Acute Frosted Retinal Periphlebitis

Frosted Branch Angiitis; Case Series and Literature Review

PURPOSE

Frosted branch angiitis (FBA) is a rare form of retinal vasculitis. Four case series and an extensive literature review of 236 cases were conducted to clarify the characteristics of this rare condition.

METHODS

Case series and literature review.

RESULTS

An analysis of the reported cases revealed that a majority (54.6%) developed FBA in the presence of an underlying disease, with recurrence and complications requiring surgical intervention being rare. The frequency of bilateral occurrence (55.0%) and prevalence in female patients (45.0%) were noted to be lower than previously reported.

CONCLUSION

In general, idiopathic FBAs are more likely to be bilateral and diagnosed at a younger age than secondary FBAs. In idiopathic FBA, fundus involvement is more generalized, exudates tend to be more translucent, and extensive retinal hemorrhage tends to be less frequent. However, there were no differential characteristic fundus features that clearly distinguished idiopathic FBA from secondary FBA.

First clinical case series of frosted branch angiitis: A diagnostic algorithm is suggested

Key Clinical Message

FBA is a clinical diagnosis of a diverse spectrum, which needs a high index of suspicion to identify the possible specific etiologies. The zones of retinal involvement can help in predicting the final visual outcome. The proposed diagnostic algorithm facilitates meticulous evaluation and targeted treatment to improve the final visual outcome.

Abstract

Frosted branch angiitis is a clinical diagnosis of a diverse spectrum, which needs a high index of suspicion to identify the possible specific etiologies. We present a series of three cases of FBA with an attempt to formulate a diagnostic algorithm and refine the definition of FBA.

Combined central retinal vein occlusion and cilioretinal artery occlusion as the initial presentation of frosted branch angiitis: a case report and literature review

PURPOSE

To report a case of combined central retinal vein occlusion (CRVO) with cilioretinal artery occlusion (CLRAO) that heralded the development of frosted branch angiitis (FBA).

CASE REPORT

A 25-year-old healthy male presented with sudden painless visual loss in his left eye with a visual acuity (VA) of 20/300. Fundus exam and fluorescein angiography showed signs of combined CRVO and CLRAO. Without treatment, his vision gradually improved until it reached 20/30 within four months. Five months after initial presentation, he returned with severe visual loss (20/400) in the same eye and a clinical picture of severe occlusive periphlebitis resembling a frosted branch angiitis pattern associated with severe macular edema. This was promptly and successfully treated with systemic steroids and immunosuppressive medications.

CONCLUSION

CRVO in young population can have an unusual course and one should carefully rule out underlying uveitic etiologies in each visit. Clinical suspicion and close follow‑up are required for early detection and timely management of FBA.

Frosted branch angiitis as an immune recovery response in newly diagnosed acquired immunodeficiency syndrome and systemic cytomegalovirus infection

Frosted branch angiitis (FBA) is an uncommon form of severe retinal perivasculitis associated with systemic inflammatory/infectious diseases. In this report, we describe a case of FBA and macular edema as a result of immune recovery response in a patient newly diagnosed with HIV infection and cytomegalovirus viremia.

Frosted branch angiitis after smallpox vaccination

Purpose

To describe a patient presenting with frosted branch angiitis soon after small-pox vaccination.

Observations

Frosted branch angiitis (FBA) is an acute onset retinal vasculitis featuring prominent perivascular sheathing in otherwise healthy individuals. FBA has been associated with noninfectious and infectious etiologies. This report describes a twenty-year-old African American female who developed bilateral frosted branch angiitis one week after small-pox vaccination. At presentation, the patient had bilateral, para-central visual field defects and subjective visual disturbances. On dilated exam, the patient demonstrated diffuse vasculitis bilaterally. The patient's field defects and clinical exam responded dramatically to oral prednisone therapy.

Conclusions and Importance

Acute idiopathic frosted branch angiitis is a rare condition which was temporally associated with small-pox vaccination.

Bartonella henselae-associated recurrent, bilateral segmental periphlebitis

Purpose

To describe a patient with atypical Bartonella henselae (B. henselae)-associated ocular inflammation that manifested with recurrent, bilateral segmental periphlebitis.

Observations

A 32-year-old White man presented with multiple paracentral scotomata in each eye. Examination revealed mild vitreous cell, segmental sheathing of the retinal veins, and inflammation of the paravenous retina in each eye. Multimodal imaging, including optical coherence tomography as well as widefield fundus autofluorescence, fluorescein angiography, and indocyanine green angiography, was consistent with bilateral, segmental retinal periphlebitis with paravenous inflammation and retinochoroidal scarring. Serology showed elevated B. henselae antibody titers, but was otherwise unrevealing, and the patient was diagnosed with presumed B. henselae-associated ocular inflammation. Treatment with systemic doxycycline (100 mg PO BID) for four weeks improved the patient's symptoms and posterior uveitis. However, after an asymptomatic period of nearly one year, his bilateral pericentral scotomata recurred and posterior segment examination confirmed new foci of retinal periphlebitis in each eye. Re-treatment with doxycycline (100 mg PO BID) for four weeks again yielded improvement, but one month after completing his antibiotic course, his visual symptoms recurred, and we observed additional areas of periphlebitis and paravenous retinitis with associated branch retinal vein occlusions in each eye. This time a dual antibiotic regimen of doxycycline (100 mg PO BID) and rifampin (300 mg PO BID) was administered for three months, with improvement. Over the next eight years, the patient experienced no further disease relapse, and the previous sites of retinal periphlebitis eventually developed perivenous fibrosis with paravenous retinochoroidal scarring.

Conclusion

Rarely, patients with B. henselae-associated ocular inflammation develop segmental retinal periphlebitis with or without retinal vein occlusion. This form of ocular bartonellosis can recur, requiring multiple courses of antimicrobial therapy.

ACUTE FROSTED RETINAL PERIPHLEBITIS IN A PATIENT WITH MEDITERRANEAN FEVER

PURPOSE

To present a case of frosted branch periphlebitis in a young Armenian patient with familial Mediterranean fever.

METHODS

Case report.

RESULTS

A 37-year-old man presented with a unilateral decreased visual acuity and floaters for 4 days on the left eye (LE). Visual acuity was 20/20 in the right eye (RE) and 20/28 in the LE. Anterior segment and fundus examinations of the RE were normal. Slit-lamp examination of LE revealed a mild nongranulomatous anterior uveitis and vitritis. Intraocular pressure was 19 mmHg in the RE and 12 mmHg in the LE. Fundoscopy of the LE showed typical appearance of frosted branch periphlebitis with perivascular sheathing of the retinal veins and scattered retinal hemorrhages. Fluorescein angiography of the RE was normal. The LE showed optic disk and segmented vascular staining without macular leakage. Optical coherence tomography of the RE was normal; LE demonstrated a localized macular thickening and few intraretinal cysts. The detailed ophthalmologic history was negative. The general history and workup were significant for familial Mediterranean fever and a positive lupus anticoagulant. One week later, the fundus findings worsened with a severe decrease of visual acuity of the LE to 20/200. A single intravitreal (IVT) injection of bevacizumab was performed. Three weeks after injection, fundus findings progressively improved with a decrease of the macular thickening and an improvement of the visual acuity to 20/25. Clinical improvement continued up to the last visit (19 weeks after the injection) with a visual acuity that reached back 20/20 with no signs of active inflammation.

CONCLUSION

This case demonstrates a possible association between unilateral frosted branch periphlebitis and familial Mediterranean fever.

Frosted branch angiitis with penetrating ocular trauma and retained intraocular foreign body

A 54-year-old male sustained ocular trauma with a projectile. Examination of the right eye revealed an intraocular foreign body (IOFB) adjacent to the optic nerve head, vitritis, vitreous hemorrhage, and translucent perivascular sheathing of the retinal vessels in all quadrants suggesting frosted branch angiitis (FBA). The patient underwent vitrectomy with removal of the IOFB and silicone oil tamponade under steroid cover. With continued use of systemic and topical steroids after surgery, complete resolution of FBA and improvement in vision were noted in a week. Prompt resolution of FBA after IOFB removal points toward a strong association between the presence of IOFB and FBA.

Frosted branch angiitis and cerebral venous sinus thrombosis as an initial onset of neuro-Behçet's disease: a case report and review of the literature

Background

Frosted branch angiitis is a rare, severe condition. It can be either a primary or a secondary condition and is characterized by rapid deterioration of vision and fulminant retinal vasculitis that manifests as diffuse sheathing of retinal vessels, macular edema, papillitis, vitritis and anterior uveitis. We aimed to describe a case of frosted branch angiitis and cerebral venous sinus thrombosis as an initial neuro-Behçet’s disease onset. Diagnosis of Behçet’s disease was based on the current 2014 International Criteria for Behçet’s Disease and the International consensus recommendation criteria for neuro-Behçet’s disease. In addition, a literature review using search parameters of “frosted branch angiitis”, “Behçet” and “neuro-Behçet” in the PubMed database is presented.

Case presentation

A 28-year-old Brazilian pardo woman presented to our hospital with abrupt bilateral vision loss associated with recurrent aphthous oral ulcers 6 months before visual symptom onset. A fundus examination showed bilateral widespread retinal vasculitis with venous and arterial white sheathing, optic disc swelling, macular edema, and retinal hemorrhages, leading to the diagnosis of frosted branch angiitis. An extensive systemic workup for retinal vasculitis was uneventful, except for brain magnetic resonance imaging demonstrating cerebral venous sinus thrombosis and lymphocytic aseptic meningitis. A diagnosis of neuro-Behçet’s disease was made, and treatment was started with methylprednisolone therapy 1 g/day for 5 consecutive days, followed by oral mycophenolate mofetil and infliximab 5 mg/kg infusion. The patient’s response was rapid, with improvement of visual acuity to hand movement and counting fingers by day 7 and final visual acuity of counting fingers and 20/130.

Conclusions

Frosted branch angiitis may be associated with infectious, noninfectious, or idiopathic causes. An extensive workup should be done to exclude systemic vasculitis such as Behçet’s disease. Treatment with systemic steroids must be promptly initiated in association with specific treatment aimed at inflammation control and blindness risk reduction.

Frosted branch angiitis secondary to herpes simplex virus infection progressing to acute retinal necrosis

PURPOSE

To describe a case of frosted branch angiitis secondary to herpes simplex virus type 2 infection that progressed to acute retinal necrosis.

METHODS

The medical records and clinical photographs were reviewed for a patient with frosted branch angiitis that progressed to acute retinal necrosis.

RESULTS

The patient rapidly developed acute retinal necrosis followed by rhegmatogenous retinal detachment. Polymerase chain reaction analysis of the vitreous was positive for herpes simplex virus type 2.

DISCUSSION

Frosted branch angiitis is a clinical sign that may represent active viral disease capable of progressing to acute retinal necrosis.

Retinal imaging in uveitis

Ancillary investigations are the backbone of uveitis workup for posterior segment inflammations. They help in establishing the differential diagnosis and making certain diagnosis by ruling out certain pathologies and are a useful aid in monitoring response to therapy during follow-up. These investigations include fundus photography including ultra wide field angiography, fundus autofluorescence imaging, fluorescein angiography, optical coherence tomography and multimodal imaging. This review aims to be an overview describing the role of these retinal investigations for posterior uveitis.

[A case report of frosted branch angiitis associated with aseptic meningitis in a young boy]

We report on an 11-year-old boy with frosted branch angiitis in both eyes associated with aseptic meningitis. The patient presented after a severe decrease in vision in both eyes and a 40°C fever. The examination of the fundus of the eyes revealed a diffuse edema of the retina and diffuse bilateral vascular sheathing. The complementary examinations revealed aseptic meningitis. Neither infectious etiologies nor systemic diseases could be confirmed and an inflammatory digestive disease was suspected because of recent diarrhea events responsible for substantial weight loss. A systemic corticotherapy slowly improved the vision in both eyes. After 1 year of medication, visual recovery was full with no sequelae on fundus examination.

[Frosted-branch angiitis revealing Behçet's disease]

A 30-year-old man with a history of skin and recurrent oral ulceration over 1 year developed loss of visual acuity in the right eye. The diagnosis of acute frosted branch angiitis was based on retinal vasculitis associated with retinal edema and hemorrhages, confirmed using fluorescein angiography (venous leakage and extensive staining of the vein walls). General examination revealed pseudofolliculitis and recurrent oral ulcers. The diagnosis of Behçet's disease was based on the international criteria. The patient was treated with prednisolone and colchicine, which were effective with a normalization of the fundus 1 month later. The initial presentation of Behçet's disease as frosted branch angiitis is exceptional, the main differential diagnosis being herpetic infections, which must be ruled out.

Retinal Vasculitis

Retinal vasculitis is a sight-threatening intraocular inflammation affecting the retinal vessels. It may occur as an isolated ocular condition, as a manifestation of infectious or neoplastic disorders, or in association with a systemic inflammatory disease. The search for an underlying etiology should be approached in a multidisciplinary fashion based on a thorough history, review of systems, physical examination, and laboratory evaluation. Discrimination between infectious and noninfectious etiologies of retinal vasculitis is important because their treatment is different. This review is based on recently published articles on retinal vasculitis and deals with its clinical diagnosis, its link with systemic diseases, and its laboratory investigation.

Frosted branch angiitis: a review

The purpose of this study is to present the first report of a case of primary frosted branch angiitis from the UK and to review the characteristics of this rare disease. Primary frosted branch angiitis causes characteristic florid translucent retinal perivascular sheathing of both arterioles and venules in association with variable uveitis, retinal oedema and visual loss, normally with good recovery. A total of 57 cases have been reported in the world literature. Atypical, typically focal frosted branch angiitis may also occur secondary to other causes of intraocular inflammation, especially cytomegalovirus retinitis. Primary frosted branch angiitis has a characteristic presentation but a variable course, typically affecting children or young adults. The disease is likely to represent a common immune pathway in response to multiple infective agents. The optimal treatment is unclear.

Retinal periphlebitis resembling frosted branch angiitis with nonperfused central retinal vein occlusion

PURPOSE

To report the unusual association between severe retinal periphlebitis resembling frosted branch angiitis and nonperfused central retinal vein occlusion (CRVO).

METHODS

Observational case reports.

RESULTS

Patient 1 was a 28-year-old man who presented with extensive sheathing involving all retinal veins in one eye followed by nonperfused CRVO. Twenty-seven months after initial presentation, he developed perfused CRVO in the other eye followed by periphlebitis that progressed into nonperfused CRVO. Patient 2 was a 47-year-old man who presented with unilateral severe retinal periphlebitis associated with nonperfused CRVO. Despite systemic administration of corticosteroid therapy, rubeosis iridis developed in both patients and neovascular glaucoma developed in Patient 1 despite full panretinal photocoagulation. Extensive systemic workup and coagulation studies were unremarkable except for the presence of antiphospholipid antibodies in both patients and elevated plasma homocysteine level in Patient 2.

CONCLUSIONS

Severe retinal periphlebitis complicated by nonperfused CRVO is associated with poor visual outcome despite appropriate medical and surgical treatment.

Human T-cell lymphotropic virus type 1-associated retinal vasculitis in children

PURPOSE

To describe predominant retinal vasculitis in children carrying human T-cell lymphotropic virus type 1 (HTLV-1).

METHODS

The authors examined clinical records of patients with HTLV-1-associated uveitis between 1987 and 2001 in Kagoshima University Hospital and reviewed cases of extensive, smoldering retinal vasculitis.

RESULTS

Three previously healthy teenagers noted mild visual symptoms and presented with extensive sheathing of retinal vessels, complicated by mild anterior segment inflammation. The retinal vascular disease responded poorly to systemic corticosteroids, had a smoldering course with persistent sheathing of retinal vessels, and eventually resulted in diffuse chorioretinal degeneration. Results of laboratory studies were unremarkable except for the presence of serum antibodies to HTLV-1. One patient developed HTLV-1-associated myelopathy 11 years after the onset of ocular disease.

CONCLUSIONS

The retinal vasculitis differed from the retinal vascular changes commonly seen in HTLV-1-associated uveitis. The authors suggest a clinical disease HTLV-1-associated retinal vasculitis that affects young HTLV-1 carriers, characterized by smoldering retinal vasculitis with ultimate retinal degeneration.

Bilateral iridocyclitis with retinal capillaritis in juveniles

PURPOSE

The authors present clinical features of 18 juvenile patients with a new type of uveitis termed bilateral iridocyclitis with retinal capillaritis (BIRC).

METHODS

The authors reviewed medical records of 18 consecutive patients who showed bilateral iridocyclitis with retinal capillary leakage but no systemic manifestations during an 11-year period from January 1985 to December 1995.

RESULTS

Twelve of the 18 patients were female and the age at onset ranged from 9 to 17 years old. All patients had many cells in the anterior chamber and anterior vitreous, together with mutton fat keratic precipitates. Fluorescein angiography showed leakage from the optic disc and retinal capillaries, mainly in the midperiphery, which corresponded to retinal cloudiness. Macular edema was minimal, and all patients maintained good vision. The inflammation responded well topical, oral, and intravenous administration of corticosteroids, the choice of which was based on the extent of retinal inflammation. Human leukocyte antigen (HLA)-DR6 and HLA-Cw7 were associated significantly with the presence of BIRC (chi square test, P < 0.0001).

CONCLUSIONS

Bilateral retinal capillaritis affecting capillaries in various areas of the retina and overlying retinal cloudiness with no distinct lesions are unique to these patients. Fluorescein angiography is essential for diagnosis of BIRC.

Acute frosted retinal periphlebitis

A 30-year-old woman developed bilateral acute vision loss without any systemic symptoms. There was diffuse retinal edema and thick perivenous sheathing with moderate vitreous inflammation. Fluorescein angiography showed late staining and dye leakage from diseased vessels. Oral corticosteroid treatment stabilized the visual acuity and fundus of the left eye but did not halt the progression to total fibrosis in the right eye.

Frosted branch angiitis associated with cytomegalovirus retinitis

We examined three patients with acquired immunodeficiency syndrome who had frosted branch angiitis associated with small patches of cytomegalovirus retinitis. Each patient had a low CD4-helper T-lymphocyte count and a T-lymphocyte helper-suppressor ratio of less than 0.1. Treatment with intravenous anticytomegalovirus antibiotics caused the vascular sheathing to resolve within two weeks in all three patients, but each patient continued to have a smoldering retinitis. Retinal biopsy in one of the patients demonstrated virions whose morphologic characteristics were consistent with cytomegalovirus on electron microscopy and the identity of which was confirmed by immunohistochemistry. Although frosted branch angiitis in otherwise healthy patients responds to corticosteroids, similar treatment with corticosteroids for frosted branch angiitis associated with cytomegalovirus retinitis in patients with AIDS does not seem to be indicated. Before corticosteroid treatment is started for a patient with the clinical signs and symptoms of frosted branch angiitis, careful medical examination of the patient is necessary.

Unilateral frosted branch angiitis

We examined two patients with monocular frosted branch angiitis. The patients were young and healthy; they rapidly developed severe visual loss with thick, white sheathing of the retinal veins and responded promptly to systemic corticosteroids. The fluorescein angiograms showed late leakage from the retinal veins, without evidence of stasis or occlusion. Frosted branch angiitis can be either a unilateral or a bilateral condition. We believe the potential for visual loss and the prompt response to systemic corticosteroids make early, accurate diagnosis and institution of therapy desirable.