Ocular manifestations in patients with systemic sclerosis

Propensity-Matched Analysis of the Risk of Age-Related Macular Degeneration with Systemic Immune-Mediated Inflammatory Disease

PURPOSE

The pathogenesis of age-related macular degeneration (AMD) involves aberrant complement activation and is a leading cause of vision loss worldwide. Complement aberrations are also implicated in many systemic immune-mediated inflammatory diseases (IMIDs), but the relationship between AMD and these conditions remains undescribed. The aim of this study is to first assess the association between AMD and IMIDs, and then assess the risk of AMD in patients with specific IMIDs associated with AMD.

DESIGN

Cross-sectional study and cohort study.

SUBJECTS AND CONTROLS

Patients with AMD were compared with control patients with cataracts and no AMD to ensure evaluation by an ophthalmologist. Patients with IMIDs were compared with patients without IMIDs but with cataracts.

METHODS

This study used deidentified data from a national database (2006-2023), using International Classification of Diseases 10 codes to select for IMIDs. Propensity score matching was based on patients on age, sex, race, ethnicity, and smoking. Odds ratios were generated for IMIDs and compared between AMD and control patients. For IMIDs associated with AMD, the risk of AMD in patients with the IMID versus patients without IMIDs was determined utilizing a cohort study design.

MAIN OUTCOME MEASURES

Odds ratio of IMID, risk ratios (RRs), and 95% confidence intervals (CIs) of AMD diagnosis, given an IMID.

RESULTS

After propensity score matching, AMD and control cohorts (n = 217 197 each) had a mean ± standard deviation age of 74.7 ± 10.4 years, were 56% female, and 9% of patients smoked. Age-related macular degeneration showed associations with systemic lupus erythematosus (SLE), Crohn's disease, ulcerative colitis, rheumatoid arthritis (RA), psoriasis, sarcoidosis, scleroderma, giant cell arteritis, and vasculitis. Cohorts for each positively associated IMID were created and matched to control cohorts with no IMID history. Patients with RA (RR, 1.40; 95% CI, 1.30-1.49), SLE (RR, 1.73; 95% CI, 1.37-2.18), Crohn's disease (RR, 1.42; 95% CI, 1.20-1.71), ulcerative colitis (RR, 1.45; 95% CI, 1.29-1.63), psoriasis (RR, 1.48; 95% CI, 1.37-1.60), vasculitis (RR, 1.48; 95% CI, 1.33-1.64), scleroderma (RR, 1.65; 95% CI, 1.35-2.02), and sarcoidosis (RR, 1.42; 95% CI, 1.24-1.62) showed a higher risk of developing AMD compared with controls.

CONCLUSIONS

The results suggest that there is an increased risk of developing AMD in patients with RA, SLE, Crohn's disease, ulcerative colitis, psoriasis, vasculitis, scleroderma, and sarcoidosis compared with patients with no IMIDs.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A Comprehensive Review of Ocular Manifestations in Systemic Diseases

Ocular manifestations often serve as critical indicators of underlying systemic diseases, providing valuable diagnostic and prognostic information. This comprehensive review aims to elucidate the complex interplay between ocular symptoms and systemic conditions, emphasising the importance of early recognition and interdisciplinary collaboration in patient management. The review encompasses various systemic diseases, including cardiovascular, autoimmune, infectious, neurological, endocrine, hematologic, genetic, dermatologic, gastrointestinal, hepatic, renal, and connective tissue disorders, highlighting their specific ocular manifestations. Diagnostic approaches, including ophthalmologic examination techniques, imaging modalities, and laboratory tests, are discussed to enhance diagnostic accuracy. Furthermore, the review outlines current management and treatment strategies, emphasising the need for a multidisciplinary approach to care. Emerging therapies and future research directions are also explored, underscoring the necessity of continued innovation in this field. This review aims to improve clinical practices, promote integrative healthcare, and ultimately enhance patient outcomes by providing a detailed overview of ocular manifestations in systemic diseases.

Ocular Manifestation in Systemic Sclerosis-A Literature Review

Systemic sclerosis (SSc) is a chronic autoimmune connective tissue disease that affects more than 2 million people worldwide. It manifests through vasculopathy, an abnormal immunological response, and fibrosis leading to dysfunction of the multiple organs. The disease is categorized into two subtypes: limited cutaneous SSc and diffuse cutaneous SSc. Scleroderma can affect vital organs with respiratory, cardiac, renal, ocular, and dermatological complications. The ocular manifestations of the disease can occur in the anterior and posterior segments of the eye. Changes in the anterior segment related to the disease include eyelid skin remodeling, dry eye syndrome, and conjunctival abnormalities. The disease's impact on the posterior segment of the eye mostly causes pathologies in the retinal microcirculatory system and abnormalities in the optic nerve. This review provides detailed insights into ocular complications associated with scleroderma.

Retinal Vascular Abnormalities and Clinical Parameters in Systemic Sclerosis

Background: Systemic sclerosis is a complex autoimmune disease characterized by vasculopathy, fibrosis, and immune dysregulation. Ocular manifestations in these patients are increasingly recognized, suggesting potential correlations between systemic vascular abnormalities and ocular microvascular changes. Advancements in molecular immunology and imaging technology using ocular coherence tomography (OCT) have unveiled intricate pathways underlying possible disease pathogenesis. Understanding the interplay between retinal vascular abnormalities and molecular immunology parameters could provide insights into disease mechanisms and potential biomarkers. Purpose: The aim of this study was to investigate vascular abnormalities, detected with optical coherence tomography angiography (OCT-A), in systemic sclerosis patients and to find correlations between the severity of the disease detected with molecular immunology findings and OCT-A parameters. Methods: A group of 32 systemic sclerosis patients were compared with 9 healthy controls. Ganglion cell complex thickness (GCC), retina thickness of the fovea and parafovea, nerve fiber layer thickness (RNFL) and cup/disc area ratio were investigated using OCT. Vessel density (VD) of the superficial (SCP) and deep capillary plexus (DCP) of the whole macular area and ETDRS grid, size of the foveal avascular zone (FAZ) and vessel density of the radial peripapillary capillary plexus (RPCP) were evaluated using OCT-A. Modified Rodnan skin score (mRSS), capillaroscopy and disease duration were used to stage disease severity. Results: There was a statistically significant reduction in retina thickness of the fovea and parafovea, VD of the whole DCP, VD of the SCP and DCP in ETDRS grid in the patient group compared to controls (p < 0.001). The patients presented a significant enlargement of the FAZ (p 0.005). No significant correlation between OCT and OCT-A parameters and disease severity scores was found. Conclusions: OCT-A could represent a non-invasive tool to detect retinal microvascular damage in systemic sclerosis.

Macular choroidal thickness, volume, and vascularity index in patients with systemic sclerosis

PURPOSE

The aim of this study was to investigate choroidal parameters in patients with systemic sclerosis (SSc) using enhanced depth imaging spectral-domain optical coherence tomography (EDI-SD-OCT) and to determine their relationships with clinical variables and ocular features.

METHODS

Thirty-three patients with SSc and 40 controls were enrolled. The groups did not differ with regard to age, sex, and axial length. The mean choroidal thickness and volume were obtained in each conventional Early Treatment of Diabetic Retinopathy Study grid subfield. The choroidal vascularity index (CVI), which provides a quantitative analysis of vasculature by calculating the proportion of the luminal area (LA) to the total choroidal area (TCA), was determined.

RESULTS

Lower choroidal thickness and volume were observed in the SSc group. The CVI was significantly higher in SSc patients, whereas the TCA, LA, and stromal area were significantly lower in the SSc group; however, the significant difference of the stromal component was more pronounced than that of the luminal component. Regression analyses did not identify any clinical factors associated with the CVI (except Ca-blocker use), central macular thickness, or volume. No significant differences in choroidal parameters were found within the SSc subtypes (diffuse cutaneous systemic sclerosis (dcSSc) vs. limited cutaneous systemic sclerosis (lcSSc)), or between eyes stratified according to SSc pattern (early, active, or late) using nailfold capillaroscopy (p > 0.05 for all).

CONCLUSION

Our results, with notably higher CVI values, may shed new light on choroidal impairment in patients with SSc. Stromal involvement appeared to dominate the vascular component.

Retinal Microvasculature in Systemic Sclerosis Patients and the Correlation between Nailfold Capillaroscopic Findings and Optical Coherence Angiography Results

Background: The comparison of retinal perfusion in the eyes of patients with systemic sclerosis (SSc) and in healthy controls using optical coherence tomography angiography (OCTA). The correlation between nailfold capillaroscopy results and OCTA findings among SSc. Methods: The study enrolled 31 patients with systemic sclerosis and 41 healthy controls. OCTA was performed in both groups to assess the retinal vasculature in the superficial (SCP) and deep (DCP) capillary plexuses and the foveal avascular zone (FAZ) area. Nailfold capillaroscopy (NC) was performed in SSc patients and compared to the FAZ area and the superficial and the deep vessel density. Results: In the SSc group, the parafoveal vessel density in DCP was significantly higher in relation to the mean value (p < 0.0001) and in each quadrant of the macula (p < 0.0001) compared to healthy subjects (p < 0.0001). The patients with early scleroderma patterns in capillaroscopy had a larger superficial and deep FAZ (p = 0.0104, p = 0.0076, respectively) than those with active and late patterns. There was a statistically significant difference in the FAZ when comparing early to active (p < 0.0001) and early to late scleroderma patterns (p < 0.0001). A statistically significant difference was found in the type of interstitial lung disease and the deep FAZ area (p = 0.0484). SSc patients with nonspecific interstitial pneumonia (NSIP) had a larger FAZ than those with usual interstitial pneumonia (UIP) (p = 0.0484). Moreover, NSIP cases had a higher parafoveal mean superficial vessel density than those with UIP (p = 0.0471). Conclusions: Our investigation showed that the peripheral microvascular system correlates with ocular microcirculatory impairment. The results indicate the important role of OCTA in the diagnosis, monitoring, and prognosis of microvascular changes in SSc.

Ocular Involvement in Systemic Sclerosis: Updated Review and New Insights on Microvascular Impairment

Systemic sclerosis (SSc) is a chronic multisystemic disease characterized by immunological activation, diffuse vasculopathy, and generalized fibrosis exhibiting a variety of symptoms. A recognized precursor of SSc is Raynaud's phenomenon, which is part of the very early disease of systemic sclerosis (VEDOSS) in combination with nailfold videocapillaroscopy (NVC) impairment. The pathophysiology of ocular involvement, alterations in internal organs, and body integumentary system involvement in SSc patients are complicated and poorly understood, with multiple mechanisms presumptively working together. The most prevalent ocular symptoms of SSc are abnormalities of the eyelids and conjunctiva as well as dry eye syndrome, due to fibroblasts' dysfunction and inflammation of the ocular surface. In particular, lagophthalmos, blepharophimosis limitation of eyelid motion, eyelid telangiectasia, and rigidity or tightening of the lids may affect up to two-third of the patients. In addition, reduction in central corneal thickness, iris defects and higher rates of glaucoma were reported. In the first reports based on retinography or fluorescein angiography, about 50% of SSc patients showed signs of vascular disease: peripheral artery occlusion, thinning of retinal pigment epithelium and choroidal capillaries, ischemic areas surrounded by intraretinal extravasation and microaneurysms, and peripheral capillary non-perfusion. Successively, thanks to the advent of optical coherence tomography angiography (OCTA), several studies highlighted significant impairment of either the choriocapillaris and retinal vascular plexuses, also correlating with NVC involvement and skin disease, even in VEDOSS disease. Given the sensitivity of this technique, ocular micro-vasculopathy may act as a tool for early SSc identification and discriminate between disease stages.

Paracentral acute middle maculopathy in systemic sclerosis and subsequent branch retinal artery occlusion

Purpose

We report a case of systemic sclerosis-associated paracentral acute middle maculopathy (PAMM) in a young woman who subsequently developed branch retinal artery occlusion.

Observations

A 22-year-old woman presented with a paracentral scotoma. Optical coherence tomography (OCT) revealed bilateral paracentral acute middle maculopathy. Upon systemic examination, she was diagnosed with systemic sclerosis (SSc). She subsequently developed branch retinal artery occlusion despite vasodilator medications. After the prescription of aspirin, she did not experience a new event for one year.

Conclusion and importance

This case illustrates that SSc may affect the retinal vascular system and vision and cause PAMM. The optimal prophylaxis for patients with recurrent retinal events should be investigated in future studies.

Ocular involvement in rheumatic diseases

Rheumatic diseases are associated with a significant decline in quality of life, which is not only related to the progression of the underlying disease but also to the development of coexisting conditions. One of the possible complications in this group of diseases is ocular involvement. Impaired vision is strongly associated with a significant decline in quality of life and can also exacerbate problems related to physical functioning. Consequently, it can lead to serious complications in the treatment of the underlying disease. Additionally, from a clinical point of view, it is also important to note that ocular diseases may precede the occurrence of inflammatory joint and spinal diseases, as well as organ involvement in systemic connective tissue disorders. Therefore, paying attention to ocular symptoms can help in early diagnosis and thus improve patient prognosis. For the aforementioned reasons, ocular diseases should be carefully considered in routine rheumatologic practice.

Peripapillary choroidal vascularity index and thickness in patients with systemic sclerosis

Introduction

Patients with systemic sclerosis (SSc) present an increased risk of developing glaucomatous optic neuropathy (GON). We investigated peripapillary choroidal parameters and peripapillary retinal nerve fiber layer (RNFL) thickness using spectral domain optical coherence tomography (SD-OCT) to determine the relationships of these factors with clinical variables.

Methods

A total of 33 patients with SSc were enrolled and compared to 40 controls. After obtaining circular scans around the optic disc, the global and quadrant peripapillary choroidal thickness (pCT) and RNFL thickness were measured. Additionally, the peripapillary choroidal vascularity index (pCVI), which allows for a quantitative analysis of the choroidal vasculature, was determined.

Results

No significant differences were found in pCT and RNFL thickness between patients with SSc and controls, or within SSc subtypes (diffuse cutaneous systemic sclerosis (dcSSc) compared to limited cutaneous systemic sclerosis (lcSSc)) (p > 0.05). The pCVI was significantly lower in patients with SSc than in control subjects (64.25 ± 1.94 vs.65.73 ± 2.12, p < 0.001).

Conclusion

Our results suggest that the statistically significant decrease in pCVI in patients with SSc compared to the control group is probably due to a decrease in the vascular layer, which would partially explain an increased risk of GON in patients with SSc.

The Function of Retinal Thickness and Microvascular Alterations in the Diagnosis of Systemic Sclerosis

In this study, we aim to investigate retinal thickness (RT) and superficial vascular density (SVD) differences between patients with systemic sclerosis (SSc) and healthy controls (HCs) by optical coherence tomography angiography (OCTA). Sixteen patients with a definitive SSc diagnosis without clinical signs of retinopathy and 16 normal control subjects were recruited. All individuals underwent OCTA scanning to assess macular RT and SVD. We divided each image into nine subregions as the early treatment diabetic retinopathy study (ETDRS). Visual acuity (VA) was considerably different between patients with SSc (32 eyes) and control subjects (32 eyes) (p < 0.001). Compared to the control group, individuals with SSc had decreased inner RT in inner superior, outer superior, outer temporal, inner temporal, center, and inner nasal regions (p < 0.05). Outer RT was decreased in the outer and inner temporal regions, and full RT was decreased in the regions of outer superior, inner superior, inner temporal, and outer temporal, in comparison to the control group (p < 0.05). Patients with SSc had significant reduction of SVD in the inner and outer of both superior and temporal, besides outer nasal regions than controls. (p < 0.05). Moreover, SVD was significantly associated with the outer temporal region of patients suffering from SSc (p < 0.05). Diagnostic Sensitivity of RT and SVD of Inner Superior Regions in SSc, as indicated by areas under curves of the Receiver Operating Characteristic (ROC), were 0.874 (95% CI: 0.786-0.962) and 0.827 (95% CI: 0.704-0.950), respectively. In conclusion, VA may be affected by RT variations inside the macula in patients with SSc. Measuring RT with OCTA could be a useful predictor of early diagnosis.

Evaluation of choroidal vascularity index in systemic sclerosis patients

OBJECTIVE

To investigate the comparison of choroidal vascularity index (CVI) between patients with systemic sclerosis and healthy individuals.

METHODS

This study was designed prospective non-randomized cross-sectional study. Eighty-six eyes (43 patients) with limited cutaneous systemic sclerosis (lcSSc), 60 eyes (30 patients) with diffuse cutaneous systemic sclerosis (dcSSc) and 60 eyes (30 subjects) of age-and sex-matched healthy individuals were recruited. Subfoveal choroidal thickness, CVI and modified Rodnan skin score (mRSS) were evaluated. Enhanced depth imaging- optical coherence tomography scans were binarized using Niblack's autolocal threshold and CVI was determined as the luminal choroidal area/total choroidal area ratio.

RESULTS

The mean CCT values were 268.00±68.59 µm, 286.90±70.88 µm, 321.73±94.13 µm in lcSSc group, dcSSc group and control group, respectively. The mean CVI was 61.84±2.84% in lcSSc group, 54.62±5.84% in dcSSc group and 62.41±4.13% in control group (p=0.001). The mean CVI of the SSc patients was 58.91±5.58 and there was significant difference between control group (p<0.001). The mean mRSS was 3.84±2.50 in lcSSc group and 14.07±6.81 in dcSSc group (p<0.001). There was a statistically significant negative correlation between mRSS and CVI (r=-0.448, p<0.001) CONCLUSION: Choroidal vascularity index provides valuable information to monitor the disease progression and lower CVI values seem to be related to the disease severity in patients with systemic sclerosis.

Predictors for Dry Eye Diseases in Patients with Systemic Sclerosis

Purpose

To evaluate the prevalence of dry eye disease (DED) in patients with both limited and diffuse subtypes of systemic sclerosis (SSc) and to determine the predictive factors associated with the occurrence of DED.

Patients and Methods

This was a prospective consecutive cross-sectional study of patients with SSc. Each patient underwent a comprehensive ophthalmological evaluation. The Ocular Surface Disease Index (OSDI) was used to assess the symptoms of DED. Tear break up time (TBUT), Schirmer I and ocular surface staining (OSS) were used for objective tests. Patients were diagnosed DED using the DEW II diagnostic method which included both symptom and objective tests. The collected data of patients with and without DED were compared to find out possible associated factors. Logistic regression analysis was used to determine the effects of these factors.

Results

Eighty-four SSc patients (25 limited and 59 diffuse subtypes) were studied. The prevalence of DED in SSc patients was 52.38%. The OSDI, tear break up time (TBUT), Schirmer I and ocular surface staining (OSS) were not significantly different between SSc subtypes. Among the 46 symptomatic patients, DED was noted in 44 (52.38%). Most patients (61.4%) were mixed aqueous deficiency-evaporative dry eye type (both TBUT and Schirmer I test positive). The mean age and the median of disease duration in DED patients were higher than those without DED with statistically significant difference (P = 0.004 and 0.019).

Conclusion

DED was common in patients with SSc. The predictors for the occurrence of DED were older age and longer disease duration. Therefore, OSDI and objective tests for DED should be evaluated in all SSc patients, particularly those with older age and longer disease duration.

Therapeutic potential of galectin-1 and galectin-3 in autoimmune diseases

Galectins are a highly conserved protein family that binds to β-galactosides. Different members of this family play a variety of biological functions in physiological and pathological processes such as angiogenesis, regulation of immune cell activity, and cell adhesion. Galectins are widely distributed and play a vital role both inside and outside cells. It can regulate homeostasis and immune function in vivo through mechanisms such as apoptosis. Recent studies indicate that galectins exhibit pleiotropic roles in inflammation. Furthermore, emerging studies have found that galectins are involved in the occurrence and development of autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), type 1 diabetes (T1D) and systemic sclerosis (SSc) by regulating cell adhesion, apoptosis, and other mechanisms. This review will briefly discuss the biological characteristics of the two most widely expressed and extensively explored members of the galectin family, galectin-1 and galectin-3, as well as their pathogenetic and therapeutic roles in autoimmune diseases. These information may provide a novel and promising therapeutic target for autoimmune diseases.