MACULAR INFARCTION AS A PRESENTING SIGN OF SYSTEMIC LUPUS ERYTHEMATOSUS

Concurrent Intracranial Hypertension and Bilateral Optic Neuritis in a Patient With Systemic Lupus Erythematosus: A Case Report

Systemic lupus erythematosus (SLE) involves dysregulation of the immune system, consequently affecting multiple organ systems, including the cardiovascular, neuropsychiatric, renal, and musculoskeletal systems. Optic neuritis and intracranial hypertension are conditions that rarely occur in SLE, and their coexistence has not been reported to date. Herein, we report the first case of a patient who was diagnosed with SLE complicated by concurrent intracranial hypertension and bilateral optic neuritis. An 11-year-old Thai girl had a low-grade fever, discoid rash, oral ulcer, chronic headache, and fluctuating diplopia. She experienced bilateral vision loss just before presentation. She was diagnosed with juvenile SLE. We believe that her headache, which was probably a symptom of optic disc edema, was due to intracranial hypertension. Furthermore, she exhibited vision loss and color vision deficit and was diagnosed with bilateral optic neuritis. Her condition improved on treatment with corticosteroids (intravenous pulse methylprednisolone for 3 days, followed by 1 mg/kg/day oral prednisolone tapered over 3 months). The occurrence of optic neuritis and intracranial hypertension during an active SLE inflammation and a rapid response to high-dose corticosteroids support the fact that SLE was the etiology of these neuropsychiatric conditions. Early diagnosis and prompt treatment in such cases can lead to favorable outcomes.

Lupus-Induced Myopic Shift

While ophthalmic manifestations of lupus are common, a myopic shift is a rare manifestation of systemic lupus erythematosus (SLE). An acute myopic shift is defined as a progressive worsening of nearsighted vision within a short time frame. Here, we describe the unique presentation of a young woman with a lupus-induced acute myopic shift. The patient presented with blurry vision and bleeding gums with a previous abnormal lymph node biopsy to rule out ocular lymphoma or leukemia. Her baseline prescription prior to coming in was −4.0D in both eyes. Upon exam, she presented with vision worsening: −7.0D in the right eye and −8.2D in the left eye. After completing blood laboratory tests, it became clear that she had pancytopenia, kidney damage, and elevated inflammatory markers pointing towards lupus. A diagnosis of acute binocular myopic shift induced by systemic lupus erythematosus was made.

Unique changes in the retinal microvasculature reveal subclinical retinal impairment in patients with systemic lupus erythematosus

PURPOSE

To determine the changes of the microvasculature and microstructure in the inner intra-retinal layers in systemic lupus erythematosus (SLE) patients without lupus retinopathy (LR).

METHODS

Thirty-two SLE patients (58 eyes) without LR (NLR), 14 patients (22 eyes) with LR and 50 healthy subjects (50 eyes) were enrolled. Spectral domain optical coherence tomography equipped with Angiovue was used to obtain three-dimensional retinal thickness maps and microvascular images of the superficial and deep retinal capillary plexuses (SRCP/DRCP) around the macula. Quantitative analyses were performed using a custom automated algorithm. Disease activity of patients was assessed using the SLE disease activity index (SLEDAI).

RESULTS

Retinal capillary skeleton density of the SRCP in SLE patients without LR was significantly lower than the controls in almost all regions, which further decreased in the LR group (P < .05). No significant changes were evident in DRCP of the NLR group (P > .05). The inner retina in the LR group was significantly thinner than the controls in most regions, though there were only a few regions that were different between the NLR and the control groups (P < .05). There were significant differences of the SLEDAI scores between the two SLE groups.

CONCLUSION

Significantly lower density in SRCP and regional thinning in inner retina were observed in the SLE patients without clinical fundus changes. OCT equipped with Angiovue might be useful in evaluating the microvascular and microstructural disorders of the inner retinal layers in SLE patients, which may contribute a quantitative approach to the early diagnosis and progression of LR.

Ocular findings in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease. Ocular complications occur in up to one-third of patients with SLE. The ocular findings may represent the initial manifestation of the disease and may lead to severe ocular morbidity and loss of vision. Early diagnosis and prompt management of patients with SLE are mandatory and require collaboration between the ophthalmologist and the rheumatologist.

Macular infarction and traumatic optic neuropathy following blunt ocular trauma

Macular infarction is a visually disabling condition caused by a variety of reasons. It has rarely been described in association with blunt ocular trauma. We describe the case of a young healthy male who sustained injury with a bull's leg and presented with severe visual loss owing to macular infarction and traumatic optic neuropathy. This report of an angiographically documented macular infarct secondary to ocular contusion highlights an additional feature in the spectrum of ocular findings following blunt trauma that might lead to a severe and permanent affliction of vision.

Bilateral perifoveal macular ischemia in sarcoidosis

PURPOSE

To represent and evaluate the findings of bilateral perifoveal macular ischemia in a patient with biopsy-proven, multiorgan involved sarcoidosis.

METHODS

Case report. A 55-year-old man, with a medical history of pulmonary disease, experienced reduced vision bilaterally. General ocular examination, fundus color photographs, fluorescence angiography, and high-resolution spectral domain optical coherence tomography were performed in both eyes.

RESULTS

The patient's visual acuity was 20/200 in the right eye and 20/30 in the left eye with normal intraocular pressure and anterior segment. Fundus examination showed symmetric changes with the loss of transparency in macular and small intraretinal hemorrhages in both eyes. Fluorescence angiography demonstrated markedly enlarged avascular zone while optical coherence tomography revealed marked cystic change in the macula bilaterally. A series of blood test was conducted without a specific diagnosis. A lung biopsy confirmed the diagnosis of pulmonary sarcoidosis, and a magnetic resonance imaging of his brain revealed neurosarcoidosis.

CONCLUSION

Bilateral perifoveal ischemia, formerly one of the three idiopathic macular telangiectasia diseases, is rare and usually suggests a systemic etiology. It is not unexpected that sarcoidosis, a multisystem, chronic inflammatory disorder, may affect retinal vessels and be associated with this peculiar form of ischemia and edema.

Posterior scleritis in patients with systemic lupus erythematosus

PURPOSE

To describe three cases of posterior scleritis associated with systemic lupus erythematosus.

METHODS

Retrospective chart review including ophthalmic examination, fundus photography, optical coherence tomography, angiography, ultrasonography, and/or magnetic resonance imaging.

RESULTS

Three patients presented with blurred vision, red eye, and/or eye pain in one or both eyes. The diagnosis of posterior scleritis was confirmed in each patient using B-scan ultrasonography. One patient presented with giant nodular scleritis. In two patients, posterior scleritis was the presenting sign of systemic lupus erythematosus. Two patients received systemic corticosteroids together with noncorticosteroid immunosuppressive medications. One patient received topical and periocular injections of corticosteroids. All three patients showed prompt resolution of their posterior scleritis in response to treatment.

CONCLUSION

While uncommon, posterior scleritis may occur in patients with systemic lupus erythematosus and, in some instances, may be the presenting sign of the disease. Prompt diagnosis and treatment was associated with good visual outcomes in our patients.

A case to illustrate the role of ophthalmologist in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) affects the eye as part of the disease or due to the drugs used in therapy. Ocular involvement is seen in one third of the patients with SLE. SLE is rare in India and found less frequently in males and children. SLE retinopathy is usually bilateral. We report an unusual case of unilateral macular infarction in a boy caused by systemic lupus erythematosus. A fourteen year old boy was presented with skin rashes and loss of vision in left eye. Posterior segment examination showed hyperemic edematous disc, arteriolar attenuation, venous dilatation, multiple cotton wool spots around the disc and macula in the left eye. There was no improvement in vision with pulse steroids and cyclophosphamide. The clinical implication of SLE retinopathy is that the disease is severe and warrants systemic immunosuppressive therapy. SLE-induced macular infarction is rare and has poor visual prognosis. As serious ocular complications of SLE can be silent, routine ophthalmological evaluation is warranted in all patients.