Bilateral frosted branch angiitis as the presenting sign of antiphospholipid antibody syndrome

First clinical case series of frosted branch angiitis: A diagnostic algorithm is suggested

Key Clinical Message

FBA is a clinical diagnosis of a diverse spectrum, which needs a high index of suspicion to identify the possible specific etiologies. The zones of retinal involvement can help in predicting the final visual outcome. The proposed diagnostic algorithm facilitates meticulous evaluation and targeted treatment to improve the final visual outcome.

Abstract

Frosted branch angiitis is a clinical diagnosis of a diverse spectrum, which needs a high index of suspicion to identify the possible specific etiologies. We present a series of three cases of FBA with an attempt to formulate a diagnostic algorithm and refine the definition of FBA.

FROSTED BRANCH ANGIITIS ASSOCIATED WITH MIXED CONNECTIVE TISSUE DISEASE

PURPOSE

To present a case of frosted branch angiitis associated with an exacerbation of mixed connective tissue disease (MCTD).

METHODS

Single case report.

RESULTS

A 31-year-old woman presented with a flare of her long-standing MCTD after a change in her immunosuppressive medications. She developed blurred vision and floaters first in the left eye but eventually in both eyes. Fundoscopy showed patchy perivascular sheathing of tertiary branch venules surrounded by retinal hemorrhages characterized as frosted branch angiitis. The patient's MCTD symptoms and retinal vasculitis improved with continued immunosuppressive therapy. At 1-month follow-up, her visual acuity had improved to 20/20 bilaterally with complete resolution on fundoscopy.

CONCLUSION

To the authors' knowledge, this is the first report of frosted branch angiitis seen in association with MCTD. The improvement in the patient's visual acuity and fundoscopic findings in this case supports the role of immunosuppressive therapy to treat secondary frosted branch angiitis associated with an autoimmune condition such as MCTD. However, it is recommended that a comprehensive medical workup is performed to exclude an infective cause, particularly in immunocompromised patients.

Bilateral Frosted Branch Angiitis in Anti-phospholipid Antibody Syndrome

Purpose: We report a case of bilateral frosted branch angiitis caused by anti-phospholipid antibody syndrome.Case summary: A 60-year-old female complained of worsening vitreous floaters and decreased visual acuity in both eyes. The initial best-corrected visual acuity (BCVA) was 0.8 in the right eye and 0.05 in the left. On slit-lamp examination, inflammatory findings were observed in the anterior chamber and vitreous body of both eyes. On fundus examination, vascular sheathing in the shape of a frosted branch was observed in the posterior pole and peripheral retina in both eyes. Optical coherence tomography indicated macular edema in the left eye. Staining and leakage of dye along the vascular sheathing were observed in both eyes with fluorescein angiography. On suspicion of panuveitis, we conducted a blood test and started eye drops and oral steroid therapy. However, vitreous inflammation, macular edema, and vascular sheathing increased; thus, we proceeded with systemic steroid therapy. We conducted blood tests at 8-week intervals; lupus anticoagulant was negative but anticardiolipin antibody and anti- ß2 glycoprotein-I antibody were positive. We diagnosed the patient with bilateral frosted branch angiitis caused by anti-phospholipid antibody syndrome. During the follow-up period, the BCVA remained steady at 0.5 in the right eye and 0.3 in the left eye, without symptom recurrence.Conclusions: Bilateral frosted branch angiitis, a rare disease, is known to respond well to systemic steroid treatment. However, if accompanied by primary anti-phospholipid antibody syndrome, as in the case presented, it may have an atypical prognosis.

ACUTE FROSTED RETINAL PERIPHLEBITIS IN A PATIENT WITH MEDITERRANEAN FEVER

PURPOSE

To present a case of frosted branch periphlebitis in a young Armenian patient with familial Mediterranean fever.

METHODS

Case report.

RESULTS

A 37-year-old man presented with a unilateral decreased visual acuity and floaters for 4 days on the left eye (LE). Visual acuity was 20/20 in the right eye (RE) and 20/28 in the LE. Anterior segment and fundus examinations of the RE were normal. Slit-lamp examination of LE revealed a mild nongranulomatous anterior uveitis and vitritis. Intraocular pressure was 19 mmHg in the RE and 12 mmHg in the LE. Fundoscopy of the LE showed typical appearance of frosted branch periphlebitis with perivascular sheathing of the retinal veins and scattered retinal hemorrhages. Fluorescein angiography of the RE was normal. The LE showed optic disk and segmented vascular staining without macular leakage. Optical coherence tomography of the RE was normal; LE demonstrated a localized macular thickening and few intraretinal cysts. The detailed ophthalmologic history was negative. The general history and workup were significant for familial Mediterranean fever and a positive lupus anticoagulant. One week later, the fundus findings worsened with a severe decrease of visual acuity of the LE to 20/200. A single intravitreal (IVT) injection of bevacizumab was performed. Three weeks after injection, fundus findings progressively improved with a decrease of the macular thickening and an improvement of the visual acuity to 20/25. Clinical improvement continued up to the last visit (19 weeks after the injection) with a visual acuity that reached back 20/20 with no signs of active inflammation.

CONCLUSION

This case demonstrates a possible association between unilateral frosted branch periphlebitis and familial Mediterranean fever.

Current concepts in the diagnosis and management of antiphospholipid syndrome and ocular manifestations

Antiphospholipid syndrome (APS) is an autoimmune disorder associated with obstetrical complications, thrombotic complications involving both arteries and veins, and non-thrombotic manifestations affecting multiple other systems presenting in various clinical forms. Diagnosis requires the presence of antiphospholipid antibodies. The exact pathogenesis of APS is not fully known. However, it has recently been shown that activation of different types of cells by antiphospholipid antibodies plays an important role in thrombosis formation. Ocular involvement is one of the important clinical manifestations of APS and can vary in presentations. Therefore, as an ophthalmologist, it is crucial to be familiar with the ocular findings of APS to prevent further complications that can develop. Furthermore, the ongoing identification of new and specific factors contributing to the pathogenesis of APS may provide new therapeutic options in the management of the disease in the future.

Ophthalmologic manifestations in primary antiphospholipid syndrome patients: A cross-sectional analysis of a primary antiphospholipid syndrome cohort (APS-Rio) and systematic review of the literature

OBJECTIVE

There is a broad spectrum of eye involvement in antiphospholipid syndrome (APS). The majority of descriptions are presented as case reports that include mostly APS patients secondary to systemic lupus erythematosus (SLE), with no compelling evidence in primary APS (PAPS). This study aimed to describe ocular manifestations in our well-defined PAPS cohort (APS-Rio) and then perform a systematic literature review (SLR) of ocular manifestations in patients with APS or positivity to aPL without SLE.

METHODS

We retrospectively analyzed PAPS patients followed at our outpatient clinics. All patients fulfilled Sydney APS classification criteria (2006). We evaluated them for ocular symptoms and previous ocular diagnoses. Antiphospholipid antibodies and clinical APS manifestations were compared between patients with and without ocular manifestations. For the SLR, electronic databases were searched up to November 2019.

RESULTS

We studied 105 PAPS patients; 90.5% were female and 56.2% were Caucasian. We found ocular manifestations in 37.1% of our cohort. Thrombosis was the main criteria manifestation (95.2%) and lupus anticoagulant was the most prevalent antibody. Ophthalmologic diagnoses were present in 7 patients, with 5 having retinal vessels thromboses. Amaurosis fugax was the leading complaint, present in 30 patients. In the univariate analysis, amaurosis fugax was related to livedo (p = 0.005), Raynaud's phenomenon (p = 0.048) and the presence of anticardiolipin antibody (≥40 GPL/MPL) (p = 0.041). Hemianopia was associated with arterial hypertension (p = 0.049). In the multivariate analysis, the only association found was between livedo and amaurosis fugax (OR 4.09, 95%CI 1.5-11.11, p = 0.006). Our SLR incorporated 96 articles of ocular manifestations in patients with PAPS or positivity to aPL without SLE. Ocular findings varied from 5 to 88%, including anterior and posterior segments, orbital and neuro-ophthalmologic changes.

CONCLUSION

There is little evidence on ocular manifestations in PAPS. We described an association between livedo and amaurosis fugax. Prospective studies are needed to promote the best treatment and avoid blindness in PAPS patients.

Paraneoplastic frosted branch angiitis as first sign of relapsed Hodgkin lymphoma

Frosted branch angiitis (FBA) is a rare form of retinal vasculitis with typical perivascular edema taking the shape of frost on a tree branch. It was reported only twice as the initial presentation of Hodgkin lymphoma (HL). Here, we present the first case of paraneoplastic FBA as the initial sign of HL relapse in an elderly female.

Frosted branch angiitis with penetrating ocular trauma and retained intraocular foreign body

A 54-year-old male sustained ocular trauma with a projectile. Examination of the right eye revealed an intraocular foreign body (IOFB) adjacent to the optic nerve head, vitritis, vitreous hemorrhage, and translucent perivascular sheathing of the retinal vessels in all quadrants suggesting frosted branch angiitis (FBA). The patient underwent vitrectomy with removal of the IOFB and silicone oil tamponade under steroid cover. With continued use of systemic and topical steroids after surgery, complete resolution of FBA and improvement in vision were noted in a week. Prompt resolution of FBA after IOFB removal points toward a strong association between the presence of IOFB and FBA.