Features of retinal arterial macroaneurysms in patients with uveitis

Unilateral Retinal Arteritis and Macroaneurysm in Sarcoidosis

BACKGROUND

Sarcoidosis, an idiopathic systemic disorder characterized by noncaseating granulomas, is often associated with granulomatous uveitis. Anterior segment involvement can present with mutton-fat keratic precipitates, anterior chamber cell, and iris nodules. Sarcoid associated posterior uveitis may present with vitritis, retinal vasculitis, and choroidal lesions.

CASE SUMMARY

Sarcoid-associated retinal vasculitis is classically thought of as predominantly involving veins, but in this case report we describe a 76-year-old Caucasian woman presenting with bilateral posterior uveitis, unilateral optic nerve head granuloma, and retinal arteritis as the first manifestation of ocular involvement in systemic sarcoidosis.

CONCLUSION

This case describes the uncommon first manifestation of ocular involvement in systemic sarcoidosis presenting with unilateral retinal arteritis, macroaneurysms and optic nerve head granuloma.

Angiotensin II is a crucial factor in retinal aneurysm formation

Retinal arterial macroaneurysms are characterized by the acquired fusiform or saccular dilatations of the retinal artery. Angiotensin II (Ang II) is a major signal molecule of the renin-angiotensin system, which exerts a range of pathogenic actions that are relevant to retinal vascular abnormalities. We aimed to study the effect of Ang II on retinal vessels and explore its relationship with retinal aneurysmal disease. C57BL/6J male mice were administered Ang II at 1000 ng/kg/min for 28 days, and the mice given saline served as controls. The mice in the treatment group were treated once daily by gastric gavage of candesartan cilexetil (an antagonist of Ang II type 1 (AT1) receptor) at 100 mg/kg/day. The in vivo imaging of murine retinas was performed using fundus photography, optical coherence tomography, fluorescein angiography, and indocyanine green angiography at 7th, 14th, and 28th days of infusion. At the end of the infusion and treatment, the morphological changes were evaluated by histopathological examination and electron microscopy; the levels of related proteins in murine retinas were examined by antibody array and Western blot analyses. We found that Ang II infusion induced aneurysm formation in mice retina, which presented as either solitary aneurysms or retinal arterial beading. The aneurysm formation was often accompanied with vessel leakage. Moreover, Ang II infusion itself may result in increased vascular permeability and ganglion cell and inner plexiform layer thickening. The blockade of AT1 receptors by systemic administration of candesartan cilexetil alleviated the Ang II-induced retinal vasculopathy. The protein level analysis further showed that Ang II upregulated IL-1β, PDGFR-β, and MMP-9 expression, and the expression of IL-1β could be inhibited by AT1 receptor antagonist. Our study provides evidence that Ang II is a crucial factor in retinal aneurysm formation and vessel leakage. It is probably the combined effect of Ang II on vessel inflammatory response, pericyte function, and extracellular matrix remodeling that predisposes the retinal arterial wall to aneurysm formation and blood-retinal barrier breakdown.

Retinal Fundus Multi-Disease Image Dataset (RFMiD): A Dataset for Multi-Disease Detection Research

The world faces difficulties in terms of eye care, including treatment, quality of prevention, vision rehabilitation services, and scarcity of trained eye care experts. Early detection and diagnosis of ocular pathologies would enable forestall of visual impairment. One challenge that limits the adoption of computer-aided diagnosis tool by ophthalmologists is the number of sight-threatening rare pathologies, such as central retinal artery occlusion or anterior ischemic optic neuropathy, and others are usually ignored. In the past two decades, many publicly available datasets of color fundus images have been collected with a primary focus on diabetic retinopathy, glaucoma, age-related macular degeneration and few other frequent pathologies. To enable development of methods for automatic ocular disease classification of frequent diseases along with the rare pathologies, we have created a new Retinal Fundus Multi-disease Image Dataset (RFMiD). It consists of 3200 fundus images captured using three different fundus cameras with 46 conditions annotated through adjudicated consensus of two senior retinal experts. To the best of our knowledge, our dataset, RFMiD, is the only publicly available dataset that constitutes such a wide variety of diseases that appear in routine clinical settings. This dataset will enable the development of generalizable models for retinal screening.

Vascular abnormalities in uveitis

Inflammation can involve several ocular structures, including the sclera, retina, and uvea, and cause vascular changes in these tissues. Although retinal vasculitis is the most common finding associated with uveitis involving the posterior segment, other vascular abnormalities may be seen in the retina. These include capillary nonperfusion and ischemia, vascular occlusions, preretinal neovascularization, microaneurysms and macroaneurysms, and telangiectasia. Moreover, vasoproliferative tumors and subsequent coat-like response can develop secondary to uveitis. Fluorescein angiography is ideal for the investigation of retinal vascular leakage and neovascularization, while optical coherence tomography angiography can provide depth resolved images from the superficial and deep capillary plexus and can demonstrate vascular remodeling. Choroidal vascular abnormalities primarily develop in the choriocapillaris or in the choroidal stroma and can appear as flow void in optical coherence tomography angiography and filling defect and vascular leakage in indocyanine green angiography. Extensive choriocapillaris nonperfusion in the presence of choroidal inflammation can increase the risk of choroidal neovascular membrane development. Iris vascular changes may manifest as dilation of vessels in stroma due to inflammation or rubeosis that is usually from ischemia in retinal periphery secondary to chronic inflammation. More severe forms of scleral inflammation, such as necrotizing scleritis, are associated with vascular occlusion in the deep episcleral plexus, which can lead to necrosis of sclera layer and uveal exposure.

Nonexudative Perifoveal Vascular Anomalous Complex: The Subclinical Stage of Perifoveal Exudative Vascular Anomalous Complex?

PURPOSE

To describe the pre-exudative stage of exudative perifoveal vascular anomalous complex (ePVAC), referred to as nonexudative PVAC (nePVAC).

DESIGN

Retrospective noncomparative case series.

METHODS

Patients diagnosed with nePVAC were identified at 4 retina referral centers worldwide. Multimodal retinal imaging, including structural optical coherence tomography (OCT) and OCT-angiography (OCT-A), were performed at baseline and follow-up visits.

RESULTS

Six eyes (6 patients, mean 75 ± 10 years of age) were included. Unrelated chorioretinal diseases were diagnosed in the affected eyes in 5 of 6 cases. At baseline, nePVAC is characterized by microvascular abnormalities featuring an isolated, perifoveal, large intraretinal aneurysm surrounded by capillary rarefaction at OCT-A examination, without any sign of exudation with structural OCT, and without visual impairment. Four patients were followed for a mean of 21 ± 14 months. During the follow-up, 3 of 4 eyes (75%) developed signs of exudation after a mean of 15 ± 9 months, associated with metamorphopsia and visual decline at the time of exudation. Best-corrected visual acuity decreased from 20/25 to 20/40 Snellen equivalent (P = .035) and central macular thickness increased from 268 ± 27 μm to 339 ± 65 μm (P = .145). Three patients were treated with 2.3 ± 0.6 intravitreal injections of anti-vascular endothelial growth factor without significant improvement of best-corrected visual acuity or macular edema.

CONCLUSIONS

nePVAC may represent the subclinical pre-exudative stage of ePVAC, notable for an absence of exudation or visual impairment. nePVAC and ePVAC should be considered as part of the same spectrum, namely PVAC. Typically, nePVAC develops signs of exudation over time, causing metamorphopsia and visual decline and therefore these lesions warrant continued close monitoring with multimodal retinal imaging.

The Expanded Spectrum of Perifoveal Exudative Vascular Anomalous Complex

PURPOSE

To expand our understanding of the uncommon entity, referred to as perifoveal exudative vascular anomalous complex (PEVAC) by describing multimodal imaging findings, including optical coherence tomography angiography (OCT-A).

DESIGN

Retrospective cohort study.

METHODS

Patients diagnosed with PEVAC were identified at 4 retina referral centers worldwide and underwent complete ophthalmologic examination including structural OCT, OCT-A, fluorescein angiography (FA), and indocyanine green angiography (ICGA). Demographics and clinical findings were analyzed at baseline and at available follow-ups.

RESULTS

Fifteen eyes (15 patients, mean age 73 ± 13 years) were included. Six of 15 eyes were diagnosed with coincident age-related macular degeneration (AMD) and 2 with myopic macular degeneration. On fundus examination PEVAC presented as a large perifoveal isolated aneurysm, unifocal in 12 of 15 eyes, associated with small retinal hemorrhages and intraretinal exudation. On structural OCT, PEVAC appeared as a round hyperreflective lesion with hyporeflective lumen, typically surrounded by intraretinal cystic spaces. Dye angiography demonstrated a well-defined hyperfluorescent lesion with variable leakage on FA and without leakage on ICGA. OCT-A showed flow signal correlating with the aneurysmal lesion connecting to retinal capillary plexuses. Seven patients were followed for 13.0 ± 10.5 months with no evidence of functional/anatomic changes. Three patients underwent anti-vascular endothelial growth factor (VEGF) intravitreal injections without improvement. Two eyes were associated with a type 3 neovascularization eccentric to PEVAC.

CONCLUSIONS

PEVAC is an isolated, perifoveal, aneurysmal abnormality, occurring in otherwise healthy patients who may manifest other macular disease including AMD and myopic macular degeneration. PEVAC did not typically respond to anti-VEGF therapy, and may be associated with type 3 neovascularization.

Pearls and pitfalls in diagnosis and management of coats disease

PURPOSE

To review current literature on Coats disease and provide a structured framework for differentiating challenging clinical features in Coats disease patients.

METHODS

We critically reappraise historical and current literature and present clinical methods for developing a thorough differential diagnosis and management strategy for Coats disease.

RESULTS

Coats disease is a sporadic, usually unilateral condition typically occurring in young males. When untreated, this disorder can lead to total exudative retinal detachment and secondary glaucoma.

CONCLUSIONS

Anti-VEGF agents are currently a treatment option in combination with ablative therapy of telangiectatic vessels. Anti-VEGF agents appear particularly useful for patients with extensive areas of exudative retinal detachment, and are an effective treatment option for total retinal detachment.

Retinal arterial macroaneurysms

Retinal arterial macroaneurysms are acquired saccular or fusiform dilatations of the large arterioles of the retina, usually within the first three orders of bifurcation. They are associated with systemic vascular conditions such as hypertension and arteriosclerotic disease occurring most commonly in elderly women. The primary reported symptom is a sudden loss of vision due to haemorrhage or oedema affecting the macula. Most of macroaneurysms regress without treatment and without causing decreased visual acuity. Poor visual outcome may occur secondary to foveal exudates and subfoveal haemorrhage.

Branch retinal artery occlusion associated with posterior uveitis

BACKGROUND

The purpose of this study is to report the clinical features and visual outcome of branch retinal artery occlusion (BRAO) associated with posterior uveitis. This is a retrospective study including the 18 eyes of 18 patients. All patients underwent a complete ophthalmic evaluation. Fundus photography, fluorescein angiography, and visual field testing were performed in all cases.

RESULTS

Diseases associated with BRAO included active ocular toxoplasmosis in 7 patients, rickettsiosis in 4, Behçet's uveitis in 2, West Nile virus infection in 1, idiopathic retinal vasculitis in 1, Crohn's disease in 1, ocular tuberculosis in 1, and idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome in 1 patient. The mean initial visual acuity was 20/50. BRAO involved the first order retinal artery in 33.3% of the eyes, the second order retinal artery in 33.3%, an arteriole in 27.8%, and a cilioretinal artery in 5.5%. The macula was involved in 44.4% of the eyes and an acute focus of retinitis or retinochoroiditis was associated to BRAO in 55.5%. Repermeabilization of the occluded artery occurred in all patients with permanent scotomas in the corresponding visual field. The mean visual acuity at last visit was 20/32.

CONCLUSIONS

BRAO, with subsequent visual impairment, may occur in the eyes with posterior uveitis. Physicians should be aware of such vision-threatening complication of infectious and inflammatory eye diseases.

Differential diagnosis of retinal vasculitis

Retinal vaculitis is a sight-threatening inflammatory eye condition that involves the retinal vessels. Detection of retinal vasculitis is made clinically, and confirmed with the help of fundus fluorescein angiography. Active vascular disease is characterized by exudates around retinal vessels resulting in white sheathing or cuffing of the affected vessels. In this review, a practical approach to the diagnosis of retinal vasculitis is discussed based on ophthalmoscopic and fundus fluorescein angiographic findings.

Retinal macroaneurysm associated with ocular sarcoidosis

PURPOSE

To characterize retinal macroaneurysm, which although rare, has been reported as a specific complication of ocular sarcoidosis.

METHODS

Ninety-seven sarcoidosis patients with intraocular inflammation diagnosed at the Uveitis Clinic of Tokyo Medical University Hospital between 1997 and 2006 were analyzed retrospectively.

RESULTS

Retinal macroaneurysm was found in nine eyes of seven patients (7.2%). The mean patient age at onset was 61 years, similar to the reported onset age in patients with macroaneurysm not associated with ocular sarcoidosis. Most aneurysms developed in the chronic phase, and not in the early phase, of ocular sarcoidosis. Two patients (29%) were affected bilaterally. Five of nine eyes (56%) had multiple lesions. Unlike retinal macroaneurysm not associated with sarcoidosis, which is usually solitary and unilateral, rates of bilateral and multiple lesions were high.

CONCLUSIONS

The clinical features of retinal aneurysm associated with ocular sarcoidosis are considerably different from those of unilateral macroaneurysm not associated with sarcoidosis.

International criteria for the diagnosis of ocular sarcoidosis: results of the first International Workshop On Ocular Sarcoidosis (IWOS)

AIM

To report criteria for the diagnosis of intraocular sarcoidosis, taking into account suggestive clinical signs and appropriate laboratory investigations and biopsy results.

DESIGN

Concensus workshop of an international committee on nomenclature.

METHODS

An international group of uveitis specialists from Asia, Africa, Europe, and America met in a concensus conference in Shinagawa, Tokyo on October 28-29, 2006. Based on questionnaires that had been sent out prior to the conference, the participants discussed potential intraocular clinical signs eligible for a diagnosis of ocular sarcoidosis. A refined definition of clinical signs, which received two-thirds majority of votes, was included in the list of signs consistent with ocular sarcoidosis. Laboratory investigations were similarly discussed and those tests reaching a two-thirds majority were retained for the diagnosis of ocular sarcoidosis. Finally diagnostic criteria were proposed based on ocular signs, laboratory investigations, and biopsy results.

RESULTS

The concensus conference identified seven signs in the diagnosis of intraocular sarcoidosis: (1) mutton-fat keratic precipitates (KPs)/small granulomatous KPs and/or iris nodules (Koeppe/Busacca), (2) trabecular meshwork (TM) nodules and/or tent-shaped peripheral anterior synechiae (PAS), (3) vitreous opacities displaying snowballs/strings of pearls, (4) multiple chorioretinal peripheral lesions (active and/or atrophic), (5) nodular and/or segmental peri-phlebitis (+/- candlewax drippings) and/or retinal macroaneurism in an inflamed eye, 6) optic disc nodule(s)/granuloma(s) and/or solitary choroidal nodule, and (7) bilaterality. The laboratory investigations or investigational procedures that were judged to provide value in the diagnosis of ocular sarcoidosis in patients having the above intraocular signs included (1) negative tuberculin skin test in a BCG-vaccinated patient or in a patient having had a positive tuberculin skin test previously, (2) elevated serum angiotensin converting enzyme (ACE) levels and/or elevated serum lysozyme, (3) chest x-ray revealing bilateral hilar lymphadenopathy (BHL), (4) abnormal liver enzyme tests, and (5) chest CT scan in patients with a negative chest x-ray result. Four levels of certainty for the diagnosis of ocular sarcoidosis (diagnostic criteria) were recommended in patients in whom other possible causes of uveitis had been excluded: (1) biopsy-supported diagnosis with a compatible uveitis was labeled as definite ocular sarcoidosis; (2) if biopsy was not done but chest x-ray was positive showing BHL associated with a compatible uveitis, the condition was labeled as presumed ocular sarcoidosis; (3) if biopsy was not done and the chest x-ray did not show BHL but there were 3 of the above intraocular signs and 2 positive laboratory tests, the condition was labeled as probable ocular sarcoidosis; and (4) if lung biopsy was done and the result was negative but at least 4 of the above signs and 2 positive laboratory investigations were present, the condition was labeled as possible ocular sarcoidosis.

CONCLUSION

Various clinical signs, laboratory investigations, and biopsy results provided four diagnostic categories of sarcoid uveitis. The categorization allows prospective multinational clinical trials to be conducted using a standardized nomenclature, which serves as a platform for comparison of visual outcomes with various therapeutic modalities.

Ocular involvement in sarcoidosis

PURPOSE

To evaluate ocular involvement in patients with sarcoidosis.

METHODS

The prevalence of ocular manifestations was studied in 139 Turkish patients with sarcoidosis as a cross section. Color photography and fluorescein angiography were performed on patients suspected of having ocular involvement.

RESULTS

Ocular involvement was seen in 12.9% patients. Of 18 patients with ocular sarcoidosis, 39% had anterior and posterior involvement, 28% only anterior, 11% only posterior, 16.7% conjuctival, and 5.6% eyelid involvement. There was no statistically significant relationship between radiological grading and ocular involvement.

CONCLUSIONS

The most common ocular involvement in this study was both anterior and posterior segment involvement.