Ocular manifestations of systemic lupus erythematosus: a review of the literature

Subclinical choroidal involvement in Systemic Lupus Erythematosus

PURPOSE

To assess the choroidal status of Systemic Lupus Erythematosus (SLE) patients using Optical Coherence Tomography (OCT) and OCT-Angiography.

METHODS

SLE patients with disease duration < 10 years, no disease activity and no ocular involvement were recruited and cross-sectionally evaluated. A demographically similar cohort of healthy subjects was used for comparison. The main outcome is choroidal vascularity index (CVI). As secondary outcomes, choriocapillaris parameters and choroidal thickness (CT) were evaluated.

RESULTS

Forty eyes of 40 subjects (20 SLE patients and 20 healthy subjects) were studied with a mean ± SD age of 36.7 ± 9.9 years. In the SLE group, the mean ± SD duration of disease was 7.35 ± 2.21 years. Increased CVI was found in the SLE group (p = 0.022). Considering the choriocapillaris, SLE patients presented a lower number (p = 0.037) and a smaller total area (p = 0.041) of signal voids. No differences between groups were found in CT. For SLE patients, CT at subfoveal, temporal and inferior locations presented a negative moderate correlation with disease duration. A strong correlation between choriocapillaris parameters and age was demonstrated for both groups.

CONCLUSIONS

This study provides evidence of subclinical choroidal changes in adult SLE patients with inactive disease and no overt ocular manifestation. Increased CVI and fewer and smaller flow voids in choriocapillaris with normal CT suggest increased choroidal vascularity in SLE.

Systemic risk factors of retinopathy in patients with systemic lupus erythematosus

OBJECTIVE

To investigate the risk factors of lupus retinopathy (LR) in patients with systemic lupus erythematosus (SLE).

METHODS

This is a retrospective, cross-sectional study. LR patients admitted at Peking Union Medical College Hospital from June 2013 to April 2023 were reviewed. Age- and gender-matched SLE patients without retinopathy were selected as controls. Medical records including clinical manifestations, laboratory data and ophthalmic examination were collected. Univariate and multivariate logistic regression analyses were conducted.

RESULTS

One hundred and twelve LR patients (198 eyes) were included, with 12 cases (14 eyes) presenting with retinal macrovascular obstruction, and 100 cases (184 eyes) only exhibiting microvasculopathy. Multivariate analysis indicated the presence of haemolytic anaemia, decreased haemoglobin (HGB) and higher relative percentage of neutrophils were independent risk factors for LR (p < 0.05). The first two were also risk factors for retinal microvasculopathy, whereas secondary antiphospholipid syndrome (APS) was for macrovascular obstruction. In male group, LR had significant associations with decreased HGB, no matter which types of retinopathy (p < 0.05). In female group, LR was significantly associated with haemolytic anaemia, presence of antiphospholipid antibodies, decreased white blood cells and relative high percentage of neutrophils. Specifically, haemolytic anaemia (p = 0.002) was significantly associated with retinal microvasculopathy, and APS (p = 0.003) was significantly associated with macrovasculature obstruction.

CONCLUSION

LR was related to haemolytic anaemia, decreased HGB levels and higher percentage of neutrophils. Retinal microvasculopathy accounted for most cases and macrovasculature obstructions were rare. Male and female patients have distinct risk factors. Early ophthalmic screening is recommended especially for those with risk factors of LR.

Ophthalmologic Implications of Connective Tissue Diseases: A Comprehensive Review of Current Knowledge and Innovations

Connective tissue diseases (CTDs), including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjögren's syndrome, and systemic sclerosis (SSc), represent a diverse group of disorders characterized by abnormalities in the proteins that support tissues and organs. These diseases can affect multiple organ systems and are often associated with significant morbidity and mortality. The eyes are frequently affected among the various organ systems involved, with ocular manifestations ranging from benign conditions such as dry eye syndrome to severe, sight-threatening complications like scleritis, retinal vasculitis, and optic neuritis. Recognizing and managing these ophthalmologic implications is crucial for preventing severe complications, providing diagnostic clues, and improving patients' quality of life. This comprehensive review aims to elucidate the current knowledge and innovations related to the ophthalmologic implications of CTDs. It details the ocular manifestations associated with major CTDs, explores diagnostic approaches to identifying and differentiating these conditions, and discusses management strategies, including pharmacological and surgical interventions. Additionally, the review highlights recent advancements and emerging therapies in diagnosing and treating CTD-related ophthalmologic conditions. The review also addresses this field's challenges and future directions, emphasizing the importance of interdisciplinary collaboration and continuous research. By synthesizing the latest research and clinical insights, this review seeks to enhance the understanding of healthcare professionals regarding the interplay between CTDs and ocular health, ultimately contributing to improved patient care and outcomes.

Ocular fundus changes and association with systemic conditions in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects multiple organs and systems. Ocular involvement is estimated to manifest in one-third of individuals with SLE, of which lupus retinopathy and choroidopathy represent the severe subtype accompanied by vision impairment. Advancements in multimodal ophthalmic imaging have allowed ophthalmologists to reveal subclinical microvascular and structural changes in fundus of patients with SLE without ocular manifestations. Both ocular manifestations and subclinical fundus damage have been shown to correlate with SLE disease activity and, in some patients, even precede other systemic injuries as the first presentation of SLE. Moreover, ocular fundus might serve as a window into the state of systemic vasculitis in patients with SLE. Given the similarities of the anatomy, physiological and pathological processes shared among ocular fundus, and other vital organ damage in SLE, such as kidney and brain, it is assumed that ocular fundus involvement has implications in the diagnosis and evaluation of other systemic impairments. Therefore, evaluating the fundus characteristics of patients with SLE not only contributes to the early diagnosis and intervention of potential vision damage, but also holds considerate significance for the evaluation of SLE vasculitis state and prediction of other systemic injuries.

Nanosuspensions in ophthalmology: Overcoming challenges and enhancing drug delivery for eye diseases

This review article provides a comprehensive overview of the advancements in using nanosuspensions for controlled drug delivery in ophthalmology. It highlights the significance of ophthalmic drug delivery due to the prevalence of eye diseases and delves into various aspects of this field. The article explores molecular mechanisms, drugs used, and physiological factors affecting drug absorption. It also addresses challenges in treating both anterior and posterior eye segments and investigates the role of mucus in obstructing micro- and nanosuspensions. Nanosuspensions are presented as a promising approach to enhance drug solubility and absorption, covering formulation, stability, properties, and functionalization. The review discusses the pros and cons of using nanosuspensions for ocular drug delivery and covers their structure, preparation, characterization, and applications. Several graphical representations illustrate their role in treating various eye conditions. Specific drug categories like anti-inflammatory drugs, antihistamines, glucocorticoids, and more are discussed in detail, with relevant studies. The article also addresses current challenges and future directions, emphasizing the need for improved nanosuspension stability and exploring potential technologies. Nanosuspensions have shown substantial potential in advancing ophthalmic drug delivery by enhancing solubility and absorption. This article is a valuable resource for researchers, clinicians, and pharmaceutical professionals in this field, offering insights into recent developments, challenges, and future prospects in nanosuspension use for ocular drug delivery.

Sight-Threatening Unilateral Posterior Scleritis With Positive Atypical p-ANCA As Early Manifestation of Lupus Spectrum Disease

Antinuclear cytoplasmic antibody (ANCA)-related scleritis is a potentially sight-threatening inflammatory condition that may occur as a primary vasculitis disorder or as a secondary vasculitis in a variety of inflammatory conditions. While ANCA has been classically associated with primary vasculitis diseases such as granulomatosis with polyangiitis (GPA), microscopic polyarteritis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA), it is interesting that in cases of lupus spectrum disease (LSD), both ANCA and atypical p-ANCA have been observed as secondary autoantibodies. Scleritis is a rare ocular manifestation of lupus disease with an incidence of around 1%. This paper describes a case of sight-threatening posterior scleritis with positive atypical p-ANCA as an early manifestation of LSD. LSD is an acknowledged condition but frequently presents a diagnostic challenge or delay due to its ambiguous symptoms which may not fully align with the classification criteria of established systemic lupus erythematosus (SLE). Nonetheless, this condition should not be underestimated due to its potential impact on major organ involvement and its tendency to progress to established SLE. The diagnosis of LSD heavily relies on clinician suspicion, considering factors such as symptoms present in at least one organ system, positivity of antinuclear antibody (ANA), and clinical suspicion of future SLE development. Early identification allows for early treatment which would benefit high-risk patients. A middle-aged Chinese lady presented with bilaterally asymmetrical eye redness and swelling, which was worse on the right side. Clinical examination revealed right eye proptosis, conjunctival injection, chemosis, scleral redness and binocular diplopia in all gazes. Right eye fundoscopic examination displayed extensive choroidal folds with a positive T-sign on the B-scan. Apart from ocular symptoms, there was no significant medical history related to autoimmune or connective tissue disorders. Her p-ANCA and c-ANCA results were negative, however atypical p-ANCA titer was positive with a high antinuclear antibody (ANA) titer of 1:1280 with a homogenous pattern. Additionally, she has a family history of systemic lupus erythematosus in her daughter. A diagnosis of right eye posterior scleritis secondary to underlying LSD was made. The scleritis was successfully treated with a combination of corticosteroid and systemic immunosuppressants and the patient was initiated on oral hydroxychloroquine to manage underlying LSD. We aim to highlight to clinicians the diagnostic challenges associated with scleritis in LSD and emphasize the importance of prompt and timely multidisciplinary management in minimizing patient mortality and morbidity, as reflected in this case. This case of a positive atypical p-ANCA scleritis in LSD serves as an excellent example of effective management.

Aeromonas veronii-associated endogenous endophthalmitis: a case report

BACKGROUND

Aeromonas veronii is a very rare and highly pathogenic microorganism. We investigate the clinical characteristics and significance of endogenous endophthalmitis caused by Aeromonas veronii in our patient.

CASE PRESENTATION

A 30-year-old Asian women with systemic lupus erythematosus, uremia, and hypertension developed acute infectious endophthalmitis caused by Aeromonas veronii. After emergency vitrectomy and antibiotic therapy, the clinical condition worsened requiring enucleation.

CONCLUSIONS

Aeromonas veronii can cause infection in the human eye, which can manifest as acute endophthalmitis. Early diagnosis and targeted therapy are important for successful treatment.

MICROVASCULATURE ALTERATIONS OF PERIPAPILLARY RETINA AND MACULA IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS WITHOUT OCULAR INVOLVEMENT BY OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To evaluate microvasculature alterations of the peripapillary retina and macula and to assess whether the changes can detect preclinical retinopathy in systemic lupus erythematosus patients.

METHODS

Cross-sectional study of 32 systemic lupus erythematosus patients without retinopathy and 22 normal controls. Optical coherence tomography angiography was used to measure the microvasculature of the peripapillary retina and macula. Vessel densities (VD, %) and fractal dimensions of superficial capillary plexus (SCP) and deep capillary plexus were calculated.

RESULTS

Compared with controls, macular vessel densities of the whole image SCP (macular vessel density of SCP-wi) and macular vessel density of inferior SCP (macular vessel density of SCP-i) were significantly reduced in systemic lupus erythematosus patients ( P < 0.05). The peripapillary vessel densities (peripapillary vessel density [pVD]) of a 2.5-mm circle of SCP (pVD of SCP Φ2.5 ), pVD of SCP Φ3.5 , and pVD of inferior region of the inner circle of SCP (pVD of SCP-ii) were significantly reduced in patients treated with hydroxychloroquine >5 years. Macular vessel density of SCP-wi declined with age (β = -0.12; P < 0.01) and pVD of SCP-ii declined with hydroxychloroquine cumulative dose (β = -0.01; P < 0.01). Macular vessel density of SCP-i had the best discrimination power of 0.77 ( P < 0.01).

CONCLUSION

Systemic lupus erythematosus patients without ocular involvement had microvasculature alterations that were particularly evident in the SCP. Peripapillary retina microvasculature may be reduced in patients with longer hydroxychloroquine treatment.

Quantitative assessment of retinal vasculature changes in systemic lupus erythematosus using wide-field OCTA and the correlation with disease activity

Purpose

To assess the retinal vasculature changes quantitatively using wide-field optical coherence tomography angiography (OCTA) in systemic lupus erythematosus (SLE), and explore its correlation with systemic clinical features.

Design

Prospective, cross-sectional, observational study.

Participants and controls

Patients with SLE who presented to the Ophthalmology Department of Peking Union Medical College Hospital from November 2022 to April 2023 were collected. The subjects were divided into retinopathy and without retinopathy groups. Age and gender-matched healthy subjects were selected as controls.

Methods

Patients with SLE and control subjects were imaged with 24×20 mm OCTA scans centered on the fovea and 6×6 mm OCTA scans centered on the optic disc. The sub-layers of OCTA images were stratified by the built-in software of the device and then the retinal thickness and vessel density were measured automatically. The characteristics of retinal OCTA parameters of SLE and its correlation with systemic clinical indicators of patients without retinopathy were analyzed.

Main outcome measures

OCTA parameters, visual acuity, intraocular pressure, and systemic clinical indicators of patients such as disease activity index, autoimmune antibodies, and inflammatory marker levels were collected.

Results

A total of 102 SLE patients were included, 24 of which had retinopathy, and 78 had unaffected retina. Wide-field OCTA could effectively detect retinal vascular obstruction, non-perfusion area, and morphological abnormalities in patients with lupus retinopathy. SLE patients without retinopathy had significantly higher retinal superficial vessel density (SVD) in foveal (P=0.02), para-foveal temporal (P=0.01), nasal (P=0.01), peripheral foveal temporal (P=0.02), and inferior areas (P=0.02), as well as subregion temporal (P=0.01) and inferior areas (P=0.03) when compared with healthy controls (n=65 eyes from 65 participants). The area under curve (AUC) value of subregion inferior SVD combined parafoveal temporal SVD was up to 0.70. There was a significantly positive correlation between SVD and disease activity in SLE without retinopathy group. Patients with severe activity had the most significant increase in SVD.

Conclusion

Wide-field OCTA can provide a relatively comprehensive assessment of the retinal vasculature in SLE. In the absence of pathological changes of the retina, the SVD was significantly increased and was positively correlated with the disease activity of SLE.

Scleral changes in systemic lupus erythematosus patients using swept source optical coherence tomography

Purpose

This study aims to examine scleral thickness in patients with systemic lupus erythematosus (SLE) without clinically evident scleritis and episcleritis, utilizing swept-source optical coherence tomography (SS-OCT).

Methods

This cross-sectional single center study compared scleral thickness (Nasal scleral thickness 1mm, 2mm, 3mm, 6mm from scleral spur; Temporal scleral thickness 1mm, 2mm, 3mm, 6mm from scleral spur) in 73 SLE patients without clinically evident scleritis and episcleritis and 48 healthy volunteers with SS-OCT. Further, we investigated the correlation between scleral thickness in SLE patients and various parameters including laboratory markers, disease duration, disease activity, and organ involvement.

Results

Across all measured sites (nasal scleral thickness at distances of 1mm, 2mm, 3mm, and 6mm from the scleral spur, and temporal scleral thickness at the same distances), the scleral thickness in the SLE group was significantly greater than that in the control group (all p-values <0.001). SLE patients with a disease duration of 5 years or less exhibited a higher scleral thickness compared to those with a more prolonged disease duration. Patients with a higher erythrocyte sedimentation rate (ESR) had a thinner temporal scleral thickness. However, no significant associations were identified between scleral thickness and disease activity, organ involvement, or other laboratory markers.

Conclusion

Scleral thickness measured by SS-OCT was higher in SLE patients than healthy controls. Changes in scleral thickness in SLE patients are related to disease duration and ESR. SS-OCT can detect asymptomatic structural changes in SLE patients and may be a useful tool in the evaluation of early scleral abnormality.

Pediatric Lupus Retinopathy: A Rare Manifestation of a Grave Systemic Disorder

We describe a rare case of pediatric systemic lupus erythematosus (pSLE) and its successful management. A nine-year-old female presented with bilateral diminution of vision, fever, and rash in the malar region, chest, abdomen, back, and arms for three months. Clinical examination and multimodal imaging revealed bilateral extensive retinal vasculitis with macular edema. Laboratory investigations revealed anemia, leucopenia, positive serum antinuclear antibody (ANA), and anti-extractable nuclear antigen (ENA) antibodies. A diagnosis of pediatric lupus retinopathy was made. Ocular and systemic manifestations responded well to intense systemic immunosuppression (pulse intravenous {IV} methylprednisolone, oral prednisolone and hydroxychloroquine {HCQ}, six cycles of IV cyclophosphamide, and oral azathioprine) along with topical steroids and laser photocoagulation, over the next 10 months. Though ocular manifestations are not a part of the diagnostic criteria for SLE, they may be markers of active systemic disease. Ophthalmologists and rheumatologists must treat this complex disease in tandem in order to provide optimum patient care.

An Orbital Pseudotumor Secondary to Systemic Lupus Erythematosus: A Case Report

Nonspecific orbital inflammation (NSOI), the primary cause of painful orbitopathy mostly in adults, can either manifest as localized or diffused. Periorbital edema or swelling is the most common sign followed by proptosis. NSOI or orbital pseudomotor secondary to systemic lupus erythematosus (SLE) is very uncommon in the Kingdom of Saudi Arabia. This is the first reported case from Saudi Arabia. The patient first presented to the outpatient department during her gestational period. Her chief complaint was right eye swelling and pain when she woke up in the morning. Her past medical history was positive for irritable bowel disease and SLE. A slit lamp examination revealed chemosis with conjunctival injections in the right eye and mild temporal chemosis in the left eye. Funduscopic examination after pupillary dilation revealed hyperemic discs with venous tortuosity more prominent in the right eye. Serum albumin level was low at 29 g/L. Orbital magnetic resonance imaging without contrast showed bilateral diffuse preseptal soft tissue swelling more prominent on the right side with diffuse bilateral congestion of intraorbital fat, including intraconal and extraconal fat. There was associated fat stranding around the optic nerves bilaterally. The bilateral extraocular muscles showed a diffusely increased T2 signal compatible with edema. The patient was given a bolus of intravenous methylprednisolone for three days. She had a satisfactory recovery. Early diagnosis is important to rule out other differential diagnoses, such as orbital cellulitis and lymphoma.

Subclinical retinopathy in systemic lupus erythematosus patients - optical coherence tomography study

Introduction

The aim was to detect subclinical structural retinal abnormalities in optical coherence tomography (OCT) in ophthalmologically asymptomatic systemic lupus erythematosus (SLE) patients without signs of lupus retinopathy or drug toxicity in fundus examination and in OCT and to assess the relationship between OCT parameters and disease activity, therapy type and burden on other organs to demonstrate the utility of OCT in early retinal impairment in SLE patients.

Material and methods

Cross-sectional study. Thirty-three SLE patients (57 eyes) and 31 healthy individuals (56 eyes) were enrolled in the study. We excluded patients with evidence of lupus retinopathy or hydroxychloroquine (HCQ) toxicity on OCT or fundus examination to reveal any subclinical changes. All patients underwent full ophthalmologic examination in the slit lamp including best corrected visual acuity, tonometry, and OCT. The Kolmogorov-Smirnov distribution test was used to assess the normal distribution in quantitative values. The differences between the individual measured parameters in the groups were analyzed using the Mann-Whitney U test. Spearman's rank correlation test was used to assess the correlation between the measured parameters and quantitative clinical data.

Results

There was no difference in the OCT findings between SLE and healthy control groups. Among the study group a negative correlation was found between disease duration and age and retinal nerve fiber layer thickness in the inferior quadrant (p = 0.0063, p = 0.0036). No correlations were observed between examined retinal parameters and duration of hydroxychloroquine therapy, hydroxychloroquine as well as chloroquine cumulative dose and disease activity indices.

Conclusions

Optical coherence tomography is a widespread ophthalmic modality used for SLE retinopathy and HCQ toxicity screening. Our study did not demonstrate its clinical potency in diagnosis of subclinical retinal involvement. An optical coherence tomography device seems to be less sensitive in subclinical retinal impairment detection than optical coherence tomography angiography.

Gene expression profile analyses to identify potential biomarkers for myopia

PURPOSE

Increasing evidence suggests myopia is not a simple refractive error, many other factors might also be involved. Here, we assessed myopic and normal corneas' gene expression profiles to identify possible diagnostic and therapeutic biomarkers for myopia.

MATERIALS AND METHODS

We obtained the expression profile of ten patients and seven normal control samples from the GSE112155 and GSE151631 datasets based on the Gene Expression Omnibus (GEO) database. We used the "limma" R package to determine the differentially expressed genes (DEGs) between myopic and normal corneas. Weighted gene co-expression network analysis (WGCNA) was used to identify critical co-expressed modules related to myopia, and enrichment analyses were used to annotate the function of genes encompassed in the compulsory module. We also validated these findings in two external datasets (GSE24641 and GSE136701).

RESULTS

We identified that the DEGs were significantly enriched in ultraviolet (UV) response, TNF-α signaling via NFκB, Angiogenesis, Myogenesis pathways, etc. We used 2095 genes to construct the co-expression gene modules and found five interesting modules because the eigengene expression of these modules was significantly differentially expressed between myopic and normal corneas. Notably, the enrichment analysis found that the genes encompassed in lightgreen module were significantly enriched in immune-related pathways. These findings were proved by subsequent analysis based on Xcell software. We found the component of B cells, CD4+ memory T cells, CD8+ central memory T cells, plasmacytoid dendritic cells, T helper 2 (Th2) cells, regulatory T cells (Tregs), etc. were significantly increased in myopic corneas, while CD8+ T cells, CD4+ T central memory cells, natural killer T (NKT) cells, and T helper 1 (Th1) cells were significantly decreased.

CONCLUSION

Our findings identified some markers that might detect diagnosis and treatment for myopia from cornea aspect. Future studies are warranted to verify the functional role of immune-related pathways in cornea during the pathogenesis or progression of myopia.

Systemic Lupus Erythematosus and Risk of Dry Eye Disease and Corneal Surface Damage: A Population-Based Cohort Study

Systemic lupus erythematosus (SLE) potentially involves multiple parts of the ocular system, including the lacrimal glands and the cornea. The present study sought to assess the risk of aqueous-deficient dry eye disease (DED) and corneal surface damage in patients with SLE. We conducted a population-based cohort study using Taiwan's National Health Insurance research database to compare the risks of DED and corneal surface damage between subjects with and without SLE. Proportional hazard regression analyses were used to calculate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) for the study outcomes. The propensity score matching procedure generated 5083 matched pairs with 78,817 person-years of follow-up for analyses. The incidence of DED was 31.90 and 7.66 per 1000 person-years in patients with and without SLE, respectively. After adjusting for covariates, SLE was significantly associated with DED (aHR: 3.30, 95% CI: 2.88-3.78, p < 0.0001) and secondary Sjögren's syndrome (aHR: 9.03, 95% CI: 6.86-11.88, p < 0.0001). Subgroup analyses demonstrated that the increased risk of DED was augmented among patients with age < 65 years and female sex. In addition, patients with SLE had a higher risk of corneal surface damage (aHR: 1.81, 95% CI: 1.35-2.41, p < 0.0001) compared to control subjects, including recurrent corneal erosion (aHR: 2.98, 95% CI: 1.63-5.46, p = 0.0004) and corneal scar (aHR: 2.23, 95% CI: 1.08-4.61, p = 0.0302). In this 12-year nationwide cohort study, we found that SLE was associated with increased risks of DED and corneal surface damage. Regular ophthalmology surveillance should be considered to prevent sight-threatening sequelae among patients with SLE.

The full range of ophthalmological clinical manifestations in systemic lupus erythematosus

Purpose

To determine the full range of ophthalmological clinical manifestations in systemic lupus erythematosus (SLE) and to compare the systemic features associated with them.

Methods

Files of 13 patients with ocular SLE (n = 20 eyes) diagnosed as per the American College of Rheumatology (ACR) 2012 revised criteria were retrospectively reviewed.

Results

The following clinical manifestations were found: keratoconjunctivitis sicca (n = three patients), anterior uveitis associated with an inflammatory pseudo-tumor orbital mass (n = one patient, one eye), episcleritis and periorbital edema (n = one patient, two eyes), posterior scleritis (n = one patient, two eyes), bilateral papillary edema in the context of idiopathic intracranial hypertension (n = one patient, one eye), inflammatory optic neuritis (n = one patient, one eye), and lupus retinopathies with varying degrees of capillary occlusions mainly arteriolar (n = seven patients, 13 eyes) and larger arteries or veins (retinal arteries occlusions and retinal veins occlusions) (n = one patient, two eyes). Some patients presented with combined ophthalmological manifestations.Systemic SLE was discovered by its ophthalmic manifestation in three cases (23%) and was previously known in the other 10 cases (77%). On average, ocular symptoms were seen 8 years after the initial diagnosis of SLE. Other systemic SLE disorders included cutaneous disorders (77%), joint disorders (38%), central nervous system (CNS) disorders (23%), renal disorders (38%), and oral ulcers (23%).Treatment of the ophthalmic system manifestations of lupus included local steroid therapies along with systemic immunosuppression.The most common laboratory ACR criteria were: high levels of antinuclear antibodies (ANA) (100%), positive anti-Sm (64%), anti-dsDNA (27%), low complement levels (27%), and positive antiphospholipid (APL) antibodies (18%).

Discussion

SLE activity in the ophthalmic system is characterized by its functional severity and the range of involvement can be categorized by anatomical involvement: presence of anterior uveitis, episcleritis, scleritis, periorbital edema, posterior uveitis with retinal vascular ischemia, or papillary edema. Not currently part of the diagnosis criteria of the SLE ACR given its rarity, the ocular localization of the pathology led to the diagnosis of SLE in three cases; thus, developing a greater understanding of ocular lupus may help in identifying and treating systemic manifestations of lupus earlier.

Systemic lupus erythematosus with acute ischemic optic neuropathy complicated with neuromyelitis optica: a case report

BACKGROUND

Neuromyelitis optica is a relapsing-remitting disease characterized by a recurrent attack of optic neuritis and transverse myelitis; sometimes associated with acute brainstem syndrome. Systemic lupus erythematosus is an autoimmune multisystem disorder in which ocular involvement such as acute ischemic optic neuropathy is a rare manifestation. However, neuromyelitis optica can be associated with systemic lupus erythematosus.

CASE PRESENTATION

A 24-year-old Bangladeshi woman was admitted to the hospital with complaints of sudden, progressive, painless vision loss in both eyes, and progressive weakness in both lower limbs for 48 hours. She also gave a history of arthralgia, a photosensitive skin rash, intermittent fever, oral ulcerations, and alopecia for the last 2 months. On examination, the fundus was suggestive of bilateral acute ischemic neuropathy, and examinations of the lower limb revealed spastic paraparesis with sensory abnormality. Laboratory investigations revealed the presence of positive anti-aquaporin 4 antibody, strongly positive antinuclear antibody, and anti-ds DNA with the longitudinally extensive lesion on magnetic resonance imaging of the spinal cord. She was treated with methylprednisolone, hydroxychloroquine, and mycophenolate, and was discharged with improvement of her paraparesis. However, her vision did not improve substantially.

CONCLUSION

The importance of this report is to shed some light on the occurrence of two devastating complications that is, bilateral acute ischemic optic neuropathy in systemic lupus erythematosus complicated by neuromyelitis optica, as well as evidence of rare presentations for systemic lupus erythematosus and treatment modalities of ischemic optic neuropathy with systemic lupus erythematosus.

Periorbital Edema as the Initial Manifestation of Pediatric Systemic Lupus Erythematosus

Periorbital edema as a sole initial manifestation, without any evidence of other significant cutaneous or systemic involvement, is rare in systemic lupus erythematosus (SLE). We report a 16 year-old female who presented with bilateral periorbital edema as the sole initial manifestation of SLE. As the disease progressed, a kidney biopsy was performed demonstrating lupus nephritis stage II. This report emphasizes the importance of the index of suspicion of SLE as one of the differential diagnosis of patients with periorbital edema in the relevant clinical context.

Vitreoretinal surgery in the management of infectious and non-infectious uveitis - a narrative review

PURPOSE

This study aims to conduct a narrative review about the current role of vitreoretinal surgery in the management of infectious and non-infectious uveitis.

METHODS

This review was performed based on a search of the PubMed database or on relevant published papers according to our current knowledge.

RESULTS

A total of 91 articles were identified in the literature review. With the advance of microincision vitrectomy surgery (MIVS), pars plana vitrectomy (PPV) has gained increasing popularity in the management of infectious and non-infectious uveitis. For diagnostic purposes, larger amounts of sample can be obtained by MIVS than traditional vitreous aspiration using needles. For treatment purposes, PPV removes vitreous opacities, decreases inflammatory cytokines and mediators of inflammation, and tackles related complications, including hypotony, epiretinal membrane, macular holes, and retinal detachment. Achieving optimum control of inflammation prior to surgery is important for surgical interventions for non-emergent therapeutic indications and complications of uveitis. Peri-operative inflammation management is essential for decreasing the risk of surgical intervention. An overall complication rate of 42-54% was reported with cataract to be the leading cause of complications.

CONCLUSION

Most reports affirm the role of PPV in the management of infectious and non-infectious uveitis, although the quality of data remains limited by a lack of applying standardized reporting outcomes, limitations in study design, and a paucity of prospective data.

Bilateral Lupus Chorioretinopathy in a Patient With Active Systemic Lupus Erythematosus

Ocular involvement is commonly seen in systemic lupus erythematosus (SLE). However, chorioretinopathy is an easily missed ocular manifestation of SLE. Early recognition and a multidisciplinary treatment approach can play a key role in reducing the ocular and systemic morbidity seen with this condition. This case report describes a patient with active SLE who presented with bilateral lupus chorioretinopathy. The patient demonstrated a significant improvement in ocular symptoms once the systemic disease was controlled.

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.

Primary Vitreoretinal Lymphoma: A Retrospective Study of 20 Eyes

Purpose. This study aimed to describe and analyze the clinical features of 20 eyes of 15 primary vitreoretinal lymphoma (PVRL) patients. Methods. This was a retrospective case series and a review of the literature. Fifteen PVRL patients (20 affected eyes) referred between February 2011 and December 2019 were recruited, and their medical records were retrospectively reviewed. Results. Among these 15 PVRL patients, seven were men (46.67%), and five had bilateral PVRL (33.33%). The median onset age was 66 ± 9.26 years and six (40%) patients had central nervous system (CNS) involvement, and two of them died of CNS-related complications. The ocular symptoms varied from decreased vision to binocular diplopia. The ocular manifestations were diverse and involved both the anterior and posterior segments, including the vitreous cells, subretinal white-yellow lesions, cotton-wool spots, and ophthalmoplegia. The rate of misdiagnosis and failure to diagnose was 100%, and 30% of them were misdiagnosed as uveitis. We found five cases revealing rare characteristics of this malignancy. Among them, there were two cases with mild hypertensive retinopathy exhibiting cotton-wool spots, one case mimicking age-related macular degeneration (AMD), one case with systemic lupus erythematosus (SLE), and one patient had extraocular muscle involvement. To the best of our knowledge, we reported PVRL exhibiting cotton-wool spots as the main manifestation and coexisting with extraocular myopathy for the first time. Conclusions. PVRL is a rare intraocular malignancy that commonly masquerades as uveitis. As the clinical signs and symptoms are atypical, ophthalmologists must carefully examine patients to avoid misdiagnosis or a failure to diagnose. Cotton-wool spots and extraocular myopathy might be the dominant initial symptoms in PVRL patients, and AMD should be considered a differential diagnosis of PVRL. SLE patients under immunosuppressive treatment could have spontaneous PVRL.

Case Report: Recurrent retinal vein occlusion as the first clinical manifestation of systemic lupus erythematosus in a male patient

Systemic lupus erythematosus (SLE) is a chronic, autoimmune disease characterized by widespread clinical manifestations and immunological disorders. A myriad of ocular manifestations can be seen in patients with SLE. The most vision-threatening complication is vaso-occlusive retinopathy including retinal vein occlusion (RVO). RVO associated with SLE is well described in the literature and its association with antiphospholipid antibodies is recognized. However, RVO as the initial manifestation of SLE is scarcely reported.

Herein, we report the first case of recurrent RVO as the revealing manifestation of SLE in a 40-year-old male patient. He had two consecutive episodes of decreased vision. Ophthalmologic examination disclosed a branch retinal vein occlusion the first time and a central retinal vein occlusion the second time. The diagnosis of SLE was established based on clinical and immunological criteria. He was prescribed antiplatelet therapy, hydroxychloroquine at 5.5 mg/kg/day, and intravitreal anti-vascular endothelial growth factor (VEGF) antibodies regimen. He slowly improved under treatment.

Orbital myositis in systemic lupus erythematosus: a case-based review

Ocular complications occur in up to one-third of patients with systemic lupus erythematosus (SLE). Among them, orbital myositis (OM) is considered a rare manifestation that affects the extraocular muscles and causes pain and restriction with eye movement. We report a case of OM in a 48-year-old female with SLE and secondary Sjogren's Syndrome, who presented headache, periorbital edema, and painful ocular movements in both eyes, with no other systemic manifestations. An orbital magnetic resonance image revealed thickening of the right medial rectus and left lateral rectus muscles. Laboratory tests were normal and there was no further disease activity. The patient was treated with prednisone 1 mg/Kg/day with a resolution of symptoms. We found 13 additional cases of OM from our literature review (11 SLE patients and 2 with discoid lupus erythematosus). There was a female predominance in these cases with a mean age of 43.6 years (SD ± 16.9). Their main clinical features included eye pain, swelling, proptosis, diplopia, and limitations in extraocular muscles, while in most of them, there was no other active systemic manifestation. Treatment with steroids led to the complete resolution of symptoms in most of these patients. The available evidence suggests that it is essential to have a high index of suspicion for OM in SLE patients even when there is no systemic disease activity so that proper treatment is initiated early.

Corneal in vivo Confocal Microscopy for Assessment of Non-Neurological Autoimmune Diseases: A Meta-Analysis

Purpose

This study aimed to evaluate the features of corneal nerve with in vivo confocal microscopy (IVCM) among patients with non-neurological autoimmune (NNAI) diseases.

Methods

We systematically searched PubMed, Web of Science, and Cochrane Central Register of Controlled Trials for studies published until May 2021. The weighted mean differences (WMDs) of corneal nerve fiber length (CNFL), corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), tortuosity, reflectivity, and beadings per 100 μm with a 95% CI between NNAI and control group were analyzed using a random-effects model.

Results

The results showed 37 studies involving collective totals of 1,423 patients and 1,059 healthy controls were ultimately included in this meta-analysis. The pooled results manifested significantly decreased CNFL (WMD: −3.94, 95% CI: −4.77–−3.12), CNFD (WMD: −6.62, 95% CI: −8.4–−4.85), and CNBD (WMD: −9.89, 95% CI: −14–−5.79) in NNAI patients. In addition, the NNAI group showed more tortuous corneal nerve (WMD: 1.19, 95% CI:0.57–1.81). The comparison between NNAI patients and healthy controls in beadings per 100 μm corneal nerve length was inconsistent. No significant difference was found in the corneal nerve fiber reflectivity between NNAI and the control group (WMD: −0.21, 95% CI: −0.65–0.24, P = 0.361).

Conclusions

The parameters and morphology of corneal nerves observed by IVCM proved to be different in NNAI patients from healthy controls, suggesting that IVCM may be a non-invasive technique for identification and surveillance of NNAI diseases.

The Application of Optical Coherence Tomography Angiography in a Patient with Systemic Lupus Erythematosus

A 15-year-old girl presented to the emergency department with a history of bilateral blurred vision for one day, with greater severity in the right eye. Fundus examinations revealed cotton wool spots, dot hemorrhage, and hard exudate. She underwent optical coherence tomography angiography (OCTA), which showed the presence of macula ischemia, decreased vascular density, mild retinal fluid, severe ischemia, some macular edema, and vascular sheathing, indicating active vasculitis in the right eye. Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect many organs in the body, including the eye. Ocular involvement is one of the most well-known features. Retinal vasculitis is a rare complication of SLE that is characterized by vascular sheathing that can progress to vaso-occlusion. We report the clinical features of SLE using OCTA.

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.

Meibomian gland alteration in patients with systemic lupus erythematosus

PURPOSE

To investigate meibomian gland (MG) alteration in patients with systemic lupus erythematosus (SLE).

METHODS

This study included 23 SLE patients evaluated with Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and 21 healthy controls (HCs). All the subjects were evaluated with Ocular Surface Disease Index (OSDI) questionnaire, and the eyes were performed examinations of tear meniscus height (TMH), non-invasive keratographic tear film break-up time (NIKBUT), Schirmer I Test, MG eyelid score, meibography score, and in vivo confocal microscopy (IVCM) on the meibomian gland.

RESULTS

There was no significant difference between the SLE patients and the HCs in the TMH, NIKBUT, and Schirmer I Test. However, the SLE patients had higher MG eyelid scores and meibography scores on both upper eyelid and lower eyelid than the HCs. Through meibography observation, 34.8% of the SLE patients presented MG deficiency in Grade 3, whereas that of all the HCs were less than Grade 3. The SLE patients were found to have significant MG atrophy and vascular enrichment around the meibomian glands (MGs). The SLE patients were also found to have excessive inflammatory cell infiltration around the MGs, especially the typical lymph node-like foci of inflammatory cell infiltration.

CONCLUSIONS

MG alteration can be found in the SLE patients. Examinations of the MGs can help diagnose or infer ocular diseases at an early stage of SLE.

Retinal thickness and microvascular alterations in the diagnosis of systemic lupus erythematosus: a new approach

BACKGROUND

To investigate the differences of retinal thickness (RT) and superficial vascular density (SVD) between patients with systemic lupus erythematosus (SLE) and healthy controls using optical coherence tomography angiography (OCTA).

METHODS

Individuals with SLE (n=12; 24 eyes) and healthy controls (n=12; 24 eyes) were recruited to this study. The study protocol was in accordance with the tenets of the Declaration of Helsinki (as revised in 2013). The monocular best-corrected visual acuity (BCVA) was determined using a Snellen eye chart. Each image was segmented into 9 early treatment diabetic retinopathy study subregions, within which the macular RT and SVD were measured by OCTA. The vascular perfusion area as a percentage of the measured area was considered to be the vascular density.

RESULTS

The mean age of the SLE group was 33.80±9.49 years, and the mean age of the control group was 33.20±9.41 years. The mean duration of SLE was 4.33±2.67 years. The BCVA was significantly different between the SLE and control groups (0.17±0.20 vs. 0.05±0.07, respectively; P=0.021). In the SLE group, inner RT was reduced in the outer superior and temporal regions and full RT was reduced in the outer temporal region, compared with the control group (P<0.05). In the outer temporal region, the area under the receiver operating characteristic curve (AUC) for the inner RT was 0.805 [95% confidence interval (CI): 0.674 to 0.935], and the full RT was 0.828 (95% CI: 0.701 to 0.955). Thinning of RT was negatively correlated with erythrocyte sedimentation rate (ESR) in the inner retina at the outer temporal and outer superior regions and the full retina at the outer temporal region (P<0.05). The SVD was significantly lower in SLE participants than in controls in the central region, all 4 inner quadrants, and 4 outer quadrants (P<0.05). In the SLE group, SVD was positively correlated with inner RT in the outer superior region, inner RT, and full RT in the outer temporal region (P<0.05).

CONCLUSIONS

Variations in RT within the macular area may affect visual acuity. The OCTA measurement of RT may be a potential marker for diagnosis of SLE and an indicator of its inflammatory activity.

EYE DISEASE IN KIDNEY TRANSPLANTATION: CLINICAL CHALLENGES IN A UNIQUE PATIENT POPULATION

Eye disease is common among kidney transplant recipients and their management is challenging. Chronic kidney disease is associated with ocular complications, both independently and in the context of various systemic disorders. In addition, chronic immunosuppression predisposes kidney transplant recipients to an array of long-term ocular issues. This may be broadly categorized into infections, malignancies, and other immunosuppression-specific side effects. The interdependence of kidney disease, transplant pharmacotherapy and ocular health therefore requires a multispecialty approach. Although the kidney transplant population has grown along with the burden of associated oculopathies, systematic guidelines targeting this patient group are lacking. This evidenced-based narrative review summarizes the pertinent issues that may present in the ophthalmic and optometric clinical settings, with emphasis on collaborative management and directions for future research.

Retinopathy in newly-diagnosed systemic lupus erythematosus: should we screen for ocular involvement?

Background

Ocular manifestations are common in systemic lupus erythematosus (SLE). Retinopathy has previously been linked to disease severity and might have a significant impact on the patient’s quality of life and has also been associated with a poor prognosis in SLE. This study aimed to determine the prevalence of retinopathy among patients who are newly diagnosed with SLE.

Methods

In a cross-sectional study, patients diagnosed with SLE at a tertiary referral clinic were assessed for inclusion between March 2016 and March 2017. Patients who had received treatment for SLE at any time were excluded, as well as patients with hypertension, diabetes mellitus, and coagulopathy. Clinical findings and laboratory test results were recorded, and patients were examined by an ophthalmologist for evidence of retinal pathologies. SLE disease activity index was also calculated for all patients.

Results

With 114 patients included in the final analysis, we found a prevalence of 15.8% for retinopathy among newly-diagnosed SLE patients. Cotton-wool spots were the most common finding (78%). Patients with retinopathy had significantly lower hemoglobin levels, C3 and C4 concentrations, and higher ANA and Anti-dsDNA levels. Also, patients with retinopathy had a significantly higher SLE DAI score.

Conclusions

We found a relatively high rate of retinopathy in SLE patients at the time of their initial diagnosis. Our findings suggest that retinopathy is an early manifestation of the disease. Ophthalmologic screening might be considered for SLE patients at the time of diagnosis, especially for those with severe disease. We also encourage researchers to further evaluate the correlation between retinopathy and disease activity, and the prognosis of ocular involvement.

Anterior Segment Optical Coherence Tomography of Tear Film and Cornea in Systemic Lupus Erythematosus Patients

Purpose

To study tear film and corneal thickness measurements in systemic lupus erythematosus (SLE) patients compared to age-matched controls using anterior segment optical coherence tomography (AS-OCT).

Methods

This was a cross-sectional study. Study participants were divided into 3 groups: Group A: SLE patients with clinical dry eye, Group B: SLE patients without clinical dry eye and Group C: healthy controls. The lower tear meniscus parameters measured using AS-OCT were tear meniscus height (TMH), tear meniscus depth (TMD) and tear meniscus area (TMA). The central corneal and corneal epithelial thickness were automatically calculated.

Results

The study included 40 eyes in Group A, 60 in Group B, and 100 in Group C. Mean age was 26.9±6.6 years for Group A, 27.6±7.3 years for Group B and 35.7±9.2 years for Group C (p= 0.06). All subjects were females except for 1 male patient in Group A. Mean TMH, TMA and TMD in Group C were 487.7±185.6 µm, 0.068±0.040 mm², and 341.2±99.1 µm, respectively, which was significantly higher compared to Group A (225.5±27.9 µm, 0.018±0.004 mm² and 171.9±26.0 µm, respectively, all p < 0.001) and Group B (395.4±118.8 µm, p < 0.001; 0.05±0.04 mm², p=0.016 and 280.6±93.4 µm, p < 0.001, respectively). Group B eyes also had significantly higher parameters compared to Group A (all p < 0.001). Mean corneal and epithelial thickness in Group C were 501.6±37.5 µm and 53.3±4.5 µm, respectively, which was significantly higher compared to Group A (496.1±24.1 µm, p=0.044 and 49.5±3.5 µm, p < 0.001, respectively) and Group B (504.2±22.03 µm, p=0.046 and 47.5±5.6 µm, p < 0.001, respectively). Group B eyes also had a significantly higher corneal thickness (p=0.031) and epithelial thickness (p=0.011) compared to Group A.

Conclusion

We demonstrated significant reduction of tear meniscus dimensions, central corneal thickness and epithelial thickness in SLE patients compared to age-matched controls using AS-OCT.

Optical Coherence Tomography Angiography as a New Tool for Evaluation of the Subclinical Retinal Involvement in Patients with Systemic Lupus Erythematosus-A Review

Knowing the proven relationship between lupus retinopathy and systemic changes and disease activity, it is crucial to find the possibility of early diagnosis of retinal changes at a subclinical level in order to provide faster medical intervention and protect the patient from irreversible changes in the eye and other organs. The aim of this review is an analysis of studies investigating early pathological changes in retinal vascularization obtained by optical coherence tomography angiography (OCTA) and their relationship to the systemic lupus erythematosus (SLE). A literature search was performed to identify all relevant articles, regarding detection of subclinical retinal changes using OCTA in systemic lupus erythematosus listed in PubMed database. Seven out of seven papers found showed a decrease in superficial capillary plexus in ocular asymptomatic patients diagnosed with SLE. A decrease in retinal vessel density measured by OCTA may be a good marker of SLE activity and poor prognosis. OCTA in a safe manner can give clinicians a new perspective on processes of vessel remodeling and answer the question of how SLE might impact the eye from a structural point of view. Adding OCTA to the standard diagnostic process of SLE patients, may detect systemic changes early and prevent further visual deterioration by stopping progression of lupus retinopathy.

Ocular Manifestations in Colombian Patients with Systemic Rheumatologic Diseases

PURPOSE

To establish the prevalence of ocular involvement in a Colombian population with rheumatologic diseases.

DESIGN

Observational cross-sectional study.

METHODS

We included a probabilistic sample size of 797 patients who attended a rheumatologic disease center in Bogotá, Colombia. Statistical analysis with descriptive measures and Chi-square independence test between rheumatologic diseases and ophthalmological symptoms and diseases was performed.

RESULTS

Eighty-four percent of the population were women, and the mean age was 54.61± 15.64 years. The most common condition was rheumatoid arthritis (33.37%), followed by fibromyalgia (22.71%), Sjögren Syndrome (19.72%), and systemic lupus erythematosus (9.91%). Almost 7% of the patients presented polyautoimmunity. Thirty-five percent of the patients reported one or more ophthalmological symptoms, being dry eye sensation the most common (30.86%), followed by ocular pain (2.76%), red-eye, and decreased visual acuity (both 2.63%). Similarly, 21.45% of the patients presented one or more ophthalmological diagnoses, being keratoconjunctivitis sicca the most common (15.93%), followed by cataract, uveitis (1.38% each), and scleritis (1.25%).

CONCLUSION

Almost a third of the patients reported any ocular involvement. It is crucial to be aware of the most common ophthalmic manifestations among the different rheumatologic diseases in our population, to offer early specialist referral and timely treatment.

Non-central serous chorioretinopathy in a patient with systemic lupus erythematosus and hydroxychloroquine retinopathy

Subretinal fluid accumulation in a patient with systemic lupus erythematosus (SLE) may represent a diagnostic challenge. We present a case of a 43-year-old man with baseline diagnosis of SLE and hydroxychloroquine-associated maculopathy who reported progressive vision loss on the right eye, associated with corticosteroids use for an arthritic crisis. Ophthalmological examination did not reveal any acute finding. On optical coherence tomography, subretinal fluid in the perifoveal area was visible on the right eye, with corresponding enlargement of the visual field defect. An increased choroidal thickness was also visible. Fluorescein angiography revealed, on the right eye, two pinpoint areas of leakage and indocyanine green angiography signs of choroidal vascular hyperpermeability. Considering a diagnosis of a non-central central serous chorioretinopathy, corticosteroids use was interrupted, with resolution of the subretinal fluid. This case illustrates the relevance of a multimodal imaging approach to guide the diagnosis of patient with an SLE with subretinal fluid.

Systemic Lupus Erythematosus-associated Retinal Vasculitis Treated with Adalimumab

PURPOSE

To present a case of refractory systemic lupus erythematosus (SLE)-associated retinal vasculitis that responded to the anti-tumor necrosis factor (TNF)-alpha inhibitor adalimumab as corticosteroid-sparing therapy.

METHODS

Descriptive case report of a patient with SLE with retinal vasculitis complicated by an ischemic retinal vein occlusion and cystoid macular edema.

RESULTS

A 30-year-old female patient with a history of SLE presented with retinal vasculitis and an ischemic, branch retinal vein occlusion with macular edema in the left eye. Oral corticosteroid was administered along with mycophenolate mofetil (MMF) as a corticosteroid-sparing agent. Despite MMF therapy, the patient developed an exacerbation of her vasculitis with the involvement of both eyes. Adalimumab was initiated with a resultant resolution of retinal vasculitis as a corticosteroid-sparing strategy with over 2 years of follow-up.

CONCLUSION

Anti-TNF-alpha therapy with adalimumab may be effective as a corticosteroid-sparing agent in select patients with ocular inflammation associated with SLE.

Autoimmune Dry Eye without Significant Ocular Surface Co-Morbidities and Mental Health

Dry eye symptoms can negatively affect the psychological, physical, and social functioning, which can potentially impair the health-related quality of life. This review evaluated the association between autoimmune related dry eye in the absence of significant ocular surface co-morbidities and mental health. This review found a significantly higher prevalence of mental health disorders (such as depression and anxiety) in systemic lupus erythematous, rheumatoid arthritis, systemic sclerosis, Behcet’s disease, and primary Sjogren’s syndrome patients when compared to the general population. Moreover, patients with depression and anxiety interpret ocular sensations differently than healthy controls and the perception of dry eye symptoms can be influenced by their mood. Somatization is common in depression, and this could influence the perception of ocular discomfort. Anti-depressants and anxiolytics with their potential side effects on the tear film status may also contribute or aggravate the dry eye symptoms in these patients. Although ophthalmologists manage the dry eye disease, as per standardized algorithms, they should be mindful of different ocular sensation interpretation and coexistent mental health issues in a large number of this patient group and initiate a multidisciplinary management plan in certain cases. While rheumatologists look after their autoimmune condition, it may be worth liaising with GP and/or psychiatrist colleagues in order to address their neuropathic type pain and mental health co-morbidities.

Evaluation of subclinical retinopathy and angiopathy with OCT and OCTA in patients with systemic lupus erythematosus

PURPOSE

To evaluate the choroidal and retinal layers with optical coherence tomography (OCT) and retinal microvascular structures with optical coherence tomography angiography (OCTA) in systemic lupus erythematosus (SLE) patients.

METHOD

In this prospective, cross-sectional and comparative study, a total of 35 SLE patients and 35 healthy control participants were included. SLE patients who were using hydroxychloroquine (HCQ) and/or immunosuppressive agents are evaluated with OCT and OCTA. SLE patients who have no HCQ maculopathy observed in OCT were included in the patient group.

RESULTS

Mean macular thickness and ganglion cell inner plexiform layer (GC-IPL) thicknesses were thinner in the patient group. When the parameters obtained with OCTA were evaluated, vessel (VD) and perfusion density (PD) were significantly lower in the patient group. Central foveal thickness and foveal avascular zone parameters were negatively correlated. In addition, VD and PD, and GC-IPL thicknesses were positively correlated.

CONCLUSION

Application of OCTA for the evaluation of microvasculature in SLE patients may be useful in subclinical changes.

Recurrent and Reversible, Bitemporal Field Defect from Presumed Chiasmitis in a Patient with Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic, recurrent and remitting autoimmune disease affecting mostly women and presenting between late adolescence and the fourth decade of life. Ocular manifestations may occur in one-third of patients with SLE, with keratoconjunctivitis sicca as the most common and optic nerve and retina abnormalities as the most severe. Neuro-ophthalmological manifestations occur in approximately 1% of patients with SLE, usually in the form of optic neuropathy. The purpose of this paper is to describe a patient who developed recurrent optic chiasmitis as an uncommon sign of disease activity in SLE.

Orbital myositis in systemic lupus erythematosus: A case report and literature review

Orbital myositis is a rare manifestation of systemic lupus erythematosus (SLE). Herein, we report a case of orbital myositis in a patient with SLE, along with a literature review. A 45-year-old female patient presented with pain in the right eye, chemosis, proptosis, and limited abduction. Computed tomography of her orbits revealed thickening of her right lateral rectus muscle. She had no other systemic symptoms. There was no elevation in the biomarkers of inflammation or disease activity. She was treated with high-dose steroids, and her symptoms resolved rapidly. It is important to maintain a high index of suspicion for orbital myositis in patients with SLE even when there are no systemic disease activities, such that early treatment can be initiated. It is also important to rule out other mimickers such as orbital cellulitis and thyroid eye disease.

Bioenergetic shift and actin cytoskeleton remodelling as acute vascular adaptive mechanisms to angiotensin II in murine retina and ophthalmic artery

Ocular vascular dysfunction is a major contributing factor to the pathogenesis of glaucoma. In recent years, there has been a renewed interest in the role of angiotensin II (Ang II) in mediating the disease progression. Despite its (patho)physiological importance, the molecular mechanisms underlying Ang II-mediated oxidative stress remain largely unexplored in the ocular vasculature. Here, we provide the first direct evidence of the alterations of proteome and signalling pathways underlying Ang II-elicited oxidative insult independent of arterial pressure changes in the ophthalmic artery (OA) and retina (R) employing an in vitro experimental model. Both R and OA were isolated from male C57Bl/6J mice (n = 15/group; n = 5/biological replicate) and incubated overnight in medium containing either vehicle or Ang II (0.1 μM) at physiological conditions. Label-free quantitative mass spectrometry (MS)-based proteomics analysis identified a differential expression of 107 and 34 proteins in the R and OA, respectively. Statistical and bioinformatics analyses revealed that protein clusters involved in actin cytoskeleton and integrin-linked kinase signalling were significantly activated in the OA. Conversely, a large majority of differentially expressed retinal proteins were involved in dysregulation of numerous energy-producing and metabolic signalling pathways, hinting to a possible shift in retinal cell bioenergetics. Particularly, Ang II-mediated downregulation of septin-7 (Sept7; p < 0.01) and superoxide dismutase [Cu-Zn] (Sod1; p < 0.05), and upregulation of troponin T, fast skeletal muscle (Tnnt3; p < 0.05) and tropomyosin alpha-3 chain (Tpm3; p < 0.01) in the OA, and significant decreased expressions of two crystallin proteins (Cryab; p < 0.05 and Crybb2; p < 0.0001) in the R were verified at the mRNA level, corroborating our proteomics findings. In summary, these results demonstrated that exogenous application of Ang II over an acute time period caused impairment of retinal bioenergetics and cellular demise, and actin cytoskeleton-mediated vascular remodelling in the OA.

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Acute Ang II stimulation elicits oxidative stress in ocular vasculature without pressor effect. .

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Dysregulation of energy-producing and metabolic pathways are implicated in the retina. .

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Actin cytoskeleton remodelling are vascular adaptation processes in the ophthalmic artery. .

Evaluation of Central and Peripheral Corneal Thicknesses in Patients with Systemic Lupus Erythematosus

Purpose

To evaluate the corneal pachymetric and topographic parameters of systemic Lupus Erythematosus (SLE) patients using Dual Scheimpflug Imaging.

Methods

This observational cross-sectional controlled study included the right eye of 30 SLE patients and 30 age-matched controls. Corneal measurements were acquired by dual Scheimpflug imaging including anterior and posterior corneal curvatures, central, mid-peripheral corneal thickness (measured at the 5 mm zone) and peripheral pachymetry (measured at the 7 mm zone). SLE disease activity index (SLEDAI) was calculated and correlated with corneal pachymetry.

Results

SLE patients had significantly thicker corneal periphery than controls. Mean central corneal pachymetry was 530.4± 27.3 microns (SD) in SLE and 547.5±31.5 microns (SD) in control group, p = 0.032. The corneal periphery – except superiorly – was significantly thicker in SLE patients than controls (p ˂0.001). Nasal peripheral corneal thickness positively correlated with disease activity index SLEDAI (p=0.03).

Conclusion

SLE patients present with thicker corneal periphery than controls characteristically sparing the superior quadrant. Possible corneal photosensitivity leading to peripheral immune complex deposition as well as flatter posterior corneal surface at the periphery are proposed explanations for these findings.

Orbital compartment syndrome as the first manifestation of SLE

The occurrence of orbital compartment syndrome is a rare and unusual complication of systemic lupus erythematosus (SLE). Patients will present with symptoms of ocular pain and diplopia and visible signs of proptosis. The condition is considered an ophthalmological emergency because the myositis involving the ocular muscles can cause irrevocable damage to the retina and optic disk, potentially leading to blindness. We report a case of a young African American male who developed orbital myositis with compartment syndrome as his initial manifestation of SLE. The patient underwent an emergent orbital decompression, followed by prompt initiation of immunosuppressant medications. To our knowledge, this is the first report of a case of myositis secondary to SLE complicated by compartment syndrome of the orbit.

Acute myopic shift in a patient with systemic lupus erythematosus

Purpose

To describe a rare case of acute, transient myopic shift occurring as a feature of a flare of systemic lupus erythematosus.

Observations

A 22-year-old Indigenous Australian woman with diagnosed systemic lupus erythematosus was admitted with blurry vision and periorbital oedema. She had a refractive error of −7.50 DS in the right eye and −3.50 DS in the left eye and cotton wool spots throughout the posterior poles of the retina of each eye. Treatment with intravenous and oral steroids resulted in rapid resolution of myopia and improvement in visual acuity.

Conclusions and importance

Systemic lupus erythematosus disproportionately affects more indigenous than non-indigenous Australians with greater disease burden and severity. This case describes a rare manifestation of this disease.

Update on Myopia Risk Factors and Microenvironmental Changes

The focus of this update is to emphasize the recent advances in the pathogenesis and various molecular key approaches associated with myopia in order to reveal new potential therapeutic targets. We review the current evidence for its complex genetics and evaluate the known or candidate genes and loci. In addition, we discuss recent investigations regarding the role of environmental factors. This paper also covers current research aimed at elucidating the signaling pathways involved in the pathogenesis of myopia.

Choroidal thickness changes in systemic lupus erythematosus patients

Purpose

To compare choroidal thickness (CT) between patients with systemic lupus erythematosus (SLE) without ophthalmologic manifestations and a control group. To study the effects in CT of disease duration, activity index, medication and systemic comorbidities.

Methods

Cross-sectional study where spectral-domain optical coherence tomography with enhanced depth imaging was used to measure CT in 13 locations, subfoveally and at 500-µm intervals along a horizontal and a vertical section from the fovea. Linear regression models were used.

Results

Sixty-eight SLE patients and fifty healthy controls were enrolled. CT multivariable analysis revealed lower values in SLE patients (12.93-26.73 µm thinner) in all locations, except the inferior quadrants (6.48-10.44 µm thicker); however, none of these results reached statistical significance. Contrary to the control group, the normal topographic variation in CT between macular quadrants and from the center to the periphery was not observed in the SLE group. Multivariable analysis in the SLE group alone revealed a significant negative association with anticoagulants (50.10-56.09 µm thinner) and lupus nephritis (40.79-58.63 µm thinner). Contrary to controls, the CT of SLE patients did not respond to changes in mean arterial pressure.

Conclusion

CT in SLE appears to be thinner, particularly in the subset of patients with nephritis and taking anticoagulants, suggesting more advanced systemic vascular disease. Choroidal responses to hemodynamic changes may also be altered in SLE.

Immune-mediated conditions affecting the brain, eye and ear (BEE syndromes)

The triad of central nervous system symptoms, visual disturbance and hearing impairment is an oft-encountered clinical scenario. A number of immune-mediated diseases should be considered among the differential diagnoses including: Susac syndrome, Cogan syndrome or Vogt-Koyanagi-Harada disease; demyelinating conditions such as multiple sclerosis or neuromyelitis optica spectrum disorder; systemic diseases such as systemic lupus erythematosus, Sjögren syndrome or Behcet disease and granulomatous diseases such as sarcoidosis. In this article, we coin the term 'BEE syndromes' to draw attention to the various immune-mediated diseases that affect the brain, eye and ear. We present common disease manifestations and identify key clinical and investigation features.