Antiphospholipid antibodies in patients with retinal vascular occlusions

Characteristics and risk factors of retinal vasculopathy in antiphospholipid syndrome

BACKGROUND

Retinal vasculopathy including retinal artery occlusion (RAO) or retinal vein occlusion (RVO) was recently found to occur more frequently in antiphospholipid syndrome (APS) patients than non-APS patients. This study aims to investigate the clinical manifestation and risk factors of retinal vasculopathy among APS patients.

METHODS

In this single-center prospective cohort study, we evaluated APS patients with or without retinal vasculopathy during 2018-2020 at Peking Union Medical College Hospital. Clinical variables were compared, and a logistical regression model was built to explore risk factors. Hierarchical cluster analysis using Euclidean distances was applied to identify clusters of variables.

RESULTS

A total of 310 APS patients (67.4% female, mean age 38.1 years) were included, of whom 18 (5.8%) were diagnosed with retinal vasculopathy (9 with RVO and 9 with RAO). No significant differences were found among most demographic characteristics, clinical manifestations, or antibody profiles. APS-related heart valve disease (odds ratio OR 13.66, 95% confidence interval CI 4.55-40.98), APS nephropathy (OR 12.77, 95% CI 4.04-40.35), and thrombocytopenia (OR 2.63, 95% CI 1.01-6.89) were predictive of retinal vasculopathy. APS-related heart valve disease and nephropathy were also found to be statistically significant predictors in multivariate logistical regression analysis. Non-criteria manifestations were aggregated with retinal vasculopathy from a cluster analysis of variables.

CONCLUSION

Patients with APS-related heart valve disease and nephropathy suffered a higher risk of retinal vasculopathy. The underlying mechanisms of aPL-associated retinal vasculopathy may involve thrombotic microangiopathy, leading to poor prognosis and therapeutic changes.

Ophthalmologic manifestations in primary antiphospholipid syndrome patients: A cross-sectional analysis of a primary antiphospholipid syndrome cohort (APS-Rio) and systematic review of the literature

OBJECTIVE

There is a broad spectrum of eye involvement in antiphospholipid syndrome (APS). The majority of descriptions are presented as case reports that include mostly APS patients secondary to systemic lupus erythematosus (SLE), with no compelling evidence in primary APS (PAPS). This study aimed to describe ocular manifestations in our well-defined PAPS cohort (APS-Rio) and then perform a systematic literature review (SLR) of ocular manifestations in patients with APS or positivity to aPL without SLE.

METHODS

We retrospectively analyzed PAPS patients followed at our outpatient clinics. All patients fulfilled Sydney APS classification criteria (2006). We evaluated them for ocular symptoms and previous ocular diagnoses. Antiphospholipid antibodies and clinical APS manifestations were compared between patients with and without ocular manifestations. For the SLR, electronic databases were searched up to November 2019.

RESULTS

We studied 105 PAPS patients; 90.5% were female and 56.2% were Caucasian. We found ocular manifestations in 37.1% of our cohort. Thrombosis was the main criteria manifestation (95.2%) and lupus anticoagulant was the most prevalent antibody. Ophthalmologic diagnoses were present in 7 patients, with 5 having retinal vessels thromboses. Amaurosis fugax was the leading complaint, present in 30 patients. In the univariate analysis, amaurosis fugax was related to livedo (p = 0.005), Raynaud's phenomenon (p = 0.048) and the presence of anticardiolipin antibody (≥40 GPL/MPL) (p = 0.041). Hemianopia was associated with arterial hypertension (p = 0.049). In the multivariate analysis, the only association found was between livedo and amaurosis fugax (OR 4.09, 95%CI 1.5-11.11, p = 0.006). Our SLR incorporated 96 articles of ocular manifestations in patients with PAPS or positivity to aPL without SLE. Ocular findings varied from 5 to 88%, including anterior and posterior segments, orbital and neuro-ophthalmologic changes.

CONCLUSION

There is little evidence on ocular manifestations in PAPS. We described an association between livedo and amaurosis fugax. Prospective studies are needed to promote the best treatment and avoid blindness in PAPS patients.

No evidence for thrombophilia in patients with retinal venous occlusion: a systematic GRADE-based review

Retinal venous occlusion represents a common retinal disorder that untreated often leads to severely reduced vision. While general risk factors for vascular disease are known to increase the risk of an event, the role of thrombophilia is controversial. The purpose of this systematic review was to evaluate the evidence for thrombophilia investigation in patients presenting with retinal venous occlusion. Eligible studies were identified by a MESH-based search in PubMed 11-13 of March 2015. The level of evidence was stated according to the guidelines published by the GRADE working group using three levels for quality of evidence: high, moderate and low. A total of 118 studies relating to the study question were identified. After excluding case stories, commentaries, cross-sectional studies and reviews/expert opinions, 28 original papers and two meta-analyses were included in the final qualitative synthesis. The majority of studies were small case-control studies, and only one large cohort study was identified. No randomized controlled trials were retrieved. All the studies were categorized as low quality of evidence. Systematic thrombophilia screening in patients presenting with retinal venous occlusion cannot be recommended.

Ocular manifestations in antiphospholipid syndrome

Antiphospholipid syndrome (APS) is characterized by increased hypercoagulability and divergent symptoms including ocular manifestations. In APS patients arterial and/or venous thromboses and repeated fetal loss are diagnosed in presence of antiphospholipid (aPL) antibodies. Antiphospholipid antibodies are heterogeneous group of immunoglobulins with different antigenic structure. Primary APS is defined in the absence of underlying disease, while secondary APS is seen within another pathological condition. In both primary and secondary APS ocular and neuroophthalmic manifestations, such as retinal arteritis, retinal venous occlusion, ischemic optic neuropathy, transient loss of vision - amaurosis fugax, diplopia and others can be diagnosed. In secondary APS occlusion of central retinal artery and vein (OACR, OVCR) is the most common finding, thus when found in younger patients it should be considered indicative of APS. Bilateral ocular changes are considered more significant since they affect both ocular function and life prognosis.

The antiphospholipid antibody syndrome: diagnostic aspects

PURPOSE OF REVIEW

The antiphospholipid antibody syndrome is an important cause of arterial and/or venous thrombosis. In this review the authors discuss recent trends in the clinical and laboratory diagnosis of this syndrome that are of relevance to ophthalmologists.

RECENT FINDINGS

The diagnostic criteria of antiphospholipid antibody syndrome have been reviewed and revalidated recently. Few prospective studies have been conducted to determine the prevalence of antiphospholipid antibodies in patients with retinal vascular occlusion and the spectrum of ophthalmologic findings in patients with established antiphospholipid syndrome. New antibody tests for antiphospholipid antibody syndrome are available with increased sensitivity and specificity, but lack of standardization, and interassay and interlaboratory variation makes it difficult to determine their clinical value.

SUMMARY

Ophthalmologists should be familiar with the spectrum of clinical manifestation of antiphospholipid syndrome, the diagnostic criteria of this disease, and be able to carry out a basic laboratory workup for this entity. A high index of suspicion for this disorder is also important in making the diagnosis.

Primary anti-phospholipid antibody syndrome (APS): current concepts

Primary anti-phospholipid syndrome (APS) is a thrombophilic state characterized by recurrent arterial and venous thrombosis, recurrent pregnancy loss, and the presence of circulating anti-phospholipid antibodies that may be responsible for thrombophilia and pregnancy morbidity. Ophthalmologic features are present in 15-88% of the patients with primary APS, thus ophthalmologists are one of the first physicians to whom the patient will present. An accurate diagnosis may save the patient from recurrent, potentially life-threatening thrombosis. In the U.S.A., an estimated 35,000 new cases of APS-related venous thrombosis occur each year in a population that is several decades younger than the patient population typically affected by thrombosis. Clinical features, such as chorea, transverse myelitis, cardiac valvular lesions, and accelerated atherosclerosis, are hypothesized to be due to a direct tissue-antibody interaction and cannot be explained purely by thrombosis. The use of recently proposed, well-defined diagnostic criteria, and better standardization of laboratory assays for the anti-phospholipid antibodies should help enable epidemiological surveys to establish the prevalence of these antibodies in patients with thrombosis and in the general population. Diagnosis of APS should be considered in all patients with recurrent systemic or ocular thrombosis in the absence of known risk factors. Several well-designed prospective studies show an increased risk of thrombosis in the presence of medium to high antibody level. With ocular involvement in as many as 88% of APS patients, an ophthalmic assessment should be an integral part of the clinical work-up of any patient with suspected or confirmed APS. The presence of isolated ocular thrombophilia with persistently elevated anti-phospholipid antibodies or lupus coagulant should confirm the diagnosis of APS. Management of these patients must be a multi-disciplinary effort with either a rheumatologist or a hematologist having the overall responsibility for coordinating treatment and monitoring the patient's immune status and anticoagulation. Treatment of isolated ocular thrombophilia in the presence of moderate to high titers of antiphospholipid antibodies should be on the same principles as patients with APS to prevent recurrent ocular or cerebral thrombosis.

Primary antiphospholipid syndrome presenting with a branch retinal artery occlusion in a 15-year-old boy

Acute vascular events are rare in the pediatric population, but there is an association with the presence of antiphospholipid antibodies. When there is no other underlying medical disorder, this is referred to as primary antiphospholipid syndrome. We present a case of a 15-year-old boy who developed an acute superior branch retinal artery occlusion. Complete evaluation revealed significant elevations in antiphospholipid antibodies. To our knowledge, there are no cases in children of primary antiphospholipid syndrome presenting with this clinical manifestation.

Central retinal vein occlusion and thrombophilia

Central retinal vein occlusion is one of the commonest vascular diseases of the eye. The pathogenesis is multifactorial with both local factors and systemic diseases being aetiologically important. Many thrombophilic conditions have recently been identified and studies looking at their potential role in CRVO have been undertaken. The aim of this review is to critically appraise these studies as to date many have given conflicting results, making it far from clear what role thrombophilic conditions play in CRVO. It appears that hyperhomocysteinaemia and antiphospholipid syndrome are causes of CRVO and there is evidence that disorders causing hypofibrinolysis may also be important. The common hereditary thrombophilic conditions however do not appear to be strong risk factors but larger studies are needed for a definitive answer.

Long-term follow-up of ischaemic retinopathy in the antiphospholipid syndrome with lupus-like disease

PURPOSE

Antiphospholipid syndrome (APS), as an acquired prothrombotic disorder, is increasingly being recognised as an important cause of systemic venous and arterial thrombosis. The defining feature of the condition is the presence of raised levels of antibodies to negatively charged phospholipids in the serum.

METHODS

We describe 2 cases of APS with ocular involvement and review the recent literature. Both patients experienced acute visual loss. It was the presenting symptom in one case--a finding that led to the diagnosis of the syndrome.

RESULTS

Management with anticoagulation therapy, in which the International Normalised Ratio (INR) has been maintained at or above 3, resulted in reperfusion of the ischaemic retina and stabilisation of the retinopathy in one patient, whilst in the other case, where the INR was less than 3, irreversible visual loss occurred.

CONCLUSION

Anticoagulation with warfarin appears to result in reperfusion of ischaemic retina with stabilisation of the neovascular process when the INR is greater than 3.

Coagulation abnormalities and their neuro-ophthalmologic manifestations

Congenital and acquired hypercoagulable states arise from an imbalance between procoagulant and anticoagulant forces. Although these conditions are present throughout the vascular tree, they typically give rise to local thrombotic lesions in discrete segments of the veins or arteries; this suggests that focal defects in the vascular wall or blood flow must be associated with a hypercoagulable state to produce thrombosis. Numerous new factors associated with hypercoagulability have been described in the past few years. Congenital and acquired hypercoagulable states are reviewed here, with an emphasis on recent data on focal thrombosis involving the eye and central nervous system.