Describing the clinical and subclinical characteristics of retinal lesions in Lupus patients; assessing the results of treatment of retinal lesions in patients with systemic lupus erythematosus.
Trang 1INTRODUCTIONSystemic lupus erythematosus (SLE) is the most common disease in the autoimmune disease group. The disease stands out with diverse lesions in many organs, internal organs, chronic progression over many years, alternating many exacerbations that greatly affect the quality of life of patients even leading to death.
The ophthalmic manifestations in Lupus can threaten the vision and impair the patient’s life quality, which is also an indicator of advanced systemic disease. In Vietnam, there are currently no reports of eye injuries caused by the pathological process of Lupus, especially the fundus lesions. So we proceed to the topic: “Studying the clinical, subclinical characteristics and treatment
of retinal lesions in patients with systemic Lupus erythematosus” with the two following goals:
1. Describing the clinical and subclinical characteristics of retinal lesions in Lupus patients
2. Assessing the results of treatment of retinal lesions in patients with systemic lupus erythematosus.
NEW CONTRIBUTIONS OF THE THESISThis is the first study in Vietnam on retinal lesions caused by Lupus, assessing the forms of retinal lesions caused by Lupus, the severity of injuries
as well as the risk of losing sight of patients. , thereby proposing systematic and periodic eye examinations for patients for early detection and timely treatment
of eye lesions caused by Lupus. This study assesses the results of treatment of retinal lesions, thereby proposing a treatment regimen as well as selecting treatment methods appropriate to each morphology and extent of lesions, contributing to preserving the function of vision. awareness for Lupus patients, improving the quality of life for patients as well as reducing the burden on families and society Partly elucidating the mechanism of lesions, the relationship between visceral lesions in Lupus and eye lesions will contribute to improving the effectiveness of treatment coordination between Ophthalmologists and physicians of Clinical Allergy Immunology
STRUCTURE OF THE THESISThe thesis is 155 pages long, consisting of the following sections: Introduction (2 pages), Chapter 1: Literature Overview (45 pages), Chapter 2: Research subjects and methods (28 pages); Chapter 3: Research results (32 pages); Chapter 4: Discussion (47 pages); Conclusion (2 pages); Recommendations (1
Trang 2CHAPTER 1 LITERATURE OVERVIEW
1.1. SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
1.1.1. Definitions: Lupus is a disease with multiple organ lesions in which the autoimmune mechanism plays the most important role in the pathogenesis mechanism. It is characterized by the production of autoantibodies against the components of the nucleus of the cell itself, multiorgan lesions, multiple acute progression, alternating with regressions of the disease. Lupus is more common
in women, especially in reproductive and working age
1.1.2. The diagnostic criteria for Lupus: According to SLICC (2012)
1.1.3. Assessing the severity of systemic lupus erythematosus: Based on the SLEDAI scale, classified as follows: Mild and moderate disease SLEDAI ≤ 10, severe disease when SLEDAI> 10.
1.1.5. The relationship between the pathological process of Lupus and the patterns of ocular lesions:
1.2. CLINICAL CHARACTERISTICS OF RETINAL LESIONS IN LUPUS 1.2.1. The morphologies of retinal vascular lesions
1.2.1.1 Retinal Vasculitis:
* Retinal Vasculitis without retinal embolism: more common in microcircular lesions, typically with the presence of cotton nodules (824%), retinal hemorrhages, changes in blood vessel shape, common in small arteries.
* Retinal Vasculitis with retinal embolism: is a retinal vascular
Trang 3disease due to inflammation of small arteries, arterioles accompanied by occlusive complications, retinal anemia, this is the main and very serious clinical manifestation of the disease, with symptoms such as: nodules cotton, superficial retinal hemorrhage (see 510%), small arterioles (13.2%), clear vascular cages, resident retinal edema or dissemination due to rupture retinal blood barrier.
1.2.1.2 Blockage of large blood vessels of the retina: more rarely, with
manifestation of occlusion or total occlusion of the central retinal vein causing severe retinal anemia, very common in the presence of antiphospholipid syndrome (APS). Lupus retinopathy has varying degrees of anemia, and the width of the anemia is proportional to the degree of visual impairment. Vascular occlusion causes severe retinal anemia, which can be accompanied by complications of new neovascularization
Macular lesions: common condition is edema and anemia in macular region
Rare optic nerve lesions (1%), manifesting edema optic nerve and optic nerve anemia in front or back.
1.3. SUBCLINICAL TESTS
Ophthalmoscopy allows the evaluation of specific lesions of inflammation
in retinal vein occlusion due to Lupus Fluorescent angiography, optical coherence tomography OCT and ultrasound mode B techniques play an important role in detecting and evaluating retinal lesions and monitoring treatment
1.4. Differential diagnosis: with causes of Retinal Vasculitis in general 1.5. TREATMENT METHODS
1.5.1. Systemic treatment: The main purpose is to suppress immuneacting
Trang 4activities, reducing the concentration of autoantibodies that fight off organs. Corticoides is the firstline treatment option and is the shortest treatment available for due to Lupus systemic vasculitis as well as retinal Vasculitis in the eyes. Corticoides treatment or have severe side effects. Synthetic antimalarial drugs such as Chloroquine, Hydroxychloroquine (HCQ) have the effect of reducing future outbreaks, preventing relapses and the progression of Lupus disease. Other drugs: antiplatelet aggregation drugs, anticoagulants, exchange plasma.
1.5.2. Local treatment: The main purpose is to prevent complications caused
by embolic condition, contributing to preserving vision for Lupus patients
1.5.2.1. Retina laser: This is the first treatment option for complications of embolism that causes anemic retinopathy due to Lupus.
Laser designation according to the degree of anemic retinopathy:
Light anemic retinopathy under 2 optic disc area: track
Anemic retinopathy averages from 2 to less than 5 optic disc areas: the laser covers the entire anemic area
Anemic retinopathy weighing over 5 optic disc areas: whole peripheral retina laser to near the temporal arc (PRP)
Retinal neovascularization in peripheral: find the starting position of neovascularization so that the laser then the entire retinal laser region is anemic, in case of neovascularization and optic nerve, the risk of vitreous body hemorrhage must be combined with intraocular injection with Avastin
1.5.2.2. AntiVEGF (Avastin)
AntiVEGF drugs are effective in preventing and treating complications of neovascular proliferation of the retina due to Lupus, which inhibits retinal neovascularization and limits the spread of existing neovascularization. Bevacizumab (Avastin) is a monoclonal antibody designated intraocular injection to treat retinal neovascularization, neovascularization and optic nerve complications with a dose of 1.25mg / 0.05ml
Indications for injection Avastin in cases:
In the case of thrombophlebitis causes severe anemic retinopathy risk of high neovascular proliferation,
Trang 52.1. RESEARCH SUBJECTS
Patients coming for outpatient examination at the Examination Department
of Bach Mai Hospital and VNIO are diagnosed to identify Lupus according to SLICC 2012 with retinal lesions in the eyes
Research period from June 2013 to June 2017
Research location: Examination Department of Bach Mai Hospital and VNIO
2.1.1. Criteria for selecting a patient: Patients diagnosed with Lupus according to SLICC 2012 will be screened for retinal lesions at the eye
2 2 /
d
p p Z
Trang 8 Examination of the fundus: by direct ophthalmoscopy, Volk superfield glasses and 3sided mirror glass
Forms of Retinal lesions:
* Retinal vasculitis: including microcirculation lesions (exudative cottons, retinal hemorrhage), retinal vascular changes, with or without retinal occlusion.+ Exudative cottons: Assessed based on the number, location and size of the secretion compared to the optic disc area
Mild level: when hemorrhage size is less than 1/4 of optic disc area
Moderate level: sized from 1/4 to 1/2 optic disc area
Severe level: large hemorrhage on 1/2 optical disc area
+ Changes in the shape of retinal blood vessels: location of Retinal Vasculitis (in capillaries, arterioles, arteries or central veins of the retina). The levels of change are as follows:
2.2.4.3 The subclinical test in the eye
Trang 9* Fluorescent angiography: detected retinal vascular lesions: retinal vasculitis, retinal embolism, anemic retinopathy.
* OCT: optical coherence tomography in case of suspected macular region lesions. Measurement of central retinal thickness and macular region.
* Ultrasound B: Used in cases where the fundus cannot be used to assess the
vitreous, retinal condition.
2.2.4.4 The subclinical test of SLE disease
Subclinical results of patients with Lupus include: blood counts, blood biochemistry, coagulation indices, urine tests, proteinuria quantification in 24 hours, tests to detect antibodies against nucleus, antibodies to DsDNA, antibodies to phospholipids, blood pressure and weight values
2.2.4.5 Indications for treatment according to morphology and degree of Retinal lesions
* Retinal Vasculitis group: Treated with Bolus Corticoides
Without retinal occlusion: monitor
If accompanied by embolism: depending on the degree of anemia to specify+ Anemic Retinopathy <2 areas of papillae: monitoring
+ Anemic Retinopathy from 25 areas of papillae: Laser covered anemic area+ Anemic Retinopathy> 5 areas of papillae: Laser peripheral peripheral retina close to 2 temporal arcs
+ In case of a major thrombophlebitis causing severe anemic retinopathy after Bolus corticoides and laser peripheral peripheral retina, it is necessary to appoint intraocular injection Avastin in combination to prevent early neovascular proliferation complications
Trang 10 If there are complications of neovascular proliferation: depending on the location of neovascularization to specify treatment
+ Retinal neovascularization in peripheral laser is close to the starting position of neovascularization and the retinal area is anemic. Postpartum retinal neovascularization requires intraocular injection of Avastin
+ Neovascularization of optic nerve: Whole peripheral retina laser is closer
to the 2 temporal arteries, if neovascularization of optic nerve are not dissipated
or there is a risk of vitreous body hemorrhage requiring intraocular injection Avastin
+ In case of examination, there is a complication of proliferation causing retinal detachment requiring surgery
Fluorescent angiography
Good results: No new anemic area. The old anemic area has been replaced by laser scarring, no new neovascularization or neovascularization remains, but regression is reduced
Bad results: New areas of retinal anemia appear, new neovascularization in retina and papillae
Optical coherence tomography (OCT): Macular edema after treatment has
Good results: when macular region retinal thickness is reduced
Bad results: when macular region retinal thickness increases
Trang 113.1.2. Age at the examination
Trang 123.1.3. Age at the onset of Lupus
Most had an early onset of illness, 80.6% of Lupus patients had Retinal lesions onset before age 30
3.1.4. . Systemic lesions of the research team
The common manifestations are new rash, inflammation and arthritis pain accounting for 64.5%. The manifestations of nerve and mental lesions were encountered with the rate of 25.8%. Kidney lesions in 22.5% of cases
3.1.5 Test variations
Increased triglycerides account for 50% of cases. The proportion of patients with positive antinuclear antibodies in the study group was 35.5%, antibodies
to DsDNA positive in 25.8% of cases
3.1.6. Severe level of Lupus
Table 3.5: Severe level of Lupus
Average SLEDAI score 17,23 ± 4,87 min 0 max 30 pointsRate of patients with SLEDAI score> 10 96,8%
Average duration of Lupus 5,19 ± 5,11 min 0 max 25 years Rate of patients having treatment
3.2. CLINICAL AND SUBCLINICAL CHARACTERISTICS, OF RETINAL LESIONS DUE TO LUPUS
3.2.1 Functional symptoms: Blurred vision accounted for 94.2%, 5.7%. There was no complaint about eyes
Trang 13eyes (n=52) %Retinal Vasculitis No retinal embolismWith retinal occlusion 1214 23,126,9Retinal occlusion merely does not cause vasculitis 26 50
retinal occlusion
No retinal embolism With retinal embolism
Retinal Vasculitis Simple
retinal occlusion
No retinal embolism With retinal embolism
Trang 143.2.3.4 Retinal neovascularization, optic nerve before treatment in studied group
The rate of neovascularization seen in the studied group is 30.8%, the proliferative retinopathy seen in 7 eyes accounts for 13.5% All cases of neovascularization, retinopathy of proliferation at baseline were in the simple occlusive group without these lesions in the retinal vasculitis group
3.2.4. Other combined lesions
Trang 153.2.4.1 Vitreous body: In all forms of retinal lesions, vitreous body in the
majority accounted for 84.6%
3.2.4.2 Choroid
Table 3.20: Choroidal lesions trong studied group
Choroidal lesions Retinal Lesion forms Total
Vasculitis Simple retinal occlusion
Vasculitis Simple retinal occlusion
Thin central retinal atrophy 2 (7,4%) 5 (18,5%) 7 (25,9%)Neovascularization under the
3.2.5.2. Grouping of vision before treatment lesion forms and degree of anemia
3.3. TREATMENT RESULTS
3.3.1. Results of treatment in the Retinal Vasculitis group:
Trang 163.3.1.3 Complementary treatment of complications of neovascular proliferation Table 3.29: Complementary treatment in the Retinal Vasculitis group
Forms Methods After 1 month monthsAfter 3 monthsAfter 6 monthsAfter 9 After 12 months timeLast Vasculitis
Trang 17Vision improved at 1 month after Bolus however at 39 months vision was lesionsd more. There were no significant differences between the mean logMAR visual value at the end of the followup compared to before treatment. Retinal Vasculitis group had 46.2% of cases with vision> 20/200 after treatment
no new neovascularization at 12 months after treatment.
3.3.2.3 Complementary treatment in the Simple retinal occlusion group: few 3.3.2.4 Treatment methods
Trang 18Chart 3.6. Visual changes of the Simple retinal occlusion group
3.3.3 Evaluating the effectiveness of treatment in 2 groups
3.3.3.1. Vision results in 2 groups
There was no difference in visual acuity of the two groups; however, the percentage of patients with postoperative visual acuity> 20/200 in 2 groups had
a statistically significant difference with p <0.05. The percentage of patients with visual acuity> 20/200 after treatment in the thromboembolism group alone was 76.9% higher than that in the vasculitis group
3.3.3.2. Success rate in 2 groups
Table 3.36: Success rate in 2 groups
Group of retinal vasculitis
Group of retinal occlusion
P
Completely successful 9 (34,6%) 7 (26,9%) >0,05