Sequential Observation of Fundus Changes in Patients with Long Standing Membranoproliferative Glomerulonephritis Type II (MPGN type II)

Retinal findings in glomerulonephritis

The complement system is part of the innate immune system activated by three distinct pathways: classical, lectin and alternative. It is also involved in retinal development and homoeostasis. Dense deposit disease is a rare renal disease associated with mutations in Complement factor H and overactivity of the alternative complement pathway. As well as glomerulonephritis, many affected individuals have retinal drusen and may be at risk of vision loss due to macular atrophy or choroidal neovascularisation. We discuss the reclassification of dense deposit disease as a type of C3 glomerulonephropathy, and hypothesise on the mechanisms of retinal abnormalities. Drusen have also been described in individuals with other types of glomerulonephritis involving abnormalities of the classical (membranoproliferative glomerulonephritis type 1) or lectin (IgA nephropathy, lupus nephritis) complement pathways. Although drusen are found in abnormalities of all three complement pathways, the age at onset, aetiology, and the threat to vision differs. This review describes drusen and other retinal abnormalities associated with the glomerulonephritides due to abnormal activation in each of the three complement activation pathways, and provides the first report of drusen occurring in a patient with the recently reclassified C3 glomerulonephritis with homozygous variant V62I in complement factor H. Optometric management of young patients presenting with retinal drusen is discussed, and complement-based therapies for visual loss are reviewed.

Clinical Manifestations of Cuticular Drusen: Current Perspectives

Cuticular drusen are part of the spectrum of age-related macular degeneration (AMD) with particular clinical and multimodal imaging characteristics. This drusen subpopulation shares several high-risk single nucleotide polymorphisms with AMD. Despite this feature, they can manifest at a relatively young age, presenting with a female preponderance. Multimodal imaging is essential for characterizing such lesions, using a combination of color fundus photographs, optical coherence tomography (OCT), fluorescein angiography (FA), and fundus autofluorescence (FAF). The classic starry-sky pattern visible on FA and the typical central hypoautofluorescent lesion with hyperautofluorescent rim on FAF is considered the result of a central retinal pigment epithelium (RPE) erosion from these triangular elevations of the RPE-basal lamina. This finding may also be responsible for the typical choroidal hypertransmission appreciated through OCT. The clinical course of cuticular drusen may be relatively benign at early stages, with small drusen presenting at a young age. However, the presence of clinical phenotypes characterized by diffuse involvement and/or accompanying large drusen in patients older than 60 years may confer a significant risk for either macular neovascularization or geographic atrophy.

Retinal manifestations in patients with complement-mediated membranoproliferative glomerulonephritis

Complement-mediated membranoproliferative glomerulonephritis is a rare progressive glomerular disease. In some patients it can be associated with retinal lesions. Therefore, the purpose of this study was to assess a case series with this diagnosis in our hospital. A cross-sectional study was conducted on 8 patients diagnosed with complement-mediated membranoproliferative glomerulonephritis. Funduscopy, optical coherence tomography (OCT) and Swept Source domain OCT angiography were performed. Only 1 of the 8 patients showed drusen-like deposits that were located under the retinal pigment epithelium in the OCT, with the presence of associated choroidal neovascularization being ruled out in OCT angiography. Therefore, membranoproliferative glomerulonephritis may produce retinal alterations with drusen or retinal pigment epithelium detachment, and requires an appropriate differential diagnosis to be made with age-related macular degeneration. The follow-up of these patients is important in order to detect vision-threatening complications.

Multimodal imaging of retinal pigment epithelial detachments in patients with C3 glomerulopathy: case report and review of the literature

Background

To describe the optical coherence tomography angiograhy (OCTA) of drusenoid pigment epithelial detachments (PEDs) in a woman affected by Complement 3 (C3) glomerulopathy, which represents a spectrum of glomerular diseases characterized on fluorescent microscopy by C3 accumulation with absent, or scanty, immunoglobulin deposits. It is due to acquired or genetically defective alternative pathway control and is generally associated with drusen-like deposits in Bruch’s membrane, as well as choriocapillaris. These retinal lesions can be associated with choroidal neovascularization and central serous chorioretinopathy (CSCR). OCTA is useful to detect neovascularization without injecting a contrast product, particularly in these patients who may have renal insufficiency.

Case presentation

A 28-year-old woman affected by C3 glomerulpathy was diagnosed with asymptomatic multiple bilateral PEDs during a routine ophthalmologic consultation. To better characterize the lesions, multimodal imaging was performed and included: optic coherence tomography (OCT), en-face OCT, OCTA, fluorescence and indocyanine angiography. The OCTA clearly identified vascular network rarefaction with decreased choriocapillary vascularization. It confirmed that PEDs associated with C3 glomerulonephritis are not vascularized, but rather of serous type.

Conclusions

Patients affected by C3 glomerulopathy can develop neovascular membranes as retinal complications of pigment epithelial detachments. Optical coherence angiography may be indicated to identify this complication, without injecting any contrast product that could produce further kidney damage.

Retinal findings in membranoproliferative glomerulonephritis

Purpose

To assess the evolution of retinal findings in patients with membranoproliferative glomerulonephritis (MPGN) by funduscopy, intravenous fluorescein angiography and optical coherence tomography.

Observations

Three women and one man were followed for a period of 1.5–37 years. Four patients (8 eyes) had drusen detected at first fundus exam at age 24, 29, 50 and 55. Three patients (6 eyes) had diffuse thickening of Bruch's membrane, and two patients (3 eyes) had detachment of the retinal pigment epithelium with serous retinal detachment. Drusen tended to widen over a period of 10-year follow-up in one case.

Conclusions and importance

Drusen remain the ocular stigmata for MPGN occuring at an early age. The retinal disease is progressive with gradual thickening of Bruch's membrane and occurrence of retinal pigment epithelium detachment.

THE ASSOCIATION BETWEEN CUTICULAR DRUSEN AND KIDNEY FUNCTION: A Population-Based Case-Control Study

PURPOSE

To determine the association between cuticular drusen (CD) and kidney function.

DESIGN

observational case-control study.

METHODS

SETTING

Population-based. Patients or Study Population: 53 participants with (CD) and 53 age- and sex-matched controls, selected from the Danish Rural Eye Study. Cuticular drusen participants were diagnosed using fluorescein angiography and controls were excluded if the patients were suspected of having CD on fundus photography or did not have an available estimated glomerular filtration rate.

MAIN OUTCOME MEASURES

creatinine and estimated glomerular filtration rate.

RESULTS

The mean estimated glomerular filtration rate of those with CD was 73.3 mL·min·1.73 m (95% confidence interval [CI]: 70.0-76.6) and 73.4 mL·minute·1.73 m (95% CI: 69.5-77.3) in controls. The difference was not significant (P: 0.970). The mean creatinine among those with CD was 72.8 μmol/L (69.3-76.4) and 73.5 μmol/L (95% CI: 69.3-77.6) among controls. The difference was not significant (P = 0.820).

CONCLUSION

The authors did not find an association between a (CD) diagnosis and decreased kidney function at a population level.

Microperimetric evaluation of macula in retinopathy of membranoproliferative glomerulonephritis type II: a case report

PURPOSE

To report on the microperimetric evaluation of the central visual field in a patient with retinopathy due to membranoproliferative glomerulonephritis.

METHODS

The central 20 degrees visual field was evaluated using fundus-related perimetry with (Nidek MP1) microperimeter in a patient with proven membranoproliferative glomerulonephritis type II, who had multiple drusen-like lesions involving the posterior pole of both eyes, with corresponding window defects on fundus fluorescein angiogram.

RESULTS

Static threshold perimetry of the central 20 degrees using a 10 dB threshold, Goldmann size II stimulus, with (Nidek-MP1) microperimeter showed reduction in retinal sensitivity in the parafoveal and in the temporal paramacular areas in both the eyes that had drusen-like lesions.

CONCLUSIONS

Early loss of function in retinopathy of membranoproliferative glomerulonephritis type II can probably be detected by fundus-related microperimetry.

Retinal function abnormalities in membranoproliferative glomerulonephritis type II

PURPOSE

To characterize retinal electrophysiologic and psychophysical abnormalities associated with membranoproliferative glomerulonephritis type II.

METHODS

Three adults with membranoproliferative glomerulonephritis type II were studied. Retinal function was measured psychophysically (automated perimetry, Farnsworth D-15 color vision testing, and dark adaptometry) and electrophysiologically (full-field flash electroretinography and electro-oculography).

RESULTS

Two symptomatic individuals had prominent drusenlike deposits and retinal pigment epithelial disturbances, findings characteristic of membranoproliferative glomerulonephritis type II retinopathy. These individuals had mild visual field and color vision abnormalities, prolonged dark adaptation, and delayed electroretinographic dark-adapted dim and bright flash responses of normal amplitude. The electro-oculogram of the most severely affected individual was abnormal. The third individual who was asymptomatic had the mildest fundus abnormalities and exhibited normal psychophysical and electrophysiologic responses.

CONCLUSIONS

Membranoproliferative glomerulonephritis type II retinopathy may be associated with symptomatic and measurable psychophysical and electrophysiologic abnormalities of retinal function.

Membranoproliferative glomerulonephritis type II associated with central serous retinopathy

Membranoproliferative glomerulonephritis type II is specifically associated with the presence of dense deposits in the basement membrane of Bruch's membrane, which result in lesions similar to basal laminar drusen, exudative drusen, and retinal pigment epithelial detachments. In advanced stages of this dense-deposit retinopathy, choroidal neovascularization may occur. We observed a 36-year-old patient with membranoproliferative glomerulonephritis type II who developed central serous retinopathy in the presence of specific dense-deposit-associated fundus lesions. The diffuse drusenlike dense deposits (at the level of Bruch's membrane) and associated retinal pigment epithelial detachments appear to contribute to the pathogenesis of central serous retinopathy. Thus changes in Bruch's membrane may be involved in the development of central serous retinopathy.

Posterior segment changes in membranoproliferative glomerulonephritis

Membranoproliferative glomerulonephritis is a renal disorder characterized by proliferation of cells and changes in the basement membrane of the glomerulus. The disease is divided into three subtypes: type I, characterized by the presence of subendothelial electrondense deposits; type II, characterized by deposition of electrondense material of unknown origin in the lamina densa of the glomerular basement membrane; and type III, characterized by lesions having both type I and type II qualities. Specific posterior segment changes have been reported with membranoproliferative glomerulonephritis type II. We examined three patients with membranoproliferative glomerulonephritis type II and two patients with type III disease. All three patients with type II disease had Bruch's membrane and retinal pigment epithelial changes, whereas both patients with type III disease had normal posterior segments.