Anticardiolipin antibodies in isolated retinal vasculitis

Retinopathy in systemic lupus erythematosus: pathogenesis and approach to therapy

The starting point in the assessment of SLE-retinopathy is the clinical examination by ophthalmoscopy and retinal fluorescein angiography. It is noted that two major clinical forms of retinopathy may occur in SLE; (1st) the "classic" type characterized by cotton-wool spots with or without intraretinal hemorrhages, and (2nd) the thrombosis of larger retinal blood vessels, such as central or branch arteries/veins. However, a well-defined pathogenetic classification of SLE-retinopathy has still not been proposed as yet. A practical classification based on the pathogenesis could be of aid to commence a more appropriate treatment. The aims of this paper are; (1st) to focus on the most implicate mechanisms of retinal vascular disease in SLE, (2nd) to mention the most common features associated with the different forms of retinopathy, and finally (3rd) to assess the prevalence of retinopathy in SLE. In our opinion, it seems that two major types of retinopathy exist in SLE: firstly, the Hughes' retinopathy due to antiphospholipid-induced retinal vascular thrombosis, for which anticoagulation is the best treatment, and secondly, the "classic" retinopathy in which at least two major causes could be associated; vasculitis and accelerated atherosclerosis. In patients with "classic" retinopathy, the most appropriate treatment still needs to be established. If "classic" retinopathy is due to vasculitis, immunosuppressive drugs should be administered, while if atherosclerosis play an etiologic role, a prophylaxis with antioxidants or the use of low-dose aspirin should be assessed.

Antiendothelial cell antibodies (AECA) in patients with uveoretinitis

AECAs have been found in 26% of patients with uveoretinitis in studies arising from three different laboratories, and their presence cannot simply be explained by coexisting extraocular disease. There is little correlation with ocular disease activity or other markers of systemic inflammation and vascular damage that can be found in this group of patients, but this lack of correlation has also been found in studies of more widespread inflammatory diseases. The changes found in the peripheral blood of patients with uveoretinitis are the result of a mixture of acute and chronic inflammation, reactions to coexisting tissue damage, as well as predisposing abnormalities of inflammation and hemostasis. Even patients with similar clinical appearances are unlikely to be pathologically homogeneous, and the reasons for the presence of AECA are likely to be various. Some patients may demonstrate a heightened antibody response to endothelium damaged by unknown mechanisms, whereas others may develop cytotoxic AECA as an integral part of the inflammatory process. The majority of serum samples with AECA demonstrated antibody-dependent cell-mediated cytotoxicity, but this potentially pathogenetic mechanism was only demonstrable in a minority of patients. It is unlikely that IgM AECA or complement-mediated cytotoxicity is a relevant mechanism of vascular damage in this group of patients. A subgroup of patients may be genetically predisposed to produce excess autoantibodies in response to tissue damage caused by a wide variety of insults. Sawyerr et al.(36) has suggested that increased serum levels of agalactosyl IgG may account for some of the AECA binding found in chronic inflammatory diseases: we have also found changes in agalactosyl IgG in patients with active isolated uveoretinitis (40), but levels did not correlate with levels of IgG AECA (unpublished results). Further longitudinal studies will be necessary on each subgroup of patients in order to determine the true clinical significance of these findings.

Antiphospholipid antibodies and retinal vascular disease

BACKGROUND

Antiphospholipid antibody retinopathy is a rare and poorly defined clinical entity in which the proper diagnosis has important ocular and systemic implications. The clinical course of five patients with antiphospholipid antibody retinopathy is described and the role of such antibodies in idiopathic retinal venous occlusive disease is investigated.

METHODS

Five case reports are presented highlighting the presentation, course, therapy, associations and outcomes of patients with antiphospholipid antibody retinopathy. In addition, twenty additional patients presenting with idiopathic retinal venous occlusive disease were tested for the presence of antiphospholipid antibodies.

RESULTS

All five patients with antiphospholipid antibody retinopathy had diffuse retinal vascular occlusion. All five patients presented with associated rheumatologic disease, including three with lupus or lupus-like disease. Antibodies to antiphospholipid were not detected in any of the twenty patients with idiopathic retinal venous occlusive disease. Prompt panretinal photocoagulation together with varying regimens of corticosteroids, immunosuppressives, or warfarin was partially successful in stabilizing the ocular and systemic disease.

CONCLUSION

The diagnosis of antiphospholipid antibody retinopathy should be suspected in patients with diffuse retinal vaso-occlusion, particularly when characterized by involvement of both arteries and veins, neovascularization at presentation, and symptoms of symptoms of systemic rheumatologic disease. Antiphospholipid antibodies do not appear to play an important role in idiopathic retinal vein occlusions.