Retinal vasculitis

Visual outcomes and prognostic factors in ischaemic retinal vasculitis

PURPOSE

Our aim was to describe the visual outcomes and determine the clinical factors in ischaemic retinal vasculitis (IRV) that were predictive of a poor visual prognosis or infectious aetiology.

METHODS

Retrospective cohort study of consecutive presentations of IRV to Auckland District Health Board from 2009 to 2022.

RESULTS

The median age at presentation was 39.2 years and 108 (53.7%) were women. The total median follow-up was 4.8 years. Infectious aetiology was present in 151 eyes (52.1%). Moderate visual loss (20/50 to 20/200) occurred in 20 eyes (6.9%) and severe visual loss (≤20/200) occurred in 41 eyes (14.1%). Median visual acuity was 20/30 (IQR 20/25 to 20/100) on presentation and 20/25 (IQR 20/20 to 20/50) at final follow-up. Retinitis (HR 4.675 p=0.048) and cystoid macular oedema (CME) (HR 7.265 p<0.001) were significantly associated with vision loss. There was concurrent macular ischaemia in 26 eyes (19.4%) and CME in 52 eyes (17.9%). Retinitis was predictive of infectious aetiology (p=0.006) and cotton wool spots for non-infectious aetiology (p<0.001). Retinal haemorrhage (HR 5.580 p=0.001), retinal vein occlusion (HR 5.071 p=0.001) and quadrants of ischaemia (HR 2.222 p=0.025) were significantly associated with vitreous haemorrhage.

CONCLUSION

In patients with IRV, 21% of affected individuals sustained moderate-to-severe vision loss over 5 years. Ultra-widefield fluorescein angiography can be used to quantify the risk of neovascular complications and guide treatment.

Cryoglobulin-Associated Retinal Vasculitis: Retrospective Case Series

Purpose: To highlight clinical and imaging features of 5 patients diagnosed with retinal vasculitis and cryoglobulins. Methods: This retrospective case series describes clinical and angiographic features of retinal vasculitis and serum cryoglobulins and is the most extensive series to our knowledge. Results: Five female patients were diagnosed with retinal vasculitis and serum cryoglobulins. The average age at time of cryoglobulin identification was 46 years (range, 28-72 years), although retinal vasculitis had been present for various durations. Fluorescein angiograms demonstrated large-vessel and small-vessel segmental leakage in 3 patients, only large-vessel segmental leakage in 1 patient, and only small-vessel segmental leakage in 1 patient. Treatment included topical steroids, intraocular steroid injections, oral corticosteroids, oral antimetabolites, and biologic therapy. At the time of this report, 4 of 5 patients had persistent angiographic leakage; however, none had retinal vascular occlusions. Conclusions: Various treatments were efficacious, although resolution was difficult. No patient experienced retinal vascular occlusions or other types of end-organ compromise.

A systematic review of OCT and OCT angiography in retinal vasculitis

BACKGROUND

Retinal vasculitis is a component of uveitis for which the Standardisation of Uveitis Nomenclature (SUN) working group has no standard diagnostic criteria or severity grading. Fluorescein angiography is the gold standard test to assess retinal vasculitis, but is invasive and time-consuming. Optical coherence tomography (OCT) provides non-invasive detailed imaging of retinal structures and abnormalities, including blood vessel architecture and flow with OCT angiography (OCT-A). However, use of OCT in retinal vasculitis beyond assessing macular oedema, is not well established. We conducted a systematic review to understand the features of retinal vasculitis in OCT, Enhanced-depth imaging OCT (OCT-EDI) and OCT-A imaging.

METHODS

The systematic search was done in March 2022 and updated in January 2023, through PubMed, EMBASE and the Web of Science database for studies related to OCT, OCT-EDI and OCT-A findings and retinal vasculitis. Bias assessment was assessed using JBI Critical Appraisal Checklist, and any findings associated with retinal vasculitis were extracted by qualitative analysis.

RESULTS

We identified 20 studies, including 8 articles on OCT, 6 on OCT-EDI and 6 on OCT-A. The studies included analytical retrospective studies, case-series, and a case-control study. Five OCT studies reported secondary complications could be detected, and four reported retinal thickness alteration in retinal vasculitis. Five studies explored choroidal thickness alteration in OCT-EDI, and four explored capillary density alterations in retinal vasculitis using OCT-A. The heterogeneity in the studies' analysis and design precluded a meta-analysis.

DISCUSSION

There were no clear OCT, OCT-EDI or OCT-A findings that demonstrated potential to supersede fluorescein angiography for assessing retinal vasculitis. Some signs of macular structural effects secondary to retinal vasculitis may help prognostication for vision. The OCT signs of inflamed retinal vessels and perivascular tissue is an unexplored area.

Treatment of non-infectious retinal vasculitis

Retinal vasculitis (RV) refers to an entity in which the retinal vasculature is inflamed, frequently with indications of inflammation elsewhere in the eye. Non-infectious RV can be idiopathic or associated with systemic disease, ocular conditions, and malignancy. It can also be classified based on the vessel affected: artery, vein, or both. Due to the lack of strong evidence-based treatment trials and algorithms for RV, physicians must often rely on their experience, which creates great variability in treating this entity. This article provides an overview of various treatment modalities used in the management of non-infectious RV, with a focus on immunomodulatory therapies. We outline a potential stepwise approach of starting with steroids to control the acute inflammation and subsequently changing to immunomodulatory therapy (IMT) for long-term treatment.

Meta-analysis of the genetic association between PTPN22, CTLA-4 variants and risk of uveitis

BACKGROUND

Though the risk of PTPN22, CTLA-4 genetic variants with uveitis have been developed, the combined results still remain uncertain and controversial.

OBJECTIVES

To perform a meta-analysis to estimate the precise association of PTPN22 (rs2488457, rs2476601) and CTLA-4 (rs231775, rs5742909, rs4553808, and rs3087243) polymorphisms with uveitis susceptibility.

METHOD

Five electronic databases (PubMed, Embase, Web of Science, CBM, CNKI) were systematically searched for relevant literature up to July 20, 2021. All statistical analysis were evaluated by STATA 12.0 software and R programming language.

RESULTS

Our meta-results indicated that PTPN22 rs2488457 conferred positive susceptibility to uveitis (OR=1.18, 95%CI=1.02-1.38, p=0.029). In stratified analysis by ethnicity, rs2488457 C allele had a growing tendency towards uveitis in Asian region (OR=1.21, 95%CI=1.00-1.45, p=0.046). For CTLA-4 rs231775, subgroup analysis based on ethnicity manifested a negative association among uveitis individuals in Africa region (OR=0.25, 95%CI=0.19-0.33, p<0.001). For CTLA-4 rs4553808, subgroup analysis by disease type revealed that GG genotype was associated with an elevated risk of Behcet's disease (OR=3.22, 95%CI=1.05-9.90, p=0.042).

CONCLUSIONS

Our research revealed that PTPN22 rs2488457 conferred strong susceptibility to uveitis in general, especially in Asian region. CTLA-4 rs231775 conveyed protection against uveitis in African populations and CTLA-4 rs4553808 displayed an increased risk of Behcet's disease.

Structural Endpoints and Outcome Measures in Uveitis

Most uveitis entities are rare diseases but, taken together, are responsible for 5-10% of worldwide visual impairment which largely affects persons of working age. As with many rare diseases, there is a lack of high-level evidence regarding its clinical management, partly due to a dearth of reliable and objective quantitative endpoints for clinical trials. This review provides an overview of available structural outcome measures for uveitis disease activity and damage in an anatomical order from the anterior to the posterior segment of the eye. While there is a multitude of available structural outcome measures, not all might qualify as endpoints for clinical uveitis trials, and thorough testing of applicability is warranted. Furthermore, a consensus on endpoint definition, standardization, and "core outcomes" is required. As stipulated by regulatory agencies, endpoints should be precisely defined, clinically important, internally consistent, reliable, responsive to treatment, and relevant for the respective subtype of uveitis. Out of all modalities used for assessment of the reviewed structural outcome measures, optical coherence tomography, color fundus photography, fundus autofluorescence, and fluorescein/indocyanine green angiography represent current "core modalities" for reliable and objective quantification of uveitis outcome measures, based on their practical availability and the evidence provided so far.

To Study the Role of Serum Homocysteine Levels and Ocular Involvement in Retinal Vasculitis

Idiopathic retinal vasculitis is a chronic disease of unknown aetiology which results in ocular morbidity in patients of productive age group. Homocysteine has been implicated in various ocular conditions like age-related macular degeneration, retinal vein occlusions, diabetic retinopathy, and optic nerve diseases. We conducted a study to investigate the relation between serum homocysteine levels and retinal vasculitis at a tertiary care centre in North India. In this case-control study, 32 cases and 64 controls were included and the duration was from June 2017 to March 2019. Serum homocysteine of cases and controls was detected by reflectance photometry using VITROS Chemistry Products HCY 2 (Homocysteine) and the normal range of serum homocysteine as per this method was 6.60 to 14.80 micro mol per litre. Our study found that of the total 32 retinal vasculitis patients, serum homocysteine was raised in 65.62% (21 cases out of 32) and in 70.31% of control group (45 out of 64). Chi square test results showed that there was no significant association found between S. homocysteine levels and Reticular vasculitis (P: 0.64). The two groups were comparable in terms of the age with mean ± SD in cases being 33.47 ± 8.336 years and controls being 35.16 ± 8.568 years with a P value of 0.37 being statistically insignificant. The data collected was analysed using SSPS-16 (Statistical Package for Social Sciences Version 16) software and test of association was Odd's ratio. Power of study was 80% and P < 0.05 is considered statistically significant. We found that there is no significant association between raised serum homocysteine and retinal vasculitis (with P < 0.64). Odds ratio was 0.80(0.33-1.99) implying that the cases and controls were statistically significantly different with respect to homocysteine levels.

Clinical features, visual outcome, and poor prognostic factors in occlusive retinal vasculitis

OBJECTIVE

To investigate the clinical features, treatment, and visual outcome of occlusive retinal vasculitis (ORV), with a focal analysis on prognostic factors associated with poor visual outcome.

METHODS

We conducted a retrospective cohort study in patients diagnosed with ORV with at least 6 months of follow-up. Demographic data, ocular features, best corrected visual acuity (BCVA), fluorescein angiography, therapy regimens, and outcomes were collected from the Massachusetts Eye Research and Surgery Institution database from 2006 to 2017. Multivariate logistic regression was performed to analyze the factors independently predicting poor visual outcome.

RESULTS

Fifty-two patients (69 eyes) were enrolled, 42 with noninfectious cause, 9 with infectious cause, and 1 with masquerade uveitis. Systemic inflammatory diseases, including necrotizing vasculitis, sarcoidosis, multiple sclerosis, systemic lupus erythematosus, and Behçet's disease comprised the causes of ORV. Forty of the 42 patients with noninfectious ORV received immunomodulatory therapy (IMT), and 35 patients (87.5%) were able to achieve steroid-free remission. Compared with the BCVA at the initial visit (0.66 [±0.11] logMAR), there was significant improvement at the most recent visit (0.37 [±0.07] logMAR, p = 0.001). A multivariate analysis demonstrated that optic nerve atrophy, macular ischemia, and poor BCVA at initial presentation were independently correlated with poor visual outcome.

CONCLUSIONS

ORV could be caused by a wide spectrum of systemic inflammatory diseases. Aggressive IMT is preferred to achieve a steroid-free durable remission for noninfectious ORV. Optic nerve atrophy, macular ischemia, and poor BCVA at the initial visit predict a poor visual outcome.

Reperfusion of retinal ischemia in retinal occlusive vasculitis with nicotinic acid and infliximab in Adamantiades-Behçet's disease

To describe a case of ischemic retinal vasculitis in Adamantiades-Behçet disease (ABD) that demonstrated significant resolution of retinal ischemia following treatment with nicotinic acid and infliximab.Observations: A 12-year-old male with a history of recurrent oral ulcers, fevers, and failure to thrive was admitted to the hospital with fever, oral and perirectal mucositis, and poor oral intake one month before presentation to uveitis clinic. He was suspected to have ABD and was treated with three doses of intravenous (IV) methylprednisolone (30 mg/kg/day) which led to improvement in his systemic symptoms. One week after admission, he complained of decreased vision in both eyes (OU), during which he was found to have anterior uveitis in OU and was referred to the Uveitis Clinic. Upon examination, his visual acuity was 20/80 in OU. Intraocular pressures were within normal limits. Anterior chamber evaluation revealed 0.5+ cells and 1.5+ flare in OU. Posterior examination revealed pale optic nerve, sclerosis and vascular sheathing of retinal arteries, and collateral vessels in OU. Fluorescein angiography (FA) showed optic disc leakage and widespread retinal ischemia in OU. The patient was diagnosed with retinal occlusive vasculitis associated with ABD. He was initially treated with infliximab (5 mg/kg), systemic methylprednisolone, and mycophenolate mofetil. Three months later, his BCVA improved to 20/70 OU with slight improvement of retinal ischemia on FA. Nicotinic acid was added to his treatment regimen. Due to logistic challenges, he did not receive infliximab treatment during the subsequent three months. However, three months after beginning nicotinic acid therapy, FA revealed significant improvement of his retinal ischemia OU. Conclusion: To our knowledge, the index report is the first to show that nicotinic acid may improve retinal ischemia in vaso-occlusive retinal vasculitis and be an integral part of the treatment regimen of this sight-threatening condition.

Recommendations statement on the immunosuppressive treatment of non-infectious, non-neoplastic, non-anterior uveitis

OBJECTIVE

To generate recommendations on the use of immunomodulators in patients with non-infectious, non-neoplastic intermediate uveitis (IU), posterior uveitis (PU) and panuveitis (PanU) based on best evidence and experience.

METHODS

A multidisciplinary panel of 5 experts was established, who defined the scope, users, and sections of the document. A systematic literature review (SLR) was performed to assess the efficacy and safety of immunomodulatory drugs in patients with non-infectious, non-neoplastic, non-anterior uveitis. The results of the SLR were presented and discussed during an expert meeting in which 34 recommendations were generated. The level of agreement with the recommendations was also tested in 25 additional experts following a Delphi process. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of the experts voted ≥7. The level of evidence and grade or recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence.

RESULTS

The SLR included 33 articles. The 34 recommendations were accepted after 2 Delphi rounds (3 of them were modified after the first round). They include specific recommendations on patients with non-infectious, non-neoplastic, PU and PanU, as well as different treatment guidelines.

CONCLUSIONS

In patients with non-infectious, non-neoplastic, non-anterior uveitis these recommendations might help treatment decision making, due to the lack of robust evidence or other globally accepted algorithms.

Optical coherence tomography angiography

Optical coherence tomography (OCT) was one of the biggest advances in ophthalmic imaging. Building on that platform, OCT angiography (OCTA) provides depth resolved images of blood flow in the retina and choroid with levels of detail far exceeding that obtained with older forms of imaging. This new modality is challenging because of the need for new equipment and processing techniques, current limitations of imaging capability, and rapid advancements in both imaging and in our understanding of the imaging and applicable pathophysiology of the retina and choroid. These factors lead to a steep learning curve, even for those with a working understanding dye-based ocular angiography. All for a method of imaging that is a little more than 10 years old. This review begins with a historical account of the development of OCTA, and the methods used in OCTA, including signal processing, image generation, and display techniques. This forms the basis to understand what OCTA images show as well as how image artifacts arise. The anatomy and imaging of specific vascular layers of the eye are reviewed. The integration of OCTA in multimodal imaging in the evaluation of retinal vascular occlusive diseases, diabetic retinopathy, uveitis, inherited diseases, age-related macular degeneration, and disorders of the optic nerve is presented. OCTA is an exciting, disruptive technology. Its use is rapidly expanding in clinical practice as well as for research into the pathophysiology of diseases of the posterior pole.

Comparison between optical coherence tomography angiography and fluorescein angiography findings in retinal vasculitis

Background

To describe optical coherence tomography angiography (OCT-A) findings in patients with retinal vasculitis and to compare them to current fluorescein angiography (FA) findings.

Methods

This was an observational case series. Nineteen eyes in 10 patients with retinal vasculitis of various etiologies were imaged with FA (TRC-50DX, Topcon) and OCT-A (SD-OCT, Optovue). The images were reviewed and analyzed.

Results

The mean age was 36 years (range 24-67 years); there were three males and seven females. The primary vessels involved were veins (89%). Fourteen eyes (74%) had active inflammatory disease during the study period, with signs of vascular sheathing and perivascular leakage on FA. Interestingly, in this group, OCT-A was not able to detect clear signs of active inflammation around the affected vessels. Nevertheless, OCT-A was able to detect secondary lesions in fourteen eyes (74%), including some findings not clearly shown on FA. Most of these were within the macular area. OCT-A was particularly effective in cases of capillary dropout, increased foveal avascular zone, telangiectasias, shunts, and areas of neovascularization.

Conclusion

FA remains an essential complementary exam for detection of retinal vasculitis. However, OCT-A extends FA findings and affords better assessment of secondary complications.

MICROVASCULAR FLOW ABNORMALITIES ASSOCIATED WITH RETINAL VASCULITIS: A Potential of Mechanism of Retinal Injury

PURPOSE

To investigate the structural optical coherence tomography and related microvascular flow characteristics in eyes with retinal vasculitis.

METHODS

Regions involved with perivascular infiltration in eyes with retinal vasculitis, but no evidence of large vessel occlusion were evaluated with optical coherence tomography (OCT), OCT angiography, and fluorescein angiography.

RESULTS

Ten eyes of 5 patients with a variety of etiologies of retinal vasculitis were evaluated. These patients did not have either cotton wool spots or deeper placoid areas of retinal ischemia. Around large vessels there was perivascular infiltration with leakage and staining seen during fluorescein angiography. Structural OCT showed slight thickening with loss of visualization of normal retinal laminations. OCT angiography showed a lack of flow signal in capillary sized vessels in the same areas. Treatment resulted in a rapid thinning of the affected areas, with the inner and middle layers of the retina becoming thinner than surrounding uninvolved areas. OCT angiography did not show a return of capillary perfusion in these regions. The thickness change in the structural OCT as shown by a heat map had a pattern mimicking the original perivascular infiltration around large retinal vessels.

CONCLUSION

Capillary level perfusion abnormalities can develop in regions adjacent to large vessel inflammatory infiltrate that result in retinal thinning without the development of usual stigmata of acute microvascular flow obstruction such as cotton wool spots. This suggests that retinal damage may occur in retinal vasculitis that would not be recognized without using OCT-based imaging modalities.

Pearls and pitfalls of optical coherence tomography angiography in the multimodal evaluation of uveitis

BACKGROUND

Optical coherence tomography angiography (OCTA) employs a novel imaging algorithm that detects the amplitude or phase decorrelation of blood cell movement. It thus provides a flow map with depth-resolved visualization of the various vascular layers in the posterior pole of the eye including the retina capillary plexus and the choroid. In the past 3 years, the number of research papers on the subject of OCTA in retinal diseases has grown exponentially including important applications in the field of uveitis. While the study of OCTA in uveitic diseases has gained remarkable relevance worldwide, interpretation can be challenging, and many limitations exist in optimally using this advanced system in uveitic eyes. The aim of this review is to describe the many significant applications of OCTA in uveitis disorders and to outline the various limitations that can confound interpretation and support uveitis specialists in the integration of OCTA in the multimodal imaging approach to inflammatory diseases.

MAIN BODY

Unlike conventional angiography that can dynamically detect inflammation and leakage of dye from retinal vessels, OCTA provides other important biomarkers of inflammation. Detailed microvascular reconstruction of normal and abnormal blood vessels and quantitative evaluation are advantages of OCTA analysis. OCTA can therefore non-invasively detect choroidal neovascularization that may complicate inflammatory disorders, and with remarkable depth-resolved capability, OCTA can identify and quantitate flow loss as a manifestation of ischemia and/or inflammation. The areas of flow deficit on OCTA at the level of the inner choroid often co-localize with hypofluorescent lesions with indocyanine green angiography. These regions of presumed choriocapillaris ischemia may occur in placoid disorders. Space-occupying granulomas may occur in disorders such as sarcoid and may or may not co-localize with choriocapillaris ischemia on ICG angiography. Blocking or shadowing artifacts should be excluded when evaluating inner choroidal abnormalities with OCT angiography. Fundus autofluorescence may assess the metabolic function of the retinal pigment epithelium (RPE) and the viability of the overlying photoreceptors and thus the activity of inflammation associated with uveitic lesions. The photoreceptors are physiologically maintained by the diffusion of oxygen from the choriocapillaris below and, to a lesser extent, from the deep retinal capillary plexus above. The depth-resolved capability of OCTA may therefore provide additional significant microvascular information about these vascular layers that may be driving the development of hyper-autofluorescent RPE inflammation and photoreceptor loss.

CONCLUSIONS

The implementation of OCTA in the evaluation and management of uveitis disorders is being spurred by our greater knowledge and understanding of its application. In order to take full advantage of this exciting new imaging modality, however, uveitis specialists must understand the limitations of interpretation and potential artifact-related pitfalls in assessment and should continue to support evaluation with multimodal imaging to best optimize diagnoses and treatment of inflammatory diseases.

Clinical Features and Incidence Rates of Ocular Complications in Patients With Retinal Vasculitis

PURPOSE

To describe the incidence rates of visual loss and ocular complications in patients with retinal vasculitis (RV).

DESIGN

Retrospective cohort study.

METHODS

Clinical data were collected for 96 patients (175 eyes) diagnosed with RV from 2003 to 2013. Main outcome measures included rates of visual loss and ocular complications. Comparison of outcomes in patients with a relapsing vs nonrelapsing disease also were analyzed.

RESULTS

Over a median follow-up of 44 months (range: 1-153 months), the rate of visual loss to 20/50 or worse was 0.13 per eye-year (/EY, 95% confidence interval [CI], 0.09/EY to 0.18/EY) and to 20/200 or worse was 0.06/EY (95% CI, 0.04/EY to 0.08/EY). The most common complications were cataract (0.31/EY), epiretinal membrane (0.16/EY), and recurrent macular edema (0.09/EY). Patients with a relapsing course (median number of relapses = 1, range: 1-6) appeared to have greater risk for visual loss to 20/50 (odds ratio [OR] = 2.07; 95% CI, 0.88-4.90, P = .09) and 20/200 or worse (OR = 2.49; 95% CI, 0.98-6.30, P = .05). Immunosuppressive drug therapy lowered the risk of visual loss, independent of relapsing disease course (OR = 0.79; 95% CI, 0.66-0.94, P = .01 and OR = 0.73; 95% CI, 0.57-0.93, P = .01 for the 20/50 or worse and 20/200 or worse thresholds, respectively).

CONCLUSIONS

Rates of visual loss and complications among patients with RV were similar to reported rates in noninfectious uveitides. Treatment with immunosuppressive drugs lowered the risk of visual loss. A relapsing course suggested an increased risk for visual loss but was not statistically significant, perhaps owing to low numbers of recurrences.

Clinical Outcome of Retinal Vasculitis and Predictors for Prognosis of Ischemic Retinal Vasculitis

PURPOSE

To determine factors affecting the visual outcome in eyes with retinal vasculitis and the rate of neovascularization relapse in ischemic vasculitis.

DESIGN

Retrospective cohort study.

METHODS

We reviewed 1169 uveitis patients from Moorfields Eye Hospital, London, UK. Retinal vasculitis was observed in 236 eyes (121 ischemic, 115 nonischemic) that were compared with a control group (1022 eyes) with no retinal vasculitis. Ultra-widefield fluorescein angiography images were obtained in 63 eyes with ischemic vasculitis to quantify area of nonperfusion measured as ischemic index.

RESULTS

The risk of vision loss was significantly more in the retinal vasculitis compared with the non-vasculitis group (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.24-2.25, P = .001). Retinal vasculitis had twice the risk of macular edema compared to the non-vasculitis group. Macular ischemia increased the risk of vision loss in vasculitis eyes by 4.4 times. The use of systemic prednisolone in eyes with vasculitis was associated with a reduced risk of vision loss (HR 0.36, 95% CI 0.15-0.82, P = .01). Laser photocoagulation was administered in 75 eyes (62.0%), out of which 29 (38.1%) had new vessel relapse and required additional laser treatment. The median ischemic index was 25.8% (interquartile range 10.2%-46%). Ischemia involving ≥2 quadrants was associated with increased risk of new vessel formation (HR 2.7, 95% CI 1.3-5.5, P = .003).

CONCLUSIONS

Retinal vasculitis is associated with an increased risk of vision loss, mainly secondary to macular ischemia, and has a higher risk of macular edema compared to eyes with no vasculitis. Ischemia involving ≥2 quadrants is a risk factor for new vessel formation.

Ocular manifestations of systemic lupus erythematosus: a clinical review

Although the eye itself is regarded an ‘immune-privileged’ organ, systemic lupus erythematosus (SLE) can affect every ocular structure, leading, if left untreated, to significant visual loss or even blindness. Since ocular inflammation in SLE can antedate the diagnosis of the systemic disease and cause significant morbidity, prompt diagnosis and treatment of the underlying systemic autoimmune disease is imperative.

Kyrieleis plaques associated with Herpes Simplex Virus type 1 acute retinal necrosis

We report the case of a 55-year-old immunocompetent male who presented with features typical of acute retinal necrosis (ARN). Polymerase chain reaction of the aqueous tap was positive for Herpes Simplex Virus (HSV) – 1. Following therapy with intravenous Acyclovir, followed by oral Acyclovir and steroids, there was marked improvement in the visual acuity and clinical picture. At one week after initiation of treatment, Kyrieleis plaques were observed in the retinal arteries. They became more prominent despite resolution of the vitritis, retinal necrosis and vasculitis and persisted till six weeks of follow-up, when fluorescein angiography was performed. The appearance of this segmental retinal periarteritis also known as Kyrieleis plaques has not been described in ARN due to HSV-1 earlier.

Association analysis of TGFBR3 gene with Behçet's disease and idiopathic intermediate uveitis in a Caucasian population

BACKGROUND

Transforming growth factor β (TGFβ) is an important immunoregulatory cytokine in regulatory T cell (Treg) and Th17-mediated pathology, including uveitis due to Behçet's disease (BD). Of the three isoforms, TGFβ2 is found at highest levels in the aqueous humour of uninflamed eyes. TGFβ signals through a cell-surface receptor comprising three subunits (TGFBR1, 2 and 3). TGFBR3 is considered necessary for TGFβ2 signal transduction, but not for other isoforms. A polymorphism in TGFBR3 (rs1805110) has previously been identified in Han Chinese patients with BD. We investigated the frequency of this polymorphism in a Caucasian population with BD and idiopathic intermediate uveitis (IIU).

METHODS

The single-nucleotide polymorphism (SNP) rs1805110 in TGFBR3 was genotyped in 75 BD patients, 92 IIU disease controls and 85 disease-free controls. The association with both diseases was analysed using Fisher's exact test.

RESULTS

No significant difference in rs1805110 allele or genotype frequency was observed. A low frequency of the T allele was observed (5.88% control, 9.33% BD, 10.33% IIU) with the TT genotype absent in patients with BD and IIU (1.18% control, 0% BD and 0% IIU). Stratification analysis according to clinical features of BD did not associate with the tested SNP.

CONCLUSIONS

RS1805110 is not associated with BD or IIU in Caucasian patients. The T allele frequency is consistent with that presented for Caucasian populations in the HapMap database (p>0.05). Our results differ from the previous analysis in Han Chinese patients (p<0.0001), however, the possibility of having a much smaller effect due to the low minority frequency cannot be excluded.

Gender differences in ocular blood flow

Gender medicine has been a major focus of research in recent years. The present review focuses on gender differences in the epidemiology of the most frequent ocular diseases that have been found to be associated with impaired ocular blood flow, such as age-related macular degeneration, glaucoma and diabetic retinopathy. Data have accumulated indicating that hormones have an important role in these diseases, since there are major differences in the prevalence and incidence between men and pre- and post-menopausal women. Whether this is related to vascular factors is, however, not entirely clear. Interestingly, the current knowledge about differences in ocular vascular parameters between men and women is sparse. Although little data is available, estrogen, progesterone and testosterone are most likely important regulators of blood flow in the retina and choroid, because they are key regulators of vascular tone in other organs. Estrogen seems to play a protective role since it decreases vascular resistance in large ocular vessels. Some studies indicate that hormone therapy is beneficial for ocular vascular disease in post-menopausal women. This evidence is, however, not sufficient to give any recommendation. Generally, remarkably few data are available on the role of sex hormones on ocular blood flow regulation, a topic that requires more attention in the future.

Ischemic retinal vasculitis and its management

Ischemic retinal vasculitis is an inflammation of retinal blood vessels associated with vascular occlusion and subsequent retinal hypoperfusion. It can cause visual loss secondary to macular ischemia, macular edema, and neovascularization leading to vitreous hemorrhage, fibrovascular proliferation, and tractional retinal detachment. Ischemic retinal vasculitis can be idiopathic or secondary to systemic disease such as in Behçet's disease, sarcoidosis, tuberculosis, multiple sclerosis, and systemic lupus erythematosus. Corticosteroids with or without immunosuppressive medication are the mainstay treatment in retinal vasculitis together with laser photocoagulation of retinal ischemic areas. Intravitreal injections of bevacizumab are used to treat neovascularization secondary to systemic lupus erythematosus but should be timed with retinal laser photocoagulation to prevent further progression of retinal ischemia. Antitumor necrosis factor agents have shown promising results in controlling refractory retinal vasculitis excluding multiple sclerosis. Interferon has been useful to control inflammation and induce neovascular regression in retinal vasculitis secondary to Behçet's disease and multiple sclerosis. The long term effect of these management strategies in preventing the progression of retinal ischemia and preserving vision is not well understood and needs to be further studied.

The course of retinal vasculitis

AIMS

To determine if characteristics of retinal vasculitis correlate with ocular complications, or the response to different lines of treatment.

MATERIALS AND METHODS

We performed a computerised database analysis of 56 patients evaluated for uveitis at the Casey Eye Institute from September 1985 until May 2010. All patients had non-infectious retinal vasculitis and at least 1 year of follow-up.

RESULTS

Although occlusive vasculitis was rare, retinal neovascularisation occurred much more commonly in the occlusive vasculitis subgroup than among the non-occlusive vasculitis subgroup (p<0.01). Epiretinal membrane (ERM) was found more commonly in the retinal vasculitis patients who presented with cotton wool spots and intraretinal haemorrhage compared to retinal vasculitis patients who presented with sheathing noted on clinical examination (p<0.01). Smoking was significantly related to vision loss. Age at presentation below 40 years correlated with therapy beyond oral corticosteroids

CONCLUSIONS

The heterogeneity of retinal vasculitis should be considered in providing prognostic information. Neovascularisation occurs more commonly in occlusive retinal vasculitis, and ERM is diagnosed more frequently in conjunction with cotton wool spots and intraretinal haemorrhage rather than just vascular sheathing. Cigarette use predicts visual loss and patients who are relatively young often receive treatment beyond oral corticosteroids.

[Retinal vasculitis as manifestation of multiple sclerosis]

Multiple sclerosis (MS) is the most common chronic disease of the central nervous system in Germany. In 80 % of patients early stages of the disease are characterized by a clinically isolated episodic course. Ocular manifestations are common and mostly affect the optic nerve or the uvea and in some cases the retinal vessels. Here we report on a bilateral retinal vasculitis as the first manifestation of MS in a 27-year-old patient. All symptoms resolved after high dose steroid treatment; however, intensive follow-up is crucial due to potential occlusive, ischemic complications.

Localized, single-organ vasculitis: clinical presentation and management

The term vasculitis usually evokes a systemic disease with catastrophic outcomes; however, vasculitides may also present in a localized form, with a better prognosis when compared with their systemic counterpart. In order to avoid confusion and facilitate classification, the term single-organ vasculitis (SOV) has been proposed. Remarkably, current criteria for the classification of the vasculitis do not include the SOV term, due in part to the lack of appropriate definitions, since most data come from case series; moreover, the scarce information available is also extremely heterogeneous. This review focuses on the epidemiology, clinical course, prognosis, and suggested treatment of the SOV, with emphasis in the most recent information available.

Profile of retinal vasculitis in a tertiary eye care center in Eastern India

Aims:

To provide a fact file on the etiology, clinical presentations and management of retinal vasculitis in Eastern India.

Materials and Methods:

Retrospective, record based analysis of retinal vasculitis cases in a tertiary care center in Eastern India from January 2007 to December 2009.

Results:

One hundred and thirteen eyes of 70 patients of retinal vasculitis were included in this study. Sixty (85.7%) patients were male (mean age 33± 11.1 years) and 10 (14.3%) were female (mean age 32.4 ± 13.6 years). Vasculitis was bilateral in 43 (61.4%) and unilateral in 27 (38.6%) patients. Commonest symptoms were dimness of vision (73; 64.6%) and floaters (36; 31.9%). Vascular sheathing (82; 72.6%) and vitritis (51; 45.1%) were commonest signs. Mantoux test was positive in 21 (30%) patients but tuberculosis was confirmed in only four (5.71%) patients. Raised serum angiotensin-converting enzyme level and positive antinuclear antibody level were reported in four (5.71%) patients each. Human leukocyte antigen B5 (HLA B5) marker was present in one (1.4%) patient. However, none of the total 70 patients were found to have a conclusively proven systemic disease attributable as the cause of retinal vasculitis. Oral corticosteroid (60; 85.7%) was the mainstay of treatment. Forty-eight (42.5%) eyes maintained their initial visual acuity and 43 (38%) gained one or more line at mean follow-up of 16.6± 6.3 months.

Conclusion:

Retinal vasculitis cases had similar clinical presentations and common treatment plan. There was no systemic disease association with vasculitis warranting a careful approach in prescribing investigations.

Kyrieleis plaques in cytomegalovirus retinitis

Purpose

The purpose of this study is to report a case of Kyrieleis plaques (segmental retinal periarteritis) associated with cytomegalovirus (CMV) retinitis.

Methods

A 47-year-old female with recently diagnosed human immunodeficiency virus and a CD4 count of 55 cells/µl presented with decreased vision and floaters in her left eye. Ophthalmic examination revealed an advancing border of white granular CMV retinitis extending into the macula. Intraocular aqueous specimen contained 420,000 copies/ml of CMV DNA by polymerase chain reaction. The patient was treated with intravitreal foscarnet and oral valganciclovir.

Results

Kyrieleis plaques involving the retinal arteries were noted on presentation and increased during the first 6 weeks of treatment as the retinitis faded. The plaques on fluorescein angiography did not leak fluorescein dye and slowly faded over 5 months.

Conclusions

Kyrieleis plaques can be seen in the setting of CMV retinitis. These plaques can be differentiated from vascular sheathing and frosted branch angiitis by its occurrence only in the retinal arteries and the absence of leakage of fluorescein dye.

VZV retinal vasculitis without systemic infection: diagnosis and monitoring with quantitative Polymerase Chain Reaction

To report a case of unilateral varicella zoster virus (VZV) retinal vasculitis aspect in an immunocompetent child without systemic infection. Clinically, no signs of retinal necrosis or frosted branch vasculitis were present. This is an observational case report. Quantitative PCR was performed on the aqueous humor (AH) using primers specific for herpes virus (cytomegalovirus, Epstein-Barr virus, herpes simplex virus 1-2, and VZV). The patient was treated with intravenous acyclovir, intravitreous ganciclovir, and oral valacyclovir. A positive quantitative PCR result was found for VZV DNA (1.72 x 10(6) viral copies/ml) in the AH. After 6 months, PCR of the AH was negative. Herpes viruses are involved in the pathogenesis of isolated retinal vasculitis. This case demonstrates that quantitative PCR is useful to detect viral DNA in AH and to monitor the viral activity and the therapeutic response.

The association of the PTPN22 620W polymorphism with Behcet's disease

OBJECTIVES

A single nucleotide polymorphism (SNP) of the gene encoding protein tyrosine phosphatase type 22 (PTPN22 620W) has recently been described as a strong common genetic risk factor for human autoimmune disease. We have analysed the association of PTPN22 620W in patients with Behçet's disease (BD).

METHODS

Genomic DNA was obtained from 270 patients with BD from the UK and the Middle East. Normal controls (n = 203) were collected from the same populations. Patients with idiopathic retinal vasculitis from the UK (n = 136) were used as disease controls. PTPN22 620W was detected by SSP-PCR analysis and agarose gel electrophoresis.

RESULTS

The results showed an inverse correlation between the presence of PTPN22 620W and Behçet's disease in either patient group tested. There was a greatly reduced prevalence in Middle Eastern compared to UK patients and controls. Finally, there was no association with either UK patients with retinal vasculitis compared with UK controls.

CONCLUSIONS

The presence of PTPN22 620W was inversely associated with BD and the distribution of the SNP in the Middle East supports previous findings in the global prevalence.

Interferon-beta and adhesion molecules (E-selectin and s-intracellular adhesion molecule-1) are detected in sera from patients with retinal vasculitis and are induced in retinal vascular endothelial cells by Toll-like receptor 3 signalling

Retinal vasculitis is a major component of ocular inflammation that plays a role in retinal tissue damage in patients with idiopathic uveitis and Behçet's disease. Here we show that type 1 interferons (IFN alpha/beta) were not detected in sera from normal individuals but were identified in up to 46% of the sera from retinal vasculitis patients. The predominant form of IFN observed was IFN-beta, which was detected in 39% of Behçet's disease patients and 47% of idiopathic uveitis patients. Seven patients whose sera contained IFN-beta were monitored prospectively. IFN-beta was shown to be present for 6-12 months in all seven of the sera samples tested. Furthermore, the adhesion molecule profile identified in this study was strikingly different when Behçet's and uveitis patient sera were compared to sera from normal controls. Sera from Behçet's disease patients contained significantly elevated levels of the soluble adhesion molecules, sE-selectin and s-intracellular adhesion molecule-1 (sICAM-1), whereas sera from patients with idiopathic uveitis contained significantly increased sE-selectin. In vitro studies evaluating the cell source of these cytokines revealed that polyriboinosinic polyribocytidylic acid (poly I:C) activated retinal vascular endothelial cells produce sE-selectin, sICAM-1 and IFN-beta. Production of these molecules was inhibited by pretreatment with anti-Toll-like receptor 3 (TLR-3) antibody. In conclusion, IFN-beta, sE-selectin and sICAM-1 are elevated in patients with retinal vasculitis and are induced in retinal vascular endothelial cells in vitro by activating the innate immune system through TLR-3. Further analysis of innate immune signalling may prove to be a novel target for future studies on pathogenic mechanisms and therapeutic approaches in retinal vasculitis.

Non-systemic vasculitic neuropathy

PURPOSE OF REVIEW

This article reviews the literature on non-systemic vasculitic neuropathy, with emphasis on recent advances, summarizing the clinical presentation, diagnosis, pathology, treatment, and outcome of this condition, and speculating on its nosological status vis-à-vis the systemic vasculitides.

RECENT FINDINGS

A new cohort of non-systemic vasculitic neuropathy patients was recently reported. Analysis of the clinical characteristics of this cohort demonstrated a higher incidence of painful, asymmetric, overlapping deficits than in previous studies. Extended follow-up revealed a high relapse rate, low risk of systemic spread, high incidence of chronic pain, relatively good neurological outcome, and low mortality rate. Analysis of therapeutic responses showed better outcomes with combination therapy than corticosteroid monotherapy. Another recent report proposed a role for magnetic resonance angiography in the diagnosis and follow-up of non-systemic vasculitic neuropathy. Recent pathological studies implicated proinflammatory cytokines and matrix metalloproteinase-9 in the mediation of vascular and axonal damage in non-systemic vasculitic neuropathy.

SUMMARY

Non-systemic vasculitic neuropathy is one of many localized vasculitides, with involvement restricted to nerves and (possibly) muscles. Inclusion and exclusion criteria differ between reported cohorts. All require a nerve biopsy diagnostic of or suspicious for vasculitis and no extra-neuromuscular involvement. Patients typically present subacutely with a painful, multifocal/asymmetric, distal-predominant neuropathy. In the absence of clinical or laboratory evidence of systemic vasculitis or a condition predisposing to such, prognosis with treatment is good. Pathological data are supportive of a primary T-cell-mediated immunopathogenesis. Some patients classified as having non-systemic vasculitic neuropathy have a systemic vasculitis presenting with neuropathy; in others, the disease is organ-specific.