Anterior segment parameters and eyelids in systemic sclerosis

Effects of systemic fingolimod treatment on anterior segment parameters and tear film functions

PURPOSE

To investigate the potential effects of systemic fingolimod treatment on parameters of the anterior segment of the eye and tear film function tests in patients with multiple sclerosis (MS).

METHODS

Forty-eight eyes of 24 individuals who were started on systemic fingolimod treatment for relapsing-remitting MS were prospectively enrolled in this study. Patients underwent examinations immediately before initiation of systemic fingolimod treatment, and at the first and sixth months of treatment. Anterior segment parameters were measured using Sirius Topography. The Schirmer-I test and tear break-up time (TBUT) were recorded during follow-up. Retinal thickness was also analyzed using spectral-domain optical coherence tomography (SD-OCT).

RESULTS

There was no statistically significant difference in retinal thickness measurements between follow-up visits. The central corneal thickness, keratometric values, anterior chamber depth, aqueous humor depth, iridocorneal angle, horizontal anterior chamber tilt and anterior chamber volume values remained similar during follow-up. The Schirmer-I test value was 15.10 ± 2.65 mm at the zeroth month and 17.03 ± 3.61 mm at the sixth month (p = 0.044). The mean TBUT was significantly higher at the six-month visit compared to baseline and the one-month visit (p0-6 < 0.001, p1-6 < 0.001), but there was no statistically significant difference between baseline and month 1 (p0-1 = 0.419).

CONCLUSION

Systemic use of fingolimod may increase Schirmer I test and TBUT values in MS patients without altering other anterior segment parameters within 6 months.

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.

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 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.

Thickness of anterior sclera and corneal layers in systemic sclerosis

PURPOSE

To evaluate the thickness of anterior sclera and corneal layers in patients with systemic sclerosis.

METHODS

The present cross-sectional study included 41 patients with systemic sclerosis and 41 age- and gender-matched healthy controls. The study and control groups were compared in terms of the thickness of anterior sclera, corneal epithelium, Bowman's layer, corneal stroma, and Descemet's membrane-endothelium complex. The thickness measurements were obtained using the anterior segment module of spectral-domain optical coherence tomography.

RESULTS

The thickness of anterior sclera, corneal epithelium, Bowman's layer, and Descemet's membrane-endothelium complex were similar in the patients with systemic sclerosis and healthy controls (P > 0.05). Total corneal thickness at the apex was 511.1 ± 33.5 µm in the systemic sclerosis group and 528.4 ± 29.5 µm in the control group (P = 0.015). The corneal stroma was thinner in the systemic sclerosis patients compared to the healthy controls (P = 0.02).

CONCLUSIONS

The corneal stroma was thinner in the patients with systemic sclerosis compared to that of healthy controls, while the thickness of the anterior sclera was similar in both groups.

The effect of systemic sclerosis and its subtypes on ocular anterior and posterior segment parameters

PURPOSE

To evaluate anterior and posterior segment parameters in the eyes of patients with systemic sclerosis (SSc) and examine the effect of disease and disease subtypes on these parameters.

METHODS

This cross-sectional study included 54 eyes of 27 SSc patients and 54 eyes of 27 age- and sex-matched healthy controls. In addition to a complete ophthalmologic examination, all patients were examined using a Scheimpflug camera, specular microscopy, and spectral domain optical coherence tomography.

RESULTS

The mean age of the patients was 52.5 ± 11.4 years and 19 patients were female. Anterior chamber volume, central corneal thickness, and central macular thickness (CMT) were significantly lower in the eyes of SSc patients compared to healthy controls (p = 0.01, p = 0.03, and p = 0.006, respectively). When evaluated according to SSc subtype, CMT was lower in diffuse SSc patients (p = 0.001), while mean retinal nerve fiber layer (RNFL) and inferior quadrant RNFL values were lower in limited SSc (p = 0.003 and p = 0.005, respectively).

CONCLUSION

In the eyes of patients with SSc, some ocular parameters may show decreases compared to healthy individuals, presumably secondary to disease-related vasculopathy and fibrosis. CMT and RNFL parameters may be affected differently according to disease subtype.

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.

An in vivo confocal microscopy study of corneal changes in patients with systemic sclerosis

To investigate corneal microstructure of systemic sclerosis (SSc) patients using in vivo confocal microscopy (IVCM). 33 patients with SSc and 30 age-matched healthy subjects were recruited. All participants underwent comprehensive ophthalmic examination including IVCM (Heidelberg Retina Tomograph III, Heidelberg Engineering GmbH, Heidelberg, Germany) and ocular surface evaluation. Subbasal nerve plexus morphology was investigated using automated software analysis (ACCMetrics V3; University of Manchester, Manchester, UK). Keratocyte cell densities in the anterior stroma were significantly lower in patients with SSc compared to controls (P < 0.0001). In 7 SSc patients no keratocyte nuclei were identified in the anterior stroma and in most patients scattered hyperreflective punctate material were observed in the anterior stroma. Significantly lower subbasal nerve fiber parameters were found in patients with SSc compared to healthy subjects (P < 0.05). There were no significant correlations between the duration of SSc and any of the corneal cell density values. Tear break-up time values (4.82 ± 3.15 s) and Ocular Surface Disease Index scores (33.27 ± 30.11) were abnormal, Schirmer values (6.78 ± 5.82 mm) were borderline in SSc patients. In SSc, corneal morphological changes and accumulation of punctate material in the stroma was detected with confocal microscopy. Severe ocular surface disease was observed in SSc patients with significant impairment in subbasal nerve plexus morphology resembling peripheral neuropathy.

Ocular microvascular damage in autoimmune rheumatic diseases: The pathophysiological role of the immune system

Pathological eye involvement represents a quite common finding in a broad spectrum of autoimmune rheumatic diseases (ARDs). Ocular signs, often occur as early manifestations in ARDs, ranging from symptoms related to the mild dry eye disease to sight-threatening pathologies, linked to the immune response against retinal and choroidal vessels. Retinovascular damage driven by markedly inflammatory reactivity need a prompt diagnosis and treatment. Immune-complexes formation, complement activation and antibody-mediated endothelial damage seem to play a key role, particularly, in microvascular damage and ocular symptoms, occurring in systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and Sjögren's syndrome (SS). Conversely, early alterations of retinal and choroidal vessels in the asymptomatic patient, often detectable coincidentally, might be indicators of widespread vascular injury in other connective tissue diseases. Particularly, endothelin-induced hypoperfusion and pathological peri-choroidal extracellular matrix deposition, might be responsible for the micro-architectural alterations and loss of capillaries detected in systemic sclerosis (SSc). Instead, interferon alpha-mediated microvascular rarefaction, combined with endothelial lesions caused by specific autoantibodies and immune-complexes, appear to play a significant role in retinal vasculopathy associated to inflammatory idiopathic myopathies (IIM). The immuno-pathophysiological mechanisms of ocular microcirculatory damage associated with the major ARDs will be discussed under the light of the most recent achievements.

Ocular manifestations in patients with systemic sclerosis

Systemic sclerosis (SSc) is a rare, chronic autoimmune disease with unknown etiology. Its prominent features are fibrosis, vasculopathy and impaired immune response. Disease can also affect eyes leading to various findings in ophthalmological examination.

The objective of this study was to determine the prevalence and type of ocular involvement in patients with SSc. A systematic literature review was conducted using electronic databases. A combination of following keywords was used: “systemic sclerosis” and ophthalmology-related search terms, including the keywords “eye”, “ocular” and “ophthalmic”.

In conclusion, eyelid and conjunctival abnormalities and dry eye disease are among the most common ocular manifestations of SSc. Their diversity is connected to complexity of the disease.

Evaluation of Ocular Surface and Meibomian Glands in Patients With Scleroderma

PURPOSE

To evaluate the prevalence of dry eye and meibomian gland dysfunction in patients with scleroderma.

METHODS

A total of 32 patients with scleroderma (study group) and 31 healthy subjects (control group) were enrolled. Besides routine ophthalmologic evaluation, Schirmer 1 test, tear break-up time, tear osmolarity, ocular surface staining with fluorescein (Oxford score), and Ocular Surface Disease Index (OSDI) score, meibomian gland dysfunction evaluation (foamy tears, telangiectasia of the eyelid, eyelid contour abnormalities, and meibomian plugs), and meibography were performed.

RESULTS

Sixty-four eyes of 32 patients with scleroderma and 62 eyes of 31 healthy individuals were evaluated. Mean ages of the study group was 48.34 ± 9.73 years (21-62 years) and of the control group was 45.84 ± 4.42 years (38-54 years) (P = 0.067). Mean duration of systemic sclerosis or scleroderma in study group was 9.78 ± 7.40 years (1-30 years). Mean tear break-up time was shorter in study group than that in the control group (P < 0.0005). No statistical differences were detected for osmolarity, OSDI score, and Schirmer 1 values between groups (P = 0.051, P = 0.053, and P = 0.358, respectively). The prevalence of grade 1 and higher Oxford score was higher in the study group (P < 0.0005). Upper meiboscores of grade 1 and higher were found to be more common in the study group than those in the control group (P = 0.036). The presence of foamy tears and telangiectasia of the eyelids were significantly higher in the study group (P = 0.002 and P = 0.002, respectively). OSDI score was the only significantly correlated data with disease duration (Spearman ρ coefficient = 0.396, P = 0.001).

CONCLUSIONS

Evaporative type dry eye is more common in patients with scleroderma than the healthy population.

A multimodal ophthalmic analysis in patients with systemic sclerosis using ocular response analyzer, corneal topography and specular microscopy

PURPOSE

To conduct a multimodal ophthalmic evaluation of systemic sclerosis (SSc) in patients using ocular response analyzer (ORA), Pentacam, and specular microscopy (SM).

METHODS

Thirty-one SSc patients and a group of age- and sex-matched controls were enrolled in this cross-sectional study. Corneal hysteresis (CH), corneal resistance factor (CRF), corneal-compensated intraocular pressure (IOPcc), and Goldmann-correlated IOP (IOPg) were measured with ORA. Anterior chamber depth (ACD), central corneal thickness (CCT), and corneal volume (CV) measurements were obtained using Pentacam. Corneal endothelial cell density (ECD) and CCT were evaluated by SM.

RESULTS

SSc patients had significantly lower CH, ACD, and ECD values compared to the control group (p = 0.018; < 0.001; < 0.001, respectively). There was no significant difference regarding CRF, IOP, CV, or CCT measurements acquired by Pentacam and SM. Regarding CCT, SM and Pentacam showed relatively better agreement in SSc patients.

CONCLUSIONS

Multimodal imaging can provide more comprehensive and useful information regarding the ocular involvement of systemic diseases. The multimodal evaluation in our study demonstrated that the pathologic effects of SSc may manifest as reductions in ACD, corneal elasticity, and ECD before there are any detectable changes in corneal thickness or IOP.

Ocular involvement in systemic sclerosis: A systematic literature review, it's not all scleroderma that meets the eye

OBJECTIVES

Systemic sclerosis (SSc) is a rare and complex autoimmune disorder characterized by microvascular damage and progressive fibrosis which affects the skin and multiple other organs. Much of the published data concerning SSc and the eye consists of single case reports or small case studies. This systematic review aims to provide an overview of the current level of evidence for SSc-related ocular changes.

MATERIALS AND METHODS

A systematic literature review was conducted using 3 electronic databases, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A combination of following keywords was used: "Systemic Sclerosis" and ophthalmology-related search terms, including the keywords "Eye", "Ocular" and "Ophthalmic". All articles were screened by 2 independent reviewers at title, abstract and full text level. We solely included case-control studies that investigated specific ocular findings in SSc patients compared to healthy controls.

RESULTS

Nine of 270 articles were retained. Dry eye symptoms are associated with SSc, whereas objective signs (Schirmer I testing) show conflicting results. There is insufficient evidence of SSc-related changes to the central corneal thickness. In terms of posterior segment involvement, choroidal vasculature appears to be affected to greater extent than the retinal microcirculation. However, the limited number of patients included in the studies renders it hazardous to draw overall conclusions.

CONCLUSIONS

There is a paucity of well-designed case-control studies investigating possible ocular involvement in SSc. Our systematic review demonstrates limited proven associations between SSc and ocular abnormalities, mainly in terms of dry eye symptoms and choroidal thickness. Future standardized prospective studies are needed to clarify the impact of the disease on the eye.

Corneal Manifestations of Systemic Sclerosis

Purpose: Corneal involvement in systemic sclerosis (SSc) is rare, but due to rich collagen composition cornea is especially vulnerable to connective tissue diseases. Therefore, our aim was to evaluate corneal parameters of SSc patients. Methods: The study included 32 SSc patients and 39 control subjects with no ocular symptoms or ocular surface disorders. All study participants underwent Pentacam evaluation and objective signs of dry eye disease (DED), and clinical parameters were evaluated. Results: All pachymetric values, most of the corneal front surface, corneal volume, as well as anterior chamber depth measurements were significantly lower in the SSc group than in the control group (p < 0.05). Significant negative correlation was found between corneal parameters and age on the one hand, and disease duration on the other. Conclusions: Early recognition of corneal impairment, a possible extraintestinal manifestation of SSc, should be included in the check-up of the disease in order to reduce sight-threatening complications.

Evaluation of Corneal Parameters with Dual Scheimpflug Imaging in Patients with Systemic Sclerosis

PURPOSE

To evaluate the cornea of systemic sclerosis (SSc) patients with Dual Scheimpflug Imaging.

METHODS

Twenty consecutive SSc patients and 20 age and sex matched controls were enrolled in this cross-sectional study. Corneal measurements were acquired by dual Scheimpflug analyzer.

RESULTS

SSc patients had statistically significant steeper corneas than the control group. The mean anterior curvature-average (SimK) was 44.93 ± 1.64 D (mean ± standard deviation) in SSc and 43.61 ± 0.99D in control group, p = 0.01. Posterior curvature was also steeper in SSc patients compared to controls (p = 0.02). There was no statistically significant difference regarding central average pachymetry (p = 0.07), thinnest pachymetry (p = 0.09).

CONCLUSIONS

Patients with SSc present with steeper corneas than controls.