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Chiou YR, Chang YS, Su CF, Li TH, Lai CC, Hwang DK, Wu FY, Chang YF. Risks of posterior segment ocular ischaemic events in patients with systemic lupus erythematosus: a population-based cohort study in Taiwan. Br J Ophthalmol 2023; 107:1687-1692. [PMID: 35922126 DOI: 10.1136/bjo-2022-321653] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/19/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUD/AIM Ocular involvement in systemic lupus erythematosus (SLE) is often primarily recognised by ophthalmologists rather than internists. This study aims to investigate the incidence and risk factors for the occurrence of posterior ocular ischaemic events (OIE), including retinal vein occlusion (RVO), retinal artery occlusion (RAO) and ischaemic optic neuropathy (ION), in patients with SLE. METHODS A national database in Taiwan was used to identify 24 472 patients newly diagnosed with SLE and 244 720 age-matched and sex-matched controls between 1997 and 2012. New occurrences of OIE and confounding factors were recorded. The Kaplan-Meier method was used to compare the risk of OIE between the two groups. Fixed effect models were applied to evaluate the risk factors for OIE. RESULTS The mean age was 36.24±15.82 years and women accounted for 88.4%. Patients with SLE had significantly increased risk of overall OIE (HR 3.89, 95% CI 3.36 to 4.50, p<0.001) as well as each OIE subtype. End-stage renal disease (ESRD; HR 2.91, 95% CI 2.05 to 4.14, p<0.001), hypertension (HR 1.77, 95% CI 1.21 to 2.58, p=0.003) and congestive heart failure (HR 1.67, 95% CI 1.12 to 2.48, p=0.01) were associated with RVO development. Hypertension (HR 2.89, 95% CI 1.10 to 3.96, p=0.02) and ischaemic stroke (HR 3.58, 95% CI 1.97 to 6.48, p<0.001) had increased risk of RAO. ESRD was associated with ION (HR 3.03, 95% CI 1.41 to 6.51, p=0.004). Intravenous steroid was associated with RVO development (HR 2.54, 95% CI 1.67 to 3.84, p<0.001). CONCLUSIONS SLE increases the risk of developing OIE. Systemic comorbidities and higher dosage of steroid in patients with SLE are associated with severe ocular ischaemic complications.
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Affiliation(s)
- Yi-Ran Chiou
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan
| | - Yu-Sheng Chang
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taipei Medical University, Shuang Ho Hospital, New Taipei City, Taiwan
| | - Chin-Fang Su
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taipei Medical University, Shuang Ho Hospital, New Taipei City, Taiwan
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tzu-Hao Li
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Shin-Kong Wu Ho Su Memorial Hospital, Taipei, Taiwan
| | - Chien-Chih Lai
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - De-Kuang Hwang
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Fang-Yi Wu
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taipei Medical University, Shuang Ho Hospital, New Taipei City, Taiwan
| | - Yu-Fan Chang
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan
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Sayeed SKJB, Khan AH, Moniruzzaman M, Mahmud R, Rahman MM. Systemic lupus erythematosus with acute ischemic optic neuropathy complicated with neuromyelitis optica: a case report. J Med Case Rep 2023; 17:21. [PMID: 36681831 PMCID: PMC9867851 DOI: 10.1186/s13256-022-03734-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 12/23/2022] [Indexed: 01/23/2023] Open
Abstract
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.
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Affiliation(s)
- S. K. Jakaria Been Sayeed
- grid.489064.7Clinical Neurology, National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
| | - Asif Hasan Khan
- grid.489064.7Clinical Neurology, National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
| | - Md. Moniruzzaman
- grid.489064.7Clinical Neurology, National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
| | - Reaz Mahmud
- grid.413674.30000 0004 5930 8317Department of Neurology, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Md. Mujibur Rahman
- grid.411509.80000 0001 2034 9320Department of Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
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Guleria S, Kumar Jindal A, Bhattarai D, Agarwal A, Moharana B, Patra PK, Gupta V, Suri D, Singh S. Retinal vasculopathy in children with systemic lupus erythematosus: report of two cases. Lupus 2020; 29:1633-1637. [PMID: 32723061 DOI: 10.1177/0961203320945384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic, autoimmune, multisystem disease associated with a variable clinical course. SLE is more severe and is associated with higher mortality in children compared to adults. Eye involvement may be seen in up to a third of patients. Retinal vasculopathy is rare in children with SLE. We report two such cases. Both patients in this series had cotton-wool spots on fundus examination, and fundus fluorescein angiography revealed findings of occlusive micro-angiopathy. These findings are characteristic of lupus retinal vasculopathy. Fundus examination is crucial in diagnosing retinal vasculopathy. All children with SLE must be evaluated in detail to detect any retinal abnormalities and should be managed with aggressive immunosuppression to save their vision.
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Affiliation(s)
- Sandesh Guleria
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Kumar Jindal
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dharmagat Bhattarai
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aniruddha Agarwal
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bruttendu Moharana
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pratap Kumar Patra
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishali Gupta
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepti Suri
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Heckman AJ, Alsaad AA, Stewart MW, Maniaci MJ. Acute Unilateral Vision Loss Due to Optic Neuropathy in a Patient with Systemic Lupus Erythematosus. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:97-100. [PMID: 30670677 PMCID: PMC6350674 DOI: 10.12659/ajcr.912875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patient: Female, 44 Final Diagnosis: Optic neuritis Symptoms: Unilateral vision loss Medication: — Clinical Procedure: Fundoscopic examination Specialty: Ophthalmology
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Affiliation(s)
- Alexander J Heckman
- Department of Internal Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Ali A Alsaad
- Department of Internal Medicine, Mayo Clinic in Florida, Jacksonville, IL, USA.,Department of Internal Medicine, Division of Cardiology, University of Chicago, NorthShore University, Evanston, FL, USA
| | - Michael W Stewart
- Department of Ophthalmology, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Michael J Maniaci
- Department of Internal Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
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Dammacco R. Systemic lupus erythematosus and ocular involvement: an overview. Clin Exp Med 2017; 18:135-149. [PMID: 29243035 DOI: 10.1007/s10238-017-0479-9] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/02/2017] [Indexed: 12/23/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease of undefined etiology and with remarkably heterogeneous clinical features. Virtually any organ system can be affected, including the eye. SLE-related eye involvement can be diagnosed in approximately one-third of the patients and is usually indicative of disease activity. An early diagnosis and the adoption of suitable therapeutic measures are necessary to prevent sight-threatening consequences, especially in patients with juvenile SLE. Periocular lesions, such as eyelid involvement and orbital inflammation, are relatively rare and, in case of orbital masses, may require a biopsy control. Keratoconjunctivitis sicca or secondary Sjögren's syndrome is the most frequent ophthalmic manifestation of SLE. According to its variable severity, lubricating tear drops may be sufficient in mild cases, whereas cyclosporine-A ophthalmic solution, glucocorticoids (GCs), methotrexate, and/or other immunosuppressive drugs may be required in the more severe cases. Partial occlusion of the lacrimal punctum by thermal cautery is rarely applied. Although uncommon, episcleritis and scleritis can sometimes be detected as an initial finding of SLE and reveal themselves as moderate to intense ocular pain, redness, blurred vision, and lacrimation. Unilateral or more often bilateral retinopathy is responsible for visual loss of variable severity and is ascribed to vasculitis of the retinal capillaries and arterioles. In addition to the combined treatment suitable for all patients with active SLE, intravitreal bevacizumab should be considered in cases of severe vaso-occlusive retinopathy and laser photocoagulation in cases of neovascularization. Purtscher-like retinopathy is likely ascribable to the formation of microemboli that results in retinal vascular occlusion and microvascular infarcts. Choroidal disease is characterized by monolateral or bilateral blurred vision. Because of the choroidal effusion, retinal detachment and secondary angle-closure glaucoma may occur. Ischemic optic neuropathy is characterized by acute-onset and progressive binocular visual impairment as a consequence of occlusion of the small vessels of the optic nerves due to immune complex vasculitis. Intravenous GC boluses followed by oral GCs and/or, in case of recurrence, intravenous cyclophosphamide and/or rituximab are commonly employed. Neovascularization can be treated by intravitreal bevacizumab and progression of retinal ischemic areas by retinal laser photocoagulation. Ocular adverse events (AE) have been described following the long-term administration of one or more of the drugs presently used for the treatment of SLE patients. Posterior subcapsular cataracts and secondary open-angle glaucoma are common AE of the prolonged GC administration. The long-term administration of hydroxychloroquine (HCQ) sulfate is well known to be associated with AE, such as vortex keratopathy and in particular the often irreversible and sight-threatening maculopathy. Length of administration > 5 years, > 1000 g total HCQ consumption, > 6.5 mg/kg daily dosing, coexistence of renal disease, and preexisting maculopathy are all considered risk factors for HCQ-induced retinopathy. Ocular AE of additional immunosuppressive and biological agents are still poorly known, given the worldwide more limited experience with their long-term use. A thorough ophthalmological control is strongly recommended at closer intervals for all SLE patients, in step with the total length of exposure to the drugs and the cumulative dose administered.
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Affiliation(s)
- Rosanna Dammacco
- Department of Basic Medical Sciences, Neurosciences and Sensory Organ, University of Bari Medical School, Clinica Oculistica, Policlinico, Piazza Giulio Cesare, 70124, Bari, Italy.
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