Ocular findings in systemic lupus erythematosus

Detection of subclinical microvascular changes in systemic lupus erythematous using optical coherence tomography angiography: A systematic review and meta-analysis

Systemic lupus erythematosus (SLE) is a chronic, systemic, autoimmune connective tissue disease that affects several vascular territories. We sought to assess the role of optical coherence tomography angiography in detecting subclinical microvascular alterations in SLE patients. PubMed, Scopus, and Web of Science databases were systematically searched until January 21, 2023. Studies using optical coherence tomography angiography as a primary diagnostic method to evaluate the macular microvasculature of SLE patients versus healthy controls were included. Primary outcomes were macular vessel density and foveal zone parameters. A meta-analysis was performed using a random-effects model. Of 301 screened abstracts, 15 were found eligible, enrolling 1,246 eyes from 1,013 patients. SLE patients presented a reduction of macular vessel density at both plexuses in all zones (whole scan, fovea, parafovea, and perifovea), and of foveal density compared with healthy controls. No differences were found at foveal avascular zone parameters. SLE patients presented a reduction of macular vessel density without signs or symptoms of SLE ocular involvement. Optical coherence tomography angiography application for the assessment of subclinical microvascular changes needs to be elucidated with longitudinal studies.

Bilateral central retinal artery occlusion as a presenting manifestation of systemic lupus erythematosus: a case-based review

Central retinal artery occlusion (CRAO) is an ophthalmic emergency that typically results in permanent vision damage even despite vigorous treatment. In this article, we describe a case of acute vaso-occlusive retinopathy that presented as the primary manifestation of SLE in the absence of elevated levels of APLAs. After treatment with intravenous steroids, immunoglobulin, intrathecal injection of dexamethasone, plasma exchange, and intravenous cyclophosphamide, SLE was well controlled in the patient, but her vision was permanently lost in the left eye. We also go over a brief review of the currently available literature on retinal vaso-occlusive disease present in SLE. The pathology mechanism of CRAO is related to immune complex-mediated "vasculitis", which is typically associated with neuropsychiatric lupus. However, the literature review identified antiphospholipid antibody syndrome (APS) in only 6 of 19 patients, indicating that other mechanisms besides APS are associated with CRAO. Systemic immunosuppression and anticoagulants are required for the treatment of this severe vaso-occlusive retinopathy. Early recognition and aggressive intervention may prevent severe loss of vision.

Ocular retinal findings in asymptomatic patients with antiphospholipid syndrome secondary to systemic lupus erythematosus

The objective is to perform a multimodal ophthalmological evaluation, including optical coherence angiography (OCTA), asymptomatic APS secondary to SLE (APS/SLE), and compare to SLE patients and control group (CG). We performed a complete structural/functional ophthalmological evaluation using OCTA/microperimetry exam in all participants. One hundred fifty eyes/75 asymptomatic subjects [APS/SLE (n = 25), SLE (n = 25), and CG (n = 25)] were included. Ophthalmologic abnormalities occurred in 9 (36%) APS/SLE, 11 (44%) SLE, and none of CG (p < 0.001). The most common retinal finding was Drusen-like deposits (DLDs) exclusively in APS/SLE and SLE (16% vs. 24%, p = 0.75) whereas severe changes occurred solely in APS/SLE [2 paracentral acute middle maculopathy (PAMM) and 1 homonymous quadrantanopsia]. A trend of higher frequency of antiphospholipid antibody (aPL) triple positivity (100% vs. 16%, p = 0.05) and higher mean values of adjusted Global Antiphospholipid Syndrome Score (aGAPSS) (14 ± 0 vs. 9.69 ± 3.44, p = 0.09) was observed in APS/SLE with PAMM vs. those without this complication. We identified that ophthalmologic retinal abnormalities occurred in more than 1/4 of asymptomatic APS/SLE and SLE. DLDs are the most frequent with similar frequencies in both conditions whereas PAMM occurred exclusively in APS/SLE patients. The possible association of the latter condition with aPL triple positivity and high aGAPSS suggests these two conditions may underlie the retinal maculopathy. Our findings in asymptomatic patients reinforce the need for early surveillance in these patients. Key Points • Retinal abnormalities occur in more than 1/4 of asymptomatic APS/SLE and SLE patients. • The occurrence of PAMM is possibly associated with APS and DLDs with SLE. • Presence of aPL triple positivity and high aGAPSS seem to be risk factors for PAMM.

Retinopathy secondary to flare-up of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) can have widespread ocular manifestations, and posterior segment involvement may be associated with poor visual outcome. We report a clinical flare-up of SLE presenting as combined vascular occlusion in one eye and drusen-like deposits, which is a newly described entity in both eyes. As an ophthalmologist, a knowledge of such presentations helps us identify and possibly help the rheumatologist titrate treatment accordingly, to prevent severe life-threatening systemic complications.

Retinal drusen are more common and larger in SLE with renal impairment

Introduction

Complement has been implicated in systemic lupus erythematosus (SLE) pathogenesis on the basis of the associations with inherited complement defects and genome-wide association study risk alleles, glomerular deposits, reduced serum levels, and occasional reports of retinal drusen. This study examined drusen in SLE and their clinical significance.

Methods

This cross-sectional observational study compared individuals with SLE recruited from renal and rheumatology clinics with hospital controls. Participants were reviewed for clinical features and underwent imaging with a nonmydriatic retinal camera. Deidentified images were examined by 2 trained graders for drusen number and size using a grid overlay.

Results

The cohort with SLE (n = 65) comprised 55 women (85%) and 10 men (15%) with a median age of 47 years (interquartile range 35–59), where 23 (35%) were of southern European or Asian ancestry, and 32 (49%) had biopsy-proven lupus nephritis. Individuals with SLE had higher mean drusen numbers than controls (27 ± 60, 3 ± 9, respectively, P = 0.001), more drusen counts ≥10 (31, 48% and 3, 5%, respectively, P < 0.001), and more medium-large drusen (14, 22% and 3, 5%, respectively, P < 0.001). In SLE, mean drusen counts were higher, and drusen were larger, with an estimated glomerular filtration rate (eGFR) <90 ml/min per 1.73 m² (P = 0.02, P = 0.02, respectively) or class IV nephritis (P = 0.03, P = 0.02).

Conclusion

Drusen composition resembles that of glomerular immune deposits. CFH controls complement activation in the extracellular matrix and CFH risk variants are shared by drusen in macular degeneration and by SLE. CFH represents a possible treatment target for SLE especially with renal impairment.

EYE DISEASE IN KIDNEY TRANSPLANTATION: CLINICAL CHALLENGES IN A UNIQUE PATIENT POPULATION

Eye disease is common among kidney transplant recipients and their management is challenging. Chronic kidney disease is associated with ocular complications, both independently and in the context of various systemic disorders. In addition, chronic immunosuppression predisposes kidney transplant recipients to an array of long-term ocular issues. This may be broadly categorized into infections, malignancies, and other immunosuppression-specific side effects. The interdependence of kidney disease, transplant pharmacotherapy and ocular health therefore requires a multispecialty approach. Although the kidney transplant population has grown along with the burden of associated oculopathies, systematic guidelines targeting this patient group are lacking. This evidenced-based narrative review summarizes the pertinent issues that may present in the ophthalmic and optometric clinical settings, with emphasis on collaborative management and directions for future research.

Epidemiology of disease-activity related ophthalmological manifestations in Systemic Lupus Erythematosus: A systematic review

OBJECTIVE

Ophthalmic complications in Systemic Lupus Erythematosus (SLE) are broad and can occur in up to a third of patients. The British Isles Lupus Assessment Group (BILAG) 2004 Index identifies 13 ocular manifestations of active SLE, as opposed to those related to previous disease activity and/or the consequences of therapy. We conducted a systematic review of published literature to determine the frequency of ophthalmic manifestations of active SLE.

METHODS

A systematic literature search of Ovid MEDLINE and EMBASE from their respective inceptions to July 2020 was conducted to identify cohort, case-control and cross-sectional studies.

RESULTS

22 studies meeting eligibility criteria were included. Most studies featured small sample sizes and were judged to have a high risk of methodological bias. The number and quality of studies did not allow us to confidently estimate the incidence of the conditions. No studies reported epidemiological data for orbital inflammation/myositis/proptosis. The prevalence of each of the other ocular manifestations, with the exception of retinal vaso-occlusive disease, was consistently less than 5%. Retinal vasculitis, uveitis and isolated cotton wool spots tended to be associated with more active SLE disease.

CONCLUSION

The prevalence of eye disease due to SLE activity is uncommon, but clinicians should be aware that some conditions tend to be associated with more active systemic disease. Further studies to determine the incidence and risk factors for these ophthalmic manifestations are needed.

Retinal vasospastic phenomenon in a known case of systemic lupus erythematosus

Retinal vasospasm was visualized in a young female; a known case of systemic lupus erythematosus (SLE) retinopathy with unaffected vision. The fundus fluorescein angiogram showed a cyclical filling and emptying of the retinal vessels which was suggestive of vasospasm and a retinal Raynaud's-like phenomenon with no obvious perfusion deficit. There was retinal thinning involving the superficial layers that was seen on optical coherence tomography (OCT), capillary fill voids on OCT angiography, and retinal surface undulations seen on multicolor imaging. All imaging was performed on Spectralis (Heidelberg, Germany).

Visual recovery and vascular reperfusion after vaso-occlusive retinopathy from anti-phospholipid syndrome associated with systemic lupus erythematosus

PURPOSE

To report a case of visual recovery and vascular reperfusion after vaso-occlusive retinopathy from anti-phospholipid syndrome associated with systemic lupus erythematosus.

OBSERVATIONS

A 15-year-old boy with a known diagnosis of systemic lupus erythematosus and a clinically significant anti-phospholipid panel presented with sudden vision loss in the left eye. Examination and ocular imaging revealed signs of vaso-occlusive retinopathy. The patient was immediately started on high dose intravenous steroids, followed by mycophenolate mofetil. He remained on aspirin. After showing no improvement in retinal arteriole and capillary perfusion he was started on therapeutic anti-coagulation with enoxaparin. He regained 20/20 vision. Intravenous fluorescein angiography demonstrated reperfusion of retinal arterioles. Optical coherence tomography angiography showed return of flow in the capillary networks.

CONCLUSIONS

We present a case of vaso-occlusive retinopathy in a patient with known systemic lupus erythematosus and a clinically significant anti-phospholipid panel, thus meeting criteria for anti-phospholipid syndrome. He was treated with intravenous methylprednisolone, mycophenolate motefil, aspirin, and enoxaparin. The patient not only had great recovery of visual acuity, but also demonstrated reperfusion of arterioles and reconstitution of flow in the retinal capillary network. These findings suggest that the vaso-occlusive disease is reversible if the diagnosis is made promptly and intensive therapy is initiated.

IMPORTANCE

Currently there are no reported cases of vaso-occlusive retinopathy from APLS and SLE with visual recovery, reperfusion, and return of capillary flow.

Ocular Manifestations in Rheumatoid Arthritis, Connective Tissue Disease, and Vasculitis: A Systematic Review and Metaanalysis

Objective.

Rheumatoid arthritis (RA) and other rheumatic diseases may present with ocular manifestations.

The purpose of our work was to determine the prevalence and type of eye involvement in RA and other connective tissue diseases through a metaanalysis and literature review.

Methods.

A systematic review of the literature was performed using Medline, Web of Science, and the Cochrane Library from their inceptions until January 7, 2019. Conjunctivitis, keratoconjunctivitis sicca, xeropthalmia, uveitis, eye hemorrhage, optic neuritis, papilledema, orbital disease, retinal artery/vein occlusion, macular edema, retinitis, chorioretinitis, scleritis, iridocyclitits, choroid hemorrhage, blindness, and amaurosis fugax were searched for prevalence in patients with RA, systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), dermatomyositis, polymyositis, systemic sclerosis, Sjögren syndrome (SS), undifferentiated connective tissue disease, giant cell arteritis, granulomatosis polyangiitis (GPA; formerly Wegener granulomatosis), systemic vasculitis, and sarcoidosis.

Results.

There were 3394 studies identified and 65 included. The prevalence of eye involvement was 18% in RA, 26% in GPA, 27% in giant cell arteritis, 27% in sarcoidosis, 31% in SLE, and 35% in APS. The most common manifestation was dry eye syndrome (“dry eye”; keratoconjunctivitis sicca) in most diseases analyzed, with an especially high frequency of 89% in SS. Anterior and posterior uveitis were the most common ocular complications in sarcoidosis, occurring in 16% (95% CI 3–28) and 6% (95% CI 3–9) of patients, respectively.

Conclusion.

Eye involvement is present in approximately one-fifth of patients with RA, and a one-quarter to one-third of patients with connective tissue diseases (other than SS at 89%) and vasculitis.

Combined Intravitreal Bevacizumab And Dexamethasone In Bilateral Lupus Retinopathy

This paper reports and discusses a case of bilateral lupus retinopathy with macular edema in a patient diagnosed with systemic lupus retinopathy and treated with combined intravitreal bevacizumab (0.025 mL/0.625 mg) and intravitreal dexamethasone (0.05 mL/0.2 mg). The patient was a 25-year-old female with a history of diminution of vision in both eyes. Best corrected visual acuity (BCVA) of the right eye was 2/60 and of the left eye was 1/60. Fundus examination revealed bilateral swelling of the optic disc nasally, cotton wool spots, and multiple flame shaped, dot and blot hemorrhages in the disc and macula. Optical coherence tomography (OCT) revealed macular edema in both eyes. Despite being treated with immunosuppressive the visual acuity did not improve. Two doses of combined intravitreal bevacizumab (0.025 mL/0.625 mg) and dexamethasone (0.05 mL/0.2 mg) were given to the patient in both eyes at an interval of one week. Two weeks after the last intravitreal injection the BCVA was 6/24 and N8 in both eyes. Fundus examination revealed a decrease in the number and size of hemorrhages, and resolution of the blurred disc margin, cotton wool spots, and hard exudates. OCT of the macula 2 weeks after the last intravitreal injection showed a significant decrease in macular edema. The intraocular pressure was not elevated for a period of 6 months. This case would be a unique case of lupus retinopathy with macular edema receiving a combined half dose of intravitreal injection bevacizumab and dexamethasone with promising results. This could be beneficial in a set up where the patients cannot afford intraocular steroid implants.

Retinal vasculopathy in patients with systemic lupus erythematosus

A retrospective case control study was conducted in the Peking Union Medical College Hospital. Medical records were reviewed for demographic data, clinical features, laboratory results, systemic lupus erythematosus (SLE) disease activity evaluations, and ophthalmic examinations to investigate the clinical characteristics and significance of retinal vasculopathy (RV) in Chinese patients with systemic lupus erythematosus. The prevalence of RV was approximately 0.66% (35/5298) in SLE patients. A total of 60 eyes were involved. The ocular presentations included decrease of visual acuity (48/60, 80%), visual field loss (7/60, 11.7%), and diplopia (3/60, 5%). Ophthalmic fundoscopic examination revealed cotton-wool spots (30/60, 50%), retinal vascular attenuation (31/60, 51.6%), and hemorrhages (41/60, 68.3%). Retinal angiogram showed that 72.7% (16/22) eyes had vaso-occlusion. The ophthalmic episodes could occur at any stage of SLE duration, with a median of 12 months (0-168 months) following SLE onset. Twenty-one (35%) eyes did not recover, or even worsened, during hospital stay. RV was found to be significantly associated with neuropsychiatric lesions (51.4% vs. 21.3%, p = .005) and hematological disturbance (62.9% vs. 34.3%, p = .005). SLE patients with RV had significantly higher SLE disease activity index scores than controls (19.9 ± 0.9 vs. 10.2 ± 0.7, p < .001). An inverse association of anti-SSA antibody with RV was detected (34.3% vs. 67.1%, p = .001). Nervous system disturbance (odds ratio (OR) = 4.340, 95% confidence interval (CI) 1.438, 13.094, p = .009) and leukocytopenia (OR = 6.385, 95% CI 1.916, 21.278, p = .003) were independent risk factors, while anti-SSA antibody positivity (OR = 0.249, 95% CI 0.087, 0.710, p = .009) was a protective factor for RV in SLE patients. In certain cases, RV is a threatening condition for SLE patients presenting with clinical ocular manifestations. Ophthalmo-fundoscopic detection is recommended as soon as SLE is diagnosed.

Bilateral chorioretinopathy in child-onset systemic lupus erythematosus

Any of the various layers of the eye may suffer injury in systemic lupus erythematosus, ranging from keratoconjunctivitis sicca to retinopathy and optic neuritis. Rheumatologists must always be aware of ocular involvement in those patients since rapid diagnosis and a prompt intervention in those severe cases can prevent visual loss or even irreversible blindness. We present here the case of a 14-year-old girl who, despite a short period of disease, developed chorioretinopathy with transitory visual impairment with a good treatment response.

Fluorescein Angiographic Findings in Patients with Active Systemic Lupus Erythematosus

PURPOSE

To evaluate the retina of patients with active systemic lupus erythematosus (SLE) using fundus fluorescein angiography (FFA), irrespective of their visual acuity or fundus examination.

METHODS

A descriptive study was performed on 30 patients with active SLE; disease activity was calculated using The Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Fundus examination and FFA angiography were done to all patients.

RESULTS

A total of 60 eyes of 30 patients were included. Their mean age was 32.6 ± 1.17 years. All patients showed disease activity at time of examination according to SLEDAI. Retinopathy was detected by FAF in 24 eyes (40%), 10 eyes of which had normal fundus examination. SLEDAI was positively correlated to the presence of retinopathy.

CONCLUSIONS

All patients with ocular lupus should be carefully evaluated for systemic involvement and, vice versa, all patients diagnosed with SLE should have a thorough ocular examination and FFA, even if they had normal fundus.

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.

Role of lupus retinopathy in systemic lupus erythematosus

Background

Lupus retinopathy is one of the most common vision-threatening complications of systemic lupus erythematosus. The presence of lupus retinopathy is an accurate guide to the presence of active systemic disease activity.

Results

A prospective study was conducted looking at 91 established cases of systemic lupus erythematosus to evaluate lupus retinopathy. The patients were divided into two groups according to the presence or absence of lupus retinopathy, and a comparison of clinical and laboratory findings between two groups was done. Among 91 SLE patients, 5 were male and 86 were female; of which, 85 (93.4 %) were outpatients and 6 (6.6 %) were inpatients. Lupus retinopathy was found in 13 eyes of 11 cases out of 91 cases (12.1 %). Among these 13 eyes with lupus retinopathy, 61.5 % had mild type of lupus retinopathy, 15.4 % had moderate type, and 23.1 % had severe lupus retinopathy.

The mean age of the cases at ophthalmological examination with and without retinopathy was 30.4 and 31.9 years, respectively. The mean serum creatinine level was 190.4 μmol/l which was higher than in the patients without retinopathy (96.2 μmol/l). The mean ESR in patients with retinopathy was higher than without retinopathy (34.2 vs. 32). Similarly, the mean platelet count in SLE patients with retinopathy was 154,245/μl and in SLE patients without retinopathy was 135,828/μl.

Conclusions

Retinal lesions in SLE patients are of critical importance, both visually and prognostically.

Diagnosis and treatment of anterior uveitis: optometric management

Anterior uveitis encompasses inflammation of the iris and/or ciliary body and is one of the most common types of ocular inflammation that primary eye care practitioners will encounter. Anterior uveitis may be caused by a variety of etiologies, including infectious, non-infectious, and masquerade diseases. The short-term and long-term treatment of uveitis should include the evaluation of location, duration, pathology, and laterality, in addition to presenting signs and symptoms of the disease. A complete review of systems, thorough examination, and laboratory testing, may assist the practitioner in narrowing the list of possible causes for the uveitis. This is imperative as once a list of diagnoses has been made, a targeted approach to treatment can be pursued.

Choroidal Thickness in Patients with Systemic Lupus Erythematosus Analyzed by Spectral-domain Optical Coherence Tomography

PURPOSE

The aim of this study is to investigate the effect of systemic lupus erythematosus (SLE) on choroidal thickness (CT) in the subfoveal and perifoveal area as measured by enhanced depth imaging optical coherence tomography (EDI-OCT) in patients with SLE.

MATERIALS AND METHODS

Fifty-eight patients with SLE (study group) and 58 healthy individuals (control group) were enrolled in the study. The subfoveal and perifoveal CT were measured by EDI-OCT.

RESULTS

The mean CT (μm) subfoveal, nasal, and temporal was 231.2 ± 57.6, 190.56 ± 30.64, and 222.65 ± 37.45 in the study group and 297.5 ± 45.1, 248.34 ± 39.67, and 286.54 ± 49.65 in the control group, respectively (p < 0.001, for all).

CONCLUSION

The mean subfoveal, nasal, and temporal CT values were statistically significantly lower in patients with SLE when compared with healthy controls.

Retinal vasculature remodeling in a case of systemic lupus erythematosus vaso-occlusive retinopathy

PURPOSE

To report a case of systemic lupus erythematosus vaso-occlusive retinopathy illustrating vascular remodeling over 4 years of follow-up.

METHODS

Observational case report of one patient.

RESULTS

A 12-year-old previously healthy girl presented with profound vision loss to 20/800 in both eyes. Her medical workup, neuro-imaging, and ophthalmic examination were consistent with coexistent central nervous system systemic lupus erythematosus and vaso-occlusive systemic lupus erythematosus retinopathy. At 15 months after presentation, retinal vasculature remodeling was evident along with severe macular atrophy. By 4 years after presentation, retinal neovascularization developed that was successfully treated with photocoagulation.

CONCLUSION

We describe a case of systemic lupus erythematosus vaso-occlusive retinopathy illustrating vascular remodeling over 4 years of follow-up.

Retinal vasculitis in two pediatric patients with systemic lupus erythematosus: a case report

We report two pediatric female patients with systemic lupus erythematosus (SLE) who presented with decreased vision. Both patients were found to have retinal vasculitis and occlusive disease. The first patient also presented with vitreous hemorrhage and later non-arteritic ischemic optic neuropathy. She was treated with panretinal photocoagulation and steroid therapy and later in her disease course was treated with rituximab and cyclophosphamide. Her vision remained decreased. The second patient was treated with rituximab and monthly cyclophosphamide infusions early in her disease course, and her vision improved dramatically. The difference in the presentations and outcomes of these two pediatric patients with SLE highlights the spectrum of severity of SLE retinopathy. We suggest that early recognition of disease and early intervention with B-cell depletion therapy in addition to a traditional cytotoxic agent should be considered in pediatric patients with SLE and occlusive retinopathy.

Laser in situ keratomileusis in patients with collagen vascular disease: a review of the literature

PURPOSE

To evaluate the current United States Food and Drug Administration (FDA) recommendations regarding laser in situ keratomileusis (LASIK) surgery in patients with collagen vascular diseases (CVD) and assess whether these patients make appropriate candidates for laser vision correction, and offer treatment recommendations based on identified clinical data.

METHODS

A literature search was conducted using PubMed, Medline, and Ovid to identify all existing studies of LASIK in patients with collagen vascular diseases. The search was conducted without date limitations. Keywords used for the search included MeSH terms: laser in situ keratomileusis, LASIK, refractive surgery, ocular surgery, and cataract surgery connected by "and" with the following MeSH and natural-language terms: collagen vascular disease, rheumatic disease, systemic disease, rheumatoid arthritis, systemic lupus erythematosus, Sjögren's syndrome, seronegative spondyloarthropathy, HLA B27, ankylosing spondylitis, reactive arthritis, psoriatic arthritis. The abstracts for all studies meeting initial search criteria were reviewed; relevant studies were included. No prospective studies were found; however, four retrospective case studies were identified that examined LASIK surgery in patients with CVD. Several case reports were also identified in similar fashion.

RESULTS

The FDA considers CVD a relative contraindication to LASIK surgery, due largely to the ocular complications associated with disease in the CVD spectrum. However, recent studies of LASIK in patients with CVD indicate LASIK may be safe for patients with very well-controlled systemic disease, minimal ocular manifestations, and no clinical signs or history of dry-eye symptoms.

CONCLUSION

LASIK surgery may be safe in patients with rheumatoid arthritis or systemic lupus erythematosus and the seronegative spondyloarthropathies if stringent preoperative criteria are met. Evidence suggests patients with Sjögren's syndrome are not suitable candidates for LASIK.

The spectrum of ocular involvement in systemic lupus erythematosus in a tertiary eye care center in Nepal

PURPOSE

Manifestations of Systemic lupus erythematosus are protean and the eye can get affected in more than a third of the cases. This study was conducted to evaluate the spectrum of ocular manifestation among Nepalese patients diagnosed with Systemic lupus erythematosus.

METHODS

In this hospital based cross-sectional study, 91 established cases of Systemic lupus erythematosus were enrolled from January 2008 to June 2009 AD. Patient particulars including age, sex, duration, systemic involvement, laboratory findings and treatment history were noted. Detailed ophthalmological examination was carried.

RESULTS

Out of 91 patients, 94.5% were females and 5.5% were males. Female/Male ratio was 17:1. Mean age of the patients was 26.59 ± 10.33 years. Ocular involvement was present in 47.3% (43) of the patients, the commonest manifestation being dry eye (39.5%) followed by lupus retinopathy (21%) and drug induced ocular complications (21%).

CONCLUSIONS

Ocular manifestations in Systemic lupus erythematosus are not uncommon.

Optic neuropathy as a presenting feature of systemic lupus erythematosus: two case reports and literature review

Systemic lupus erythematosus (SLE) may affect the eyes and/or visual system in up to a third of patients; however, optic nerve involvement has been rarely reported. SLE presenting as optic neuropathy is exceptional. We report two new cases of optic neuropathy as a presenting feature of SLE. The first patient presented with an ischemic optic neuropathy and antiphospholipid antibodies, and the second presented with optic neuritis. A literature review for previous cases of SLE presenting as optic neuropathy was performed. Early diagnosis of SLE-associated optic neuropathy is warranted and leads to a better prognosis.

The biomechanical properties of the cornea in patients with systemic lupus erythematosus

PUPOSE: The purpose of this study was to compare the biomechanical properties of the cornea and intraocular pressure (IOP) between patients with systemic lupus erythematosis (SLE) and age-matched controls.

PATIENTS AND METHODS

In this prospective study, 30 healthy individuals (control group) and 30 patients with SLE (study group) underwent Reichert ocular response analyzer (ORA) measurements. In the right eye of each participant, the corneal hysteresis (CH), corneal resistance factor (CRF), and Goldman-related IOP (IOPg) were recorded using the ORA.

RESULTS

Mean CH, CRF, IOPg were significantly different between groups. Mean CH was 10.2 ± 0.6 mm Hg in the study group and 11.3 ± 1.3 in the control group (P=0.02); mean CRF was 9.7 ± 1.1 mm Hg and 11.9 ± 1.5 mm Hg, respectively (P=0.001). Mean IOP(g) was 13.9 ± 2.9 mm Hg in the study group and 16.9 ± 2.6 mm Hg in the control group (P=0.001).

CONCLUSION

The biomechanical properties of the cornea are altered in patients with SLE compared with normal controls. These findings should be taken into account when measuring IOP values in patients with SLE as IOP readings may be underestimated in SLE eyes.

[Choroidal vascular occlusion]

Systemic lupus erythematosus (SLE) is a chronic, relapsing and remitting autoimmune disease of unknown etiology. As in other rheumatic diseases sicca syndrome is often present. Additionally retinal vascular pathologies such as cotton wool spots and intraretinal hemorrhages are present in 7-8% of patients with SLE. SLE-related retinal vascular pathologies are activity markers and a prognostic factor for poor outcome. The case of a 38-year-old patient is reported with decompensated SLE who presented in our clinic with floaters and flickering scotoma but good visual acuity. Funduscopy and fluorescence angiography revealed bilateral choroidal vessel occlusions. Additionally, a hemorrhagic choroidal infarction and a preretinal hemorrhage were detected in the right eye. In summary SLE can result in choroidal vasoocclusion especially if decompensated arterial hypertension is present.

Colour Doppler ultrasound of the ocular circulation in patients with systemic lupus erythematosus identifies altered microcirculatory haemodynamics

We assessed whether quantitative analysis of Doppler flow velocity waveforms is able to identify subclinical microvascular abnormalities in SLE and whether eigenvector analysis can detect changes not detectable using the resistive index (RI). Fifty-four SLE patients with no conventional cardiovascular risk factors, major organ involvement or retinopathy were compared to 32 controls. Flow velocity waveforms were obtained from the ophthalmic artery (OA), central retinal artery (CRA) and common carotid artery (CA). The waveforms were analysed using eigenvector decomposition and compared between groups at each arterial site. The RI was also determined. The RI was comparable between groups. In the OA and CRA, there were significant differences in the lower frequency sinusoidal components ( P < 0.05 for each component). No differences were apparent in the CA between groups. Eigenvector analysis of Doppler flow waveforms, recorded in proximity of the terminal vascular bed, identified altered ocular microvascular haemodynamics in SLE. Altered waveform structure could not be identified by changes in RI, the traditional measure of downstream vascular resistance. This analytical approach to waveform analysis is more sensitive in detecting preclinical microvascular abnormalities in SLE. It may hold potential as a useful tool for assessing disease activity, response to treatment, and predicting future vascular complications.

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.

Severe vaso-occlusive retinopathy as the primary manifestation in a patient with systemic lupus erythematosus

Severe vaso-occlusive retinopathy as the initial manifestation of systemic lupus erythematosus (SLE) is rare. We report a 16-year-old female who developed bilateral visual impairment. Fundus examinations showed bilateral "cherry-red spot" appearance, multiple confluent cotton wool spots, and widespread arterial occlusion. Laboratory studies showed leukopenia, antinuclear antibody (+), and anti-double-stranded DNA antibody (+). Malar rashes, oral ulcers, and bilateral knee joint tenderness were noted during physical examination. SLE was diagnosed and pulse therapy started immediately. Best corrected visual acuity of the left eye improved to 6/10 after treatment. However, there was no visual improvement in the right eye. Four months later, bilateral panretinal laser photocoagulation was performed due to retinal neovascularization. However, tractional retinal detachment of the right eye and vitreous hemorrhage of the left eye still occurred. After undergoing cryoretinopexy of the right eye and intravitreous tissue plasminogen activator injection of the left eye, the visual acuity of the patient's right eye remained hand movement only at 10 cm, but that of the left eye returned to 6/10. The ocular and systemic conditions were stable in the follow-up period of more than 2 years. This case demonstrates that in patients with severe vaso-occlusive retinopathy, a generalized immunological disorder, like SLE, should be suspected.

An unusual presentation of lupus retinopathy

We have described an unusual presentation of lupus retinopathy in the form of macular arterio-arterial and arterio-venular shunts with extensive macular ischemia as a presenting sign.

Therapy insight: The recognition and treatment of retinal manifestations of systemic vasculitis

A variety of retinal signs can occur in patients who have systemic vasculitides, or who experience complications of these diseases or their treatment. Although treatment of these retinal manifestations is usually the treatment of the systemic disease, specific treatment is occasionally indicated to preserve vision. The more prevalent of the systemic vasculitides are giant cell arteritis, polyarteritis nodosa, Wegener's granulomatosis, Churg-Strauss syndrome, relapsing polychondritis and systemic lupus erythematosus. Less frequently occurring vasculitides include Takayasu's arteritis, Goodpasture's disease, microscopic polyangiitis and Henoch-Schönlein purpura, as well as vasculitis secondary to scleroderma and rheumatoid arthritis. This article describes the pathogenesis, clinical features and treatment of retinal manifestations of systemic vasculitides.