranean fever (FMF).Methods: A randomly selected eye and fellow eye of 20 FMF patients and 20 control eyes were evaluated. The average age of patients and control subjects were 12.9 ± 2.7 and 13.4 ± 2.7, respectively (p = .57). Peripapillary retinal nerve fiber layer thickness, optic nerve head parameters, macular ganglion cell inner plexiform layer and ganglion cell complex thickness, foveal and parafoveal vascular densities, superficial/deep foveal avascular zone area and choroidal thickness were measured using swept source optical coherence tomography angiography.Results: Among the overall measurements, temporal quadrant parafoveal vessel density of patients was significantly higher than that of controls (49.20 ± 2.57% vs 47.14 ± 3.17%, p = .04) and nasal quadrant vessel density was lower (42.88 ± 4.13% vs 46.76 ± 3.18%, p = .02).Conclusions: This study indicated that FMF as an autoimmune disease may affect foveal vascular structure in children besides multiple other organ involvement.

Comparison of optical coherence tomography angiography results of adult patients with Familial Mediterranean fever and healthy individuals

Purpose

The aim of this study is to assess the macular ultrastructure measuring by optical coherence tomography angiography in adult patients with Familial Mediterranean fever.

Methods

Participants were 62 Familial Mediterranean fever patients and 54 healthy individuals in control group with similar age and sex. The superficial and deep vascular plexus structures covering the central fovea in an area of 6 mm × 6 mm were measured using AngioVue images taken with optical coherence tomography angiography. Vasculature structure, foveal avascular zone, acircularity index of foveal avascular zone (the ratio of the perimeter of foveal avascular zone and the perimeter of a circle with the equal area), and superficial and deep retinal plexus densities were measured.

Results

The inferior deep vascular density was measured: 49.17% ± 8.59% in Familial Mediterranean fever patients, 55.56% ± 5.92% in the control group. The deep inferior-hemi vascular density was measured: 48.59% ± 10.34% in Familial Mediterranean fever patients, 56.54% ± 8.05% in the control group. Deep inferior and deep inferior-hemi vascular density was significantly reduced in Familial Mediterranean fever patients compared with healthy controls (p = 0.04 and p = 0.03, respectively).

Conclusion

The vascular abnormalities in optical coherence tomography angiography show subclinical signs of microangiopathy in Familial Mediterranean fever patients. This observation, which can be obtained only through optical coherence tomography angiography, may be an ocular hallmark for Familial Mediterranean fever disease.

Choroidal and retinal thickness in systemic autoimmune and inflammatory diseases: A review

To identify the risk of relapse and subclinical inflammatory stages of systemic autoimmune diseases, new tools are needed. In the recent years, choroidal thickness and retinal thickness measured with ocular coherence tomography (OCT) have been proposed as an inflammatory marker for different systemic diseases, especially for conditions with a vascular component. Our aim in this article is to review the literature regarding the role of choroidal and retinal thickness as a potential inflammatory marker in systemic autoimmune and inflammatory diseases measured by OCT. Current literature suggests that the choroid of patients thickens in active phases of inflammatory diseases with vascular involvement. This pattern is observed in lupus, systemic sclerosis, Behçet disease, spondylitis, and familial Mediterranean fever. Choroidal thickness may decrease with biological treatments, along with systemic inflammation. Repeated flares and long-term disease, however, may thin the choroid, as a result of prolonged insult to the microvasculature and subsequent atrophy. Less is known about the effect of these diseases on retinal thickness. In summary, choroidal and retinal thickness measured by OCT may be promising markers for inflammation in systemic autoimmune and inflammatory diseases; however, more studies are warranted before generalizing choroidal thickness measurements by OCT as a marker for disease activity. The role of retinal thickness is more unclear due to a lack of studies in this field.