Idiopathic retinitis, vasculitis, aneurysms, and neuroretinitis (IRVAN): new observations and a proposed staging system

PURPOSE

To review the clinical features, disease progression, and effects of treatment on idiopathic retinitis, vasculitis, aneurysms, and neuroretinitis (IRVAN).

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Ten patients with IRVAN originally reported in 1995 and 12 additional patients identified since the original series.

INTERVENTION

Patients in the series had testing that may have included fluorescein angiography, indocyanine green angiography, and systemic evaluation. Treatments included panretinal laser photocoagulation, cryotherapy, vitrectomy surgery, and injection of periocular or intravitreal steroids.

MAIN OUTCOME MEASURES

Initial visual acuity (VA), initial stage at diagnosis, clinical course, surgical intervention, final VA, and complications of disease.

RESULTS

A total of 44 eyes of 22 patients were studied; 9 eyes had reached stage 1 or 2 disease at last follow-up, 17 had reached stage 3, and 12 had reached stage 4 or 5. At the time of last follow-up, 14 eyes had maintained 20/20 vision, 15 had between 20/40 and 20/200 vision, and 9 had 20/300 vision or worse. Later stages of retinal ischemia are associated with worse VA. Thirty-two of 38 followed eyes were treated. Twenty-five were treated initially with panretinal laser photocoagulation. The clinical course of each eye after initiation of panretinal laser photocoagulation was evaluated with respect to the final VA and stage of ischemic retinopathy at the initiation of treatment. Panretinal laser photocoagulation was initiated in 3 eyes at stage 2, 16 at stage 3, 5 at stage 4, and 1 at stage 5. Seven eyes underwent grid laser retinal photocoagulation of the macula for macular edema.

CONCLUSIONS

Idiopathic retinitis, vasculitis, aneurysms, and neuroretinitis is an isolated retinal vascular disease that can progress rapidly to severe vision loss due to ischemic sequelae despite treatment with panretinal laser photocoagulation. Based on our review of the largest cohort of IRVAN patients, early panretinal laser photocoagulation should be considered when angiographic evidence of widespread retinal nonperfusion is present, and before (or shortly after) the development of neovascularization. A functional staging system is proposed to improve treatment paradigms.

Functional outcome and prognostic factors in 304 eyes managed by retinectomy

BACKGROUND

This study was undertaken to relate the anatomic and functional results of patients who underwent retinectomy for complex retinal detachment (RD) to preoperative prognostic variables.

METHODS

Three hundred and four eyes of 302 patients whose surgery involved retinectomy were included in the analysis. All eyes had established proliferative vitreoretinopathy (PVR grade C). The main outcome measures were (1) postoperative visual acuity of 6/24 or better, (2) status of the retina at the end of follow-up, and (3) incidence of hypotony whilst under review.

RESULTS

PVR was secondary to rhegmatogenous RD in 237 eyes (78%), posterior trauma in 51 eyes (16.8%), tractional RD in vasoproliferative vasculitides in 12 eyes (4%), acute retinal necrosis in 2 eyes and endophthalmitis in 2 eyes. Complete reattachment rate after one operation was 51%, with final complete reattachment success rate of 72%. The visual acuity improved in 138 eyes (45%), remained the same in 73 eyes (24%) and became worse in 89 cases (29%). Postoperative visual acuity of 6/24 or better was significantly associated with preoperative vision, the duration of silicone oil tamponade, silicone oil removal and retinectomy size. There was also some evidence of association between visual outcome and the number of clock hours of retinal detachment. Final retinal attachment was significantly associated with silicone oil removal and preoperative vision, and final hypotony was significantly associated with silicone oil removal. The incidence of sympathetic ophthalmia in our study was 0.09% (one case).

CONCLUSIONS

Good functional outcome is possible following retinectomy surgery despite advanced pathology and often multiple surgical procedures. Retinal redetachment as a result of reproliferation and hypotony appear to be the main reasons for anatomical and functional failure. The clinical features we have identified as good indicators for improved final visual acuity such as shorter tamponade duration, removal of silicone oil, smaller retinectomy size, fewer previous operations and better preoperative vision are surrogate markers of less advanced PVR and should prompt retinal surgeons to consider retinectomy at an earlier stage in the process of PVR development. Clinicians should be aware of the small risk of sympathetic ophthalmia from complex retinal surgery.

Endothelial dysfunction and low-grade inflammation and the progression of retinopathy in Type 2 diabetes

AIMS

To study whether microalbuminuria, endothelial dysfunction and low-grade inflammation are associated with the presence and progression of diabetic retinopathy.

METHODS

Patients with Type 2 diabetes (n = 328) attending a diabetes clinic were followed for 10 years and examined annually during the last 7 years. Retinopathy was assessed after pupillary dilatation by direct ophthalmoscopy (baseline) and two-field 60 degrees fundus photography (follow-up). Urinary albumin excretion, and markers of endothelial function (von Willebrand factor, tissue-type plasminogen activator, soluble E-selectin (sE-selectin), and soluble vascular cell adhesion molecule 1) and inflammatory activity (C-reactive protein and fibrinogen) were determined.

RESULTS

The prevalence of retinopathy was 33.8%. The median diabetes duration at baseline was 7 years (interquartile range 2-12 years). The highest tertiles of baseline urinary albumin excretion and glycated haemoglobin (HbA(1c)) were associated with prevalent retinopathy: odds ratio (OR) 95% confidence interval (CI) 2.80 (1.44-5.46) and 2.19 (1.11-4.32), respectively. Progression of retinopathy occurred in 188 patients. The second and third tertiles of baseline sE-selectin were associated with progression of retinopathy [1.44 (1.04-2.01) and 1.61 (1.19-2.18)] but not independently of HbA(1c). None of the other markers was significantly associated with the presence or progression of retinopathy. High baseline HbA(1c) was significantly associated with progression of retinopathy: 1.65 (1.21-2.25).

CONCLUSIONS

In this population of patients with Type 2 diabetes who attended a diabetes clinic, there was some evidence for a role of endothelial dysfunction in the progression of retinopathy. We could not demonstrate a role for low-grade inflammation. Our study emphasizes the importance of glycaemic control in the development and progression of retinopathy.

Full panretinal photocoagulation and early vitrectomy improve prognosis of retinal vasculitis associated with tuberculoprotein hypersensitivity (Eales' disease)

BACKGROUND/AIMS

Eales' disease is an uncommon vasoproliferative retinal disease affecting otherwise healthy young men that is characterised by obliterative retinal periphlebitis, with sequelae such as recurrent vitreous haemorrhage and traction retinal detachment. This study was undertaken to determine whether visual prognosis of Eales' disease could be improved by appropriate medical and surgical treatment.

METHODS

The authors retrospectively studied 30 patients (46 eyes) who were treated from 1992 to 2001. Recorded data included patient age, sex, race, medical history, medications, results of the ophthalmological examination, results of diagnostic laboratory evaluation, and details of systemic and surgical treatments. The mean follow up was 10.6 months.

RESULTS

19 patients (23 eyes) who presented with active periphlebitis received systemic steroids and antituberculous therapy. Extensive full panretinal photocoagulation was performed in 21 eyes that presented with new vessel formation and peripheral capillary closure with or without vitreous haemorrhage. Vitrectomy and endolaser panretinal photocoagulation was necessary in 15 eyes, for severe non-clearing vitreous haemorrhage in 11 eyes and vitreous haemorrhage with traction retinal detachment in four eyes. Complete regression of the disease was achieved in all eyes. Vitrectomy resulted in a significant visual improvement with 14 of the 15 eyes (93.3%) achieving > or =20/200 visual acuity. Overall, the distribution of visual acuities among eyes improved from presentation to final follow up, with 36.4% of eyes having 20/40 or better acuity at presentation compared with 63.6% of eyes by final follow up.

CONCLUSIONS

These results suggest that aggressive treatment of Eales' disease with systemic steroids and antituberculous therapy, full panretinal photocoagulation and early vitrectomy, when necessary, may result in improving the anatomic and visual outcome.

Retinal vasculitis

Retinal vasculitis represents a group of diseases characterized by inflammation affecting the retinal vasculature. It is an uncommon disorder that may occur as an isolated disease or more commonly in association with other ocular diseases or a variety of systemic diseases. With a wide variety of disease associations, a search for an underlying etiology should be undertaken based on a meticulous history, review of systems, and physical examination. The laboratory evaluation of patients with retinal vasculitis is an essential component of the work-up to facilitate detection of any underlying disease or to establish a limited differential diagnosis. The management of infectious causes of retinal vasculitis consists of antimicrobial therapy while noninfectious retinal vasculitis is managed with corticosteroids and/or immunosuppressive agents. Because retinal vasculitis is an uncommon disease, there are only a limited number of publications over the past year related to this topic.

Acute posterior multifocal placoid pigment epitheliopathy associated with a systemic necrotizing vasculitis

PURPOSE

The authors present a case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) associated with a systemic necrotizing vasculitis with mixed features of Wegener granulomatosis and polyarteritis nodosa (PAN).

METHODS

Case report.

RESULTS

A 29-year-old woman developed a severe nosebleed, followed by a low-grade fever, night sweats, and a productive cough. One month later, she began experiencing high fevers, headache, myalgia, neck stiffness, and abdominal pain as well as bilateral blurred vision from APMPPE. Systemic evaluation revealed nasal ulcerations, bilateral pleural effusions, and a bilateral maxillary and ethmoid sinusitis, consistent with Wegener granulomatosis. However, ANCA testing was negative, and a renal and mesenteric angiogram showed aneurysmal dilatations suggestive of PAN. Her ocular and systemic symptoms markedly improved with systemic corticosteroids.

CONCLUSIONS

The cause of APMPPE is unknown. This case of APMPPE associated with systemic necrotizing vasculitis provides support for the choroid as being primarily involved by a diffuse vasculitic process that interrupts choroidal perfusion and causes the characteristic fundus findings in APMPPE.

Extensive dynamics in location, shape, and size of aneurysms in a patient with idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome. Idiopathic retinal vasculitis, aneurysms, and neuroretinitis

PURPOSE

To describe an unusual case of idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome with rapid dynamics in the number and appearance of the aneurysms.

DESIGN

Observational case report.

METHODS

Clinical and angiographic data of the patient were reviewed.

RESULTS

In the course of only 6 months, preexisting retinal aneurysms resolved while new ones appeared. Changes were observed in the shape and size of preexisting lesions. The resolution of lesions in eyes previously untreated by laser is reported for the first time.

CONCLUSIONS

Vascular lesions in IRVAN syndrome may show an unusually rapid turnover. The resolution of aneurysms is a part of the natural course of the disease and may occur without previous retinal laser photocoagulation.

A long-term follow-up of Eales' disease

PURPOSE

To provide long-term follow-up information on Eales' patients.

METHODS

Eales' patients, who had been examined at varying periods between the years 1970 and 1991 with a minimum five-year follow-up, were included in the study.

RESULTS

A total of 130 patients were followed up for a minimum of five and a maximum of 26.5 years. The retinal lesions found during the first examination included vascular sheathing, disc and/or retinal neovascularization, vitreous hemorrhage, branch retinal vein occlusion, retinitis proliferans, and retinal detachment. Visual acuity improved in 37 (20%) of the 185 treated eyes, was maintained in 79 (43%), and worsened in 69 (37%). The complications were tractional detachment, cataract, rubeosis iridis, neovascular glaucoma, and phthisis bulbi.

CONCLUSION

The most important elements in dealing with Eales' disease are periodic follow-up, a good and adequate laser treatment, pars plana vitrectomy combined with procedures for nonclearing vitreous hemorrhage, and retinal vasoproliferative changes to stabilize the retinal lesions and maintain functional levels of vision.

Linear scleroderma 'en coup de sabre' associated with cerebral and ocular vasculitis

Linear scleroderma 'en coup de sabre' (LSCS) has been reported in association with intracranial abnormalities. We report the case of an 11-year-old boy with LSCS who presented with recurrent headaches. Cranial magnetic resonance imaging (MRI) and angiography were consistent with the diagnosis of a cerebral vasculitis. In addition, retinal examination showed an exudative inflammatory lesion consistent with vasculitis.

Bilateral Parry-Romberg Syndrome Associated with Retinal Vasculitis

PURPOSE

To describe an unusual case of bilateral progressive facial hemiatrophy (Parry-Romberg syndrome (PRS)) associated with retinal vasculitis.

METHODS

In a 37-year-old man with bilateral PRS, retinal vasculitis of the right eye was evident on fundus examination and fluorescein angiography. Right temporalis muscle biopsy and needle electromyography of the masseter muscles were performed. The patient underwent immunosuppressive therapy and retinal laser photocoagulation.

RESULTS

Biopsy specimens showed large fibrosis with focal lymphohistiocytic infiltration of the muscle fibers. Electromyographic findings are consistent with a primary muscle disease. Visual acuity improved from 20/25 to 20/20 in the right eye with a follow-up of one year.

CONCLUSIONS

The evidence of retinal vasculitis and the histologic findings of facial changes observed in this PRS case could support the pathogenetic model of a chronic inflammatory process as a plausible explanation for progressive facial hemiatrophy.

Primary vascular occlusion in IRVAN (idiopathic retinal vasculitis, aneurysms, neuroretinitis) syndrome

IRVAN is a rare retinal vascular disease characterized by the presence of aneurysmal dilations along the retinal arteriolar tree. Visual loss occurs from sequelae to proliferative changes or due to severe macular exudation and rarely from secondary vascular occlusion following laser photocoagulation of the aneurysms. We herein report a patient with a primary vascular occlusion in a patient with IRVAN and suggest that such patients may already have a natural predisposition to develop a vascular occlusion.

Therapeutic Effects of Laser Photocoagulation and/or Vitrectomy in Eales' Disease

PURPOSE

To determine visual outcomes and regression of retinal neovascularization following laser photocoagulation and/or vitrectomy in eyes with Eales' disease.

METHODS

In a retrospective noncomparative study, the authors reviewed the existing data of 67 eyes of 54 patients with a diagnosis of Eales' disease who had undergone laser photocoagulation and/or vitrectomy based on their clinical presentations. Main outcome measures were visual acuity changes and regression of retinal neovascularization of the eyes following treatment.

RESULTS

Both laser therapy and vitrectomy improved visual acuity and induced regression of retinal neovascularization. Forty-three eyes had undergone laser therapy; their rate of visual acuity 320/30 improved from 53% before treatment to 60% after treatment. Twenty-four eyes had undergone vitrectomy; rate of visual acuity 320/30 improved from 13% before surgery to 38% after surgery. In eyes that had undergone laser therapy, additional laser therapy controlled recurrent neovascularization in 47% of the eyes, but ultimately, 12% of them required vitrectomy. In the primary vitrectomized group, additional required treatment was repeat vitrectomy in 21%, and/or laser therapy in 29% of the eyes.

CONCLUSIONS

Although laser photocoagulation should be the first line of treatment in Eales' disease, it cannot always induce regression of retinal neovascularization. In such cases vitrectomy may further enhance therapeutic success.

Secondary rhegmatogenous retinal detachment following intravitreal bevacizumab in patients with vitreous hemorrhage or tractional retinal detachment secondary to Eales' disease

BACKGROUND

To report the occurrence of secondary rhegmatogenous retinal detachment (RRD) after intravitreal bevacizumab injection in patients with Eales' disease.

METHODS

This is a retrospective, non-controlled, comparative case series. We reviewed 14 eyes of 14 patients with Eales' disease who had received pretreatment with intravitreal bevacizumab (1.25 mg/0.05 ml) and subsequently undergone a pars plana vitrectomy for non-resolving vitreous hemorrhage and/or tractional retinal detachment. Clinical records were reviewed. The primary outcome measure was the occurrence of secondary RRD after intravitreal bevacizumab injection.

RESULTS

Four patients had developed secondary RRD, with retinal breaks that were localized to the base of tractional retinal bands, within 1 week of receiving intravitreal bevacizumab. On comparative analysis, median age of patients who had developed secondary RRD was 26.5 years, significantly less than the median age of 33.5 years in the rest (P = 0.022). Median post-operative best-corrected visual acuity (BCVA) in patients who developed secondary RRD was logMAR 0.7 (0.3-0.8), significantly worse than the BCVA of logMAR 0.3 (0.0-0.5) in the rest (P = 0.015). None of the patients who developed secondary RRD had a complete posterior vitreous detachment (PVD) at presentation.

CONCLUSION

Intravitreal bevacizumab injections may be associated with the serious complication of secondary RRD in patients of Eales' disease within 7 days of injection.

Is granuloma annulare related to intermediate uveitis with retinal vasculitis?

AIM

To report on eight patients with severe idiopathic intermediate uveitis (IU) and granuloma annulare (GA), a self limiting cutaneous condition of unknown aetiology.

METHODS

Retrospective case series. Clinical ophthalmic and dermatological data were studied and fluorescein angiography and skin biopsies were reviewed.

RESULTS

All patients with idiopathic IU had similar ocular features (eight with vitritis, seven with retinal vasculitis) and developed complications such as cystoid macular oedema (n=5), cataract (n=4), and glaucoma (n=3). Systemic diseases were not found, but a localised type of GA was observed in all.

CONCLUSION

Seven out of eight patients with IU and GA developed severe retinal vasculitis. Further studies are needed for a better understanding of this association, a common pathogenesis, and its eventual clinical consequences.

Surgical outcomes for vitrectomy in Eales' disease

AIM

To present and analyse the anatomical and functional outcomes for vitrectomy in Eales' disease.

METHODS

This retrospective case series enrolled 63 patients (71 eyes) who underwent pars plana vitrectomy (PPV) for the complications of Eales' disease. Indications included nonclearing vitreous haemorrhage (VH) with/without epiretinal membranes in 49 (69%) eyes, and retinal detachments (RD) involving/threatening macula in 22 (31%). Additional procedures (scleral buckling; gas/oil tamponade) were performed at surgeon's discretion. Minimum follow-up was 6 months. The primary outcome measures were change in best-corrected visual acuity (BCVA) and posterior segment status.

RESULTS

The mean age of the patients was 29.6 years (range: 15-70 years); 60 were male (95%). Preoperatively, posterior vitreous detachment (PVD) existed in 28 (39.4%) eyes. Forty (56.3%) eyes underwent only PPV; the rest required additional surgical procedures (q.v.). The mean baseline BCVA (1/60) improved to 6/24 postoperatively (P<0.0001). Fifty-four eyes of 50 patients (76%) showed an improvement of > or =2 equivalent Snellen lines; six eyes (four patients) remained stable (+/-1 line); visual acuity worsened in 11 eyes (nine patients). The mean final BCVA was similar in eyes operated for VH and RD (P=0.08); but the magnitude of change from baseline was greater in the VH group (P=0.009). PVD had a borderline association with final BCVA (P=0.056); but did not influence the functional/anatomical improvement. Thirteen eyes required repeat interventions; 11 (15.49%) eyes experienced surgical failure.

CONCLUSIONS

Although surgical outcomes in Eales' disease depend on preoperative PVD/RD to some extent; good results are possible in the presence of incomplete PVD and tractional sequelae.

Acute idiopathic frosted branch angiitis

This is a case of acute idiopathic frosted branch angiitis in a 4-year-old African American girl with history of sickle cell trait. She developed bilateral, subacute vision loss attributed to acute idiopathic frosted branch angiitis and was treated with systemic corticosteroids with a good recovery of vision. Acute idiopathic frosted branch angiitis is a rare disease, usually with a good prognosis. This is, to our knowledge, the 10th reported case in the United States.

Hemorrhagic Occlusive Retinal Vasculitis After First Eye Cataract Surgery Without Subsequent Second Eye Involvement

A case of monocular postoperative hemorrhagic occlusive retinal vasculitis (HORV) after uncomplicated bilateral cataract surgery is described. HORV is a severe syndrome that leads to painless visual loss after uncomplicated cataract surgery. The same surgical procedure was adopted in both eyes except for the use of intracameral vancomycin, which was injected only in the eye that developed HORV. Diffuse retinal ischemia with vascular sheathing and intraretinal hemorrhages were detected during the fourth postoperative day. Despite treatment, the patient developed severe neovascular glaucoma. This case supports the causative role of vancomycin in the pathogenesis of HORV and suggests avoiding it for chemoprophylaxis. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:764-766.].

A new perspective for analyzing clinical characteristics of idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome

PURPOSE

We aimed to analyze the clinical characteristics of idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome. Furthermore, we aimed to correlate the number and location of retinal aneurysms with the size of retinal non-perfusion area and neovascularization.

METHODS

Six patients with IRVAN syndrome (1 male and 5 females, age 5-38 years) were enrolled in this study. Fundus fluorescein angiography (FFA) was used to determine the total number of retinal aneurysms, number of aneurysms within the first branch of the retinal artery, minimum distance between the non-perfusion margin and the optic disc, and the number of retinal aneurysms in each quadrant, as well as the type of neovascularization.

RESULTS

The size of the non-perfusion area was positively correlated with the total number of retinal aneurysms, the number of aneurysms within the first branch of the retinal artery, and the number of retinal aneurysms in each quadrant (P < 0.05). During the 5-year follow-up, one patient exhibited a dynamic change in the number and location of retinal aneurysms.

CONCLUSIONS

In IRVAN syndrome, the number and location of retinal aneurysms correlate with the size of retinal non-perfusion area and type of neovascularization.

INTRAVITREAL TRIAMCINOLONE IN SUSAC SYNDROME

PURPOSE

To report the use of intravitreal triamcinolone for Susac Syndrome in one patient.

METHODS

Case report.

RESULTS

A 23-year-old woman presented with presented with sudden visual loss in the left eye with associated neurologic symptoms. Ophthalmic examination and fluorescein angiography showed multiple areas of branch retinal artery occlusion, bilaterally. Magnetic resonance imaging showed dot-like, diffusion-restricted lesions in the corpus callosum, and audiometry showed low-frequency sensory hearing loss, compatible with Susac Syndrome. The patient received a single intravitreal injection of triamcinolone (4 mg) in the left eye. One week later, before beginning systemic corticosteroids, all signs and symptoms resolved in the left eye only.

CONCLUSION

In cases of delayed systemic corticosteroid therapy, intravitreal triamcinolone resolves the ocular manifestations of Susac Syndrome.

Association of Meniere's disease and retinal vascular calibre: a prospective observational study in China

OBJECTIVE

It is believed that Meniere's disease (MD) is associated with vascular disorders, but few studies have reported the relationship between retinal vascular disorders and MD. We evaluated and compared the retinal vascular calibres in patients with MD with healthy subjects matched for age, sex and vascular risk factors using retinal photographs to explore the association between MD and retinal vascular calibre.

STUDY DESIGN

A prospective study.

SETTING

Tertiary referral centre.

PARTICIPANTS

Sixty patients with MD and 62 healthy subjects matched for age, sex and vascular risk factors were enrolled in this study. Twenty-four patients with MD had migraines, and 36 patients with MD did not have migraines.

MAIN OUTCOME MEASURE

Retinal vascular calibres were calculated and compared not only between patients with MD and healthy subjects but also between subgroups of patients with MD.

RESULTS

Compared with healthy subjects, patients with MD had a slightly larger retinal artery calibre (126.30±10.45vs 119.61±15.86, p=0.006) and a higher retinal artery/vein ratio (0.79±0.09vs 0.75±0.10, p=0.005). Among patients with MD, those with migraines had a larger retinal artery calibre (130.73±11.55vs 123.35±8.61, p=0.006) than those without migraines. Moreover, the presence of migraines and the high frequency of vertigo attacks appeared to increase the retinal artery calibre.

CONCLUSIONS

Our study suggests that a relationship exists between retinal vascular calibre and MD. Although the pathophysiological relationship between migraine and MD remains unclear, the presence of migraine attacks may aggravate endolymphatic hydrops (EH) and accelerate the outflow of EH in patients with MD. More extensive studies are required to explore the association between retinal vascular calibre and MD.