Retinal vasculitis in systemic lupus erythematosus: an indication of active disease

Various Ocular Manifestations in Systemic Lupus Erythematosus: A Case Series

Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disorder with various systemic and ocular clinical manifestations. In patients with SLE, central retinal vein and artery occlusion, choroidopathy, and occlusive vasculitis are among the most significant and clinically relevant ocular manifestations, although they do not commonly occur. We present a case series of three SLE patients of different races and genders who developed ocular-related clinical features of SLE during the course of their systemic disease. The clinical outcomes of each patient were different, affecting their vision in bilateral eyes, with some patients having better visual recovery while others having permanently poor vision. These outcomes were not significantly related to the patients' age, gender, or race.

[Clinical and immunological characteristics of systemic lupus erythematosus with retinopathy]

OBJECTIVE

To investigate the clinical and immunological characteristics of systemic lupus erythematosus (SLE) with retinopathy.

METHODS

Fifty SLE patients with retinopathy without hypertension and diabetes (retinopathy group) who were hospitalized in the Peking University People's Hospital from January 2009 to July 2022 were screened. Fifty SLE patients without blurred vision during the course of the SLE and without retinopathy in the fundus examinations (non-retinopathy group) matched for sex and age were selected. Their clinical manifestations, laboratory tests and lymphocyte subsets were statistically analyzed.

RESULTS

The most common fundus ocular change of the SLE patients with retinopathy was cotton-wool spots (33/50, 66.0%), followed by intraretinal hemorrhage (31/50, 62.0%). Retinopathy could occur at any stage of SLE duration, with a median of 1 year (20 days to 30 years). The proportion of lupus nephritis (72.0% vs. 46.0%, P=0.008) and serositis (58.0% vs. 28.0%, P=0.002) in the retinopathy group were significantly higher than those in the non-retinopathy group. The proportion of neuropsychiatric systemic lupus erythematosus (NPSLE) in the retinopathy group was higher, but there was no significant difference between the two groups. Compared with the non-retinopathy group, the proportion of positive anti-cardiolipin antibody (30.0% vs. 12.0%, P=0.027), the SLEDAI score (median 22.0 vs. 10.5, P < 0.001), erythrocyte sedimentation rate (P < 0.001), C-reactive protein (P=0.019) and twenty-four hours urine total protein level (P=0.026) in the retinopathy group were significantly higher, and the hemoglobin level was significantly lower [(91.64±25.18) g/L vs. (113.96±18.57) g/L, P < 0.001]. The proportion of CD19⁺ B cells in peripheral blood of the patients with SLE retinopathy was significantly increased (P=0.010), the proportion of CD4⁺ T cells was significantly decreased (P=0.025) and the proportion of natural killer (NK) cells was lower (P=0.051) when compared with the non-retinopathy group.

CONCLUSION

Retinopathy in SLE suggests a higher activity of SLE disease with more frequent hematologic and retinal involvement. It is recommended to perform fundus examination as soon as a patient is diagnosed with SLE. SLE patients with retinopathy may have stronger abnormal proliferation of B cells, and aggressive treatment should be applied to prevent other important organs involvement.

Occlusive retinal vasculitis: novel insights into causes, pathogenesis and treatment

PURPOSE OF REVIEW

Occlusive retinal vasculitis (ORV) has a large differential diagnosis and varied therapeutic approaches. This review highlights existing and novel causes and treatment options for ORV.

RECENT FINDINGS

Mutations in CAPN5, TREX1, and TNFAIP3 have been associated with dominantly inherited forms of ORV. Various intraocular therapeutics have been shown to occasionally cause ORV; the most recent medications associated with ORV are vancomycin and brolucizumab. In cases of ORV linked to Behçet's disease, clinical trials support the use of tumor necrosis factor alpha inhibitors.

SUMMARY

Identification of the underlying etiology of ORV is critical to help guide treatment. Treatment in ORV involves both treatment any underlying infection or autoimmune condition, cessation of the any offending causative agent and local treatment of neovascular complications.

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.

Optical Coherence Tomography Angiography Biomarkers of Retinal Thickness and Microvascular Alterations in Sjogren's Syndrome

Purpose

To investigate the differences of retinal thickness (RT) and superficial vascular density (SVD) between patients with Sjogren's syndrome (SS) and healthy controls (HCs) using optical coherence tomography angiography (OCTA).

Methods

Individuals with SS and healthy controls were enrolled (n = 12 per group). An en-face OCTA scan was performed on each eye. Images were segmented into 9 subregions and macular RT and SVD were measured and compared between the 2 groups.

Results

Visual acuity (VA) differed significantly between patients with SS (24 eyes) and controls (24 eyes) (p < 0.001). In patients with SS, inner RT was reduced in the inner superior region, outer RT was reduced in the outer nasal (ON) region, and full RT was reduced in the ON region compared with the control group (p < 0.05). RT was negatively correlated with serum IgG level in the outer and full retina at ON regions (p < 0.05). SVD in the inner nasal, ON, and inner temporal regions was significantly lower in patients with SS than in control subjects (p < 0.05). SVD was positively correlated with full RT in the ON region in patients with SS (p < 0.05). The areas under the receiver operating characteristic (ROC) curves for the diagnostic sensitivity of outer RT and full RT in the ON region for SS were 0.828 (95% CI: 0.709–0.947) and 0.839 (95% CI: 0.715–0.963), respectively.

Conclusions

In patients with SS, retinal thinning in the macular area—which affects vision—can also reflect the severity of dry eyes in SS and has clinical value for assisted imaging diagnosis.

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.

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.

Anti-recoverin antibodies indicate fundus abnormalities in systemic lupus erythematosus

OBJECTIVES

Lupus fundus abnormalities are a sight-threatening complication of systemic lupus erythematosus (SLE) and its pathogenesis remains to be studied. The aim of this study was to assess the clinical characteristics associated with the presence of anti-recoverin antibodies in patients with SLE, especially those with fundus abnormalities.

METHODS

Seventy-six participants were enrolled, including 21 patients with fundus abnormalities (fundus group), 30 patients without fundus abnormalities (non-fundus group) and 25 healthy individuals. Serum anti-recoverin antibody levels were measured using enzyme-linked immunosorbent assay, and clinical and laboratory data were obtained from medical records.

RESULTS

Compared with the non-fundus group, the fundus group had a higher incidence of hematuria (p < 0.05). The Systemic Erythematosus Disease Activity Index (SLEDAI) score in the fundus group was significantly higher than the non-fundus group (21.48 ± 8.06 versus 10.80 ± 5.74, p < 0.001). The levels of serum anti-recoverin antibodies in the fundus group were significantly higher than the non-fundus group (p = 0.029) or the healthy control group (p = 0.011). Anti-recoverin-negative and -positive patients differed on a number of clinical parameters, including incidence of fever, rash, antinuclear antibody, anti-dsDNA antibody, erythrocyte sedimentation rate, immunoglobulin G, complement C3 and complement C4. The average SLEDAI score of anti-recoverin-positive patients was significantly higher than anti-recoverin-negative patients (17.73 ± 8.11 versus 12.56 ± 8.37, p < 0.05).

CONCLUSIONS

Anti-recoverin antibodies were related to higher disease activities in SLE, especially those with fundus abnormalities, suggesting that anti-recoverin antibodies may play an important role in the pathogenesis of fundus abnormalities in SLE.

When systemic lupus erythematosus affects vision: a rare presentation of this condition

A 23-year-old woman with fever, oral ulcers, arthalgias and weight loss of 2-week duration suddenly developed blurred vision, with reduced visual acuity, cotton wool exudates and retinal vascular tortuosity. Laboratory testing revealed anaemia, lymphopaenia, positive antinuclear antibody and high anti-dsDNA antibody titre with low complement components. There was no evidence of infection, clinching the diagnosis of lupus retinopathy. Steroid therapy alone was highly effective and was also accompanied by a normalisation of haemoglobin and lymphocyte counts, after which azathioprine was added. Hydroxychloroquine was introduced after resolution of retinal changes. Immunosuppressive therapy was progressively tapered over the course of 12 months and then discontinued, and the patient remains in remission 48 months after the initial presentation. Our patient exemplifies a very rare manifestation of systemic lupus erythematosus. We emphasise the importance of its early detection and complexity of treatment in order to reduce visual morbidity.

Unique changes in the retinal microvasculature reveal subclinical retinal impairment in patients with systemic lupus erythematosus

PURPOSE

To determine the changes of the microvasculature and microstructure in the inner intra-retinal layers in systemic lupus erythematosus (SLE) patients without lupus retinopathy (LR).

METHODS

Thirty-two SLE patients (58 eyes) without LR (NLR), 14 patients (22 eyes) with LR and 50 healthy subjects (50 eyes) were enrolled. Spectral domain optical coherence tomography equipped with Angiovue was used to obtain three-dimensional retinal thickness maps and microvascular images of the superficial and deep retinal capillary plexuses (SRCP/DRCP) around the macula. Quantitative analyses were performed using a custom automated algorithm. Disease activity of patients was assessed using the SLE disease activity index (SLEDAI).

RESULTS

Retinal capillary skeleton density of the SRCP in SLE patients without LR was significantly lower than the controls in almost all regions, which further decreased in the LR group (P < .05). No significant changes were evident in DRCP of the NLR group (P > .05). The inner retina in the LR group was significantly thinner than the controls in most regions, though there were only a few regions that were different between the NLR and the control groups (P < .05). There were significant differences of the SLEDAI scores between the two SLE groups.

CONCLUSION

Significantly lower density in SRCP and regional thinning in inner retina were observed in the SLE patients without clinical fundus changes. OCT equipped with Angiovue might be useful in evaluating the microvascular and microstructural disorders of the inner retinal layers in SLE patients, which may contribute a quantitative approach to the early diagnosis and progression of LR.

Swept source optical coherence tomography angiography in patients treated with hydroxychloroquine: correlation with morphological and functional tests

PURPOSE

To evaluate swept source optical coherence tomography angiography (SS-OCTA) in patients treated with hydroxychloroquine (HCQ) for more than 5 years and to compare results with the tests currently recommended for screening of HCQ retinopathy.

METHODS

In this controlled pilot study, consecutive patients treated with HCQ for more than 5 years underwent SS-OCTA, SS-OCT B-scan and en-face C-scan, fundus autofluorescence (FAF), 10-2 automated visual field (AVF) testing and multifocal electroretinography (mfERG). On SS-OCTA, evaluation of the retinal superficial capillary plexus, middle capillary plexus, and deep capillary plexus (DCP) and the choriocapillaris (CC) was obtained.

RESULTS

We included 10 patients under HCQ treatment (20 eyes, mean age 38.91±11.73 years) and 18 healthy control patients (36 eyes, mean age 38.87±8.6 years). Mean duration of HCQ treatment was 10.0±3.25 (5-15) years and HCQ cumulative dose/body weight was 15.86±5.56 g/kg. The HCQ group showed a reduction of the vessel density in the 1 mm central, in the nasal and temporal subfields of DCP and in the 1 mm central subfield of CC, an increased foveal avascular zone in the three capillary plexuses, a greater frequency of CC flow voids and a reduced foveal choroidal thickness (p<0.05). Best-corrected visual acuity (BCVA), mfERG, SS-OCT B-scan and C-scan, AVF and FAF were normal in 20/20 eyes (100%).

CONCLUSIONS

In patients treated with HCQ for more than 5 years, choroidal thinning and flow abnormalities at SS-OCTA in the retinal capillary plexuses and CC may be observed even if BCVA, FAF, mfERG, AVF and SS-OCT are normal.

Lupus retinopathy: a marker of active systemic lupus erythematosus

Retinopathy in the context of systemic lupus erythematosus (SLE) is associated with severe disease and poorer prognosis. We studied retinopathy in our cohort of Indian lupus patients. Four hundred and thirty-seven patients fulfilling the Systemic Lupus International Collaborating Clinics-American College of Rheumatology-2012 criteria, attending the department of Clinical Immunology were enrolled under this cross-sectional study. A comprehensive clinical (including ophthalmological) examination and immunological profile were performed. Retinopathy was defined if cotton-wool spots, haemorrhages, vasculitis, retinal detachment or optic disc changes as papilledema, optic atrophy were present. Disease activity was assessed using SLE disease activity index (SLEDAI). Mean age of participants was 28.06 ± 9.7 years (93.1% females); median disease duration 12 months (Interquartile range-IQR 6.36). Forty-five (10.3%) had SLE associated retinopathy. Autoimmune haemolytic anaemia [31.1 vs 14.5%, p value 0.004, odd's ratio-OR (95% confidence interval-CI) 2.65 (1.33-5.29)], serositis [33.3 vs 18.9%, p value 0.023, OR (CI) 2.14 (1.11-4.10)], lupus nephritis [62.2 vs 40.8%, p value 0.006, OR (CI) 2.38 (1.26-4.50)], seizures [28.9 vs 12.8%, p value 0.004, OR (CI) 2.77 (1.36-5.65)] and median SLEDAI score (24 vs 12, p < 0.01) were significantly higher in those with retinopathy. On adjusted binary logistic regression, autoimmune hemolytic anemia, lupus nephritis and presence of antibodies to Smith antigen were predictors for retinopathy. Retinopathy is common in SLE, a marker of active disease with frequent renal involvement and should be screened for in all patients with lupus.

Ocular manifestations in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) can involve many parts of the eye, including the eyelid, ocular adnexa, sclera, cornea, uvea, retina and optic nerve. Ocular manifestations of SLE are common and may lead to permanent blindness from the underlying disease or therapeutic side effects. Keratoconjunctivitis sicca is the most common manifestation. However, vision loss may result from involvement of the retina, choroid and optic nerve. Ocular symptoms are correlated to systemic disease activity and can present as an initial manifestation of SLE. The established treatment includes prompt systemic corticosteroids, steroid-sparing immunosuppressive drugs and biological agents. Local ocular therapies are options with promising efficacy. The early recognition of disease and treatment provides reduction of visual morbidity and mortality.