Management of retinal vein occlusion

Amaurosis fugax, Crohn's Disease and the Anticardiolipin Antibody

Crohn's disease is associated with a hypercoagulable state due to platelet or clotting abnormalities which may be responsible for the thromboembolic episodes seen in this condition. We report the occurrence of anticardiolipin antibodies in a patient with Crohn's disease who presented with Amaurosis fugax and suggest that these antibodies may be a further cause of the hypercoagulable state of Crohn's disease in some patients.

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.

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.

Ocular vaso-occlusive disease in primary antiphospholipid syndrome

PURPOSE

To evaluate the ocular involvement in patients with the primary antiphospholipid syndrome.

METHODS

The authors performed a cross-sectional ophthalmologic study of 17 patients with the primary antiphospholipid syndrome. Retinal fluorangiography was performed in 13 patients.

RESULTS

Visual symptoms were described by ten patients. Visual acuity was markedly decreased in five eyes. Conjunctival telangiectases and microaneurysms, in addition to single instances of bilateral episcleritis and limbal keratitis, were the anterior segment findings. Fundus abnormalities were present in 15 patients. Venous tortuosity was the most common finding but there were instances of optic disc edema, vitreous hemorrhages, cotton-wool spots, vitreous bands, serous detachment of the macula, and retinal capillary abnormalities. Fluorangiography showed vaso-occlusive retinopathy in six eyes (5 patients, 29%). Choriocapillary vessel occlusion was observed in two eyes (1 patient) and binocular reticular degeneration of pigmentary epithelium was present in another case.

CONCLUSION

The eye is frequently involved in the primary antiphospholipid syndrome, and serious ocular damage may occur. Detailed ophthalmologic evaluation is warranted in these patients.

Amaurosis fugax, Crohn's disease and the anticardiolipin antibody

Crohn's disease is associated with a hypercoagulable state due to platelet or clotting abnormalities which may be responsible for the thromboembolic episodes seen in this condition. We report the occurrence of anticardiolipin antibodies in a patient with Crohn's disease who presented with Amaurosis fugax and suggest that these antibodies may be a further cause of the hypercoagulable state of Crohn's disease in some patients.

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

We report two patients with contrasting patterns of retinal vascular occlusion associated with the primary anti-phospholipid antibody syndrome. The immuno-pathological features and clinical associations are discussed. This condition is of interest to ophthalmologists because of its association with thrombosis in the eye, brain and elsewhere and because it provides new insights into the pathogenesis of retinal vascular disease in young patients.

The investigation of patients with retinal vascular occlusion

The investigation of patients with retinal artery occlusion, retinal vein occlusion and cotton wool spots is discussed. The majority are due to either emboli or atheroma and occur in elderly patients. A full clinical history and examination remain the essential part of the investigation but the ophthalmologist must select patients in whom further investigation is warranted. The recent recognition of the importance of antiphospholipid antibodies and natural anticoagulant deficiency states in the pathogenesis of thrombosis has identified a group of young people in whom specific therapy may be indicated.

Antiphospholipid antibodies: a risk factor for occlusive ocular vascular disease in systemic lupus erythematosus and the 'primary' antiphospholipid syndrome

Seven cases of occlusive ocular vascular disease affecting retinal and choroidal vessels were found among 84 consecutive patients with raised levels of anticardiolipin antibodies attending the lupus arthritis clinic at St Thomas's Hospital from 1985 to 1987. Six patients with systemic lupus erythematosus (SLE) and one with a 'primary antiphospholipid syndrome' had occlusive ocular vascular disease affecting a variety of vessels. This gives a prevalence of occlusive ocular vascular disease of 8% in this subgroup of patients, significantly higher than the 0.5-2.0% previously reported in patients with SLE. Four of these patients also suffered from cerebrovascular disease, supporting the previously documented association between occlusive ocular vascular disease and central nervous system disease in SLE. Additionally, other features of the antiphospholipid syndrome were frequently present. These findings suggest that patients with SLE and raised anticardiolipin antibodies have a higher risk of developing occlusive ocular vascular disease than has been previously reported.