Retinopathy Associated With Systemic Lupus Erythematosus

Ki Yoon Chang; Hyun Park Jung; Gon Yu Hyeong

doi:10.3341/jkos.2009.50.8.1215

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Chang, Jung, and Hyeong: Retinopathy Associated With Systemic Lupus Erythematosus

Original Article

J Korean Ophthalmol Soc 2009;50(8):1215-1220.

Published online: 7 September 2009

DOI: https://doi.org/10.3341/jkos.2009.50.8.1215

Retinopathy Associated With Systemic Lupus Erythematosus

Ki Yoon Chang, MD¹, Hyun Park Jung, MD¹, Gon Yu Hyeong, MD, PhD^1,²

¹Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea

²Seoul Artificial Eye Center, Seoul National University Hospital Clinical Research Institute, Seoul, Korea

Address reprint requests to Hyeong Gon Yu, MD, PhD Department of Ophthalmology, Seoul National University College of Medicine #28 Yeongeon-dong, Jongno-gu, Seoul 110-744, Korea Tel: 82-2-2072-2438, Fax: 82-2-741-3187, E-mail: hgonyu@snu.ac.kr

Received 20 November 200826 May 2009

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose:

To investigate the clinical characteristics of retinopathy associated with systemic lupus erythematosus (SLE) and its risk factors.

Methods:

Medical records of patients who were diagnosed with SLE were reviewed retrospectively. The presence of retinal hemorrhage, vasculitis and a cotton wool patch were regarded as lupus retinopathy, but concomitant diabetic retinopathy and hypertensive retinopathy were excluded from the study. The correlation between the development of lupus retinopathy and the presence of positive autoantibodies was also investigated.

Results:

Ocular morbidity was found in 173 of 260 (66%) SLE patients. Retinopathy was detected in 52 eyes of 33 patients (12%), which included 36 eyes of 21 patients (63%) with classic retinopathy and 11 eyes of 10 patients (30%) with vaso-occlusive retinopathy. The presence of classic retinopathy coincided with the flare-up of lupus activity and completely resolved without visual impairment. However, vaso-occlusive retinopathy was not related with lupus activity, and resulted in significant visual impairments of 20/200 or less in six eyes of five patients. The disease activity of lupus assessed by the maximum SLE disease activity index was higher in patients with retinopathy (p<0.05), and the prevalence of antiphospholipid antibody was higher in patients with vaso-occlusive retinopathy than in patients with classic retinopathy (66.7% vs. 37.5%, p<0.05).

Conclusions:

Vaso-occlusive retinopathy in SLE can result in permanent visual impairment. Patients with high SLE activity or positive anti-phospholipid antibodies have a high possibility of developing SLE retinopathy and should be referred for ophthalmologic examination.

Keywords: Activity, Antiphospholipid antibody, Retinopathy, Systemic Lupus Erythematosus

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Figure 1.

Comparison of peak SLEDAI among patients with retinopathy, without retinopathy, and each subtype of retinopathy. ^∗ttest; †Mann Whitney-U test; ‡ Patients without retinopathy.

Table 1.

Ocular manifestations found in SLE

Ocular manifestations	No of patients (%)
Keratoconjunctivitis sicca	80 (30.8)
Cataract	60 (23.1)
Retinopathy	33 (12.6)
Choroidopathy	8 (3.1)
Optic neuropathy	5 (1.9)
Uveitis	4 (1.5)
Others	17 (6.5)
No abnormality	87 (33.5)

Table 2.

Difference of demographics between patients with retinopathy and without retinopathy

	No retinopathy (n=227)	Retinopathy (n=33)	p-value
Age at ocular exam	37.2±12.5	36.2±13.7	0.657^∗
Age at SLE diagnosis	33.6±11.9	34.3±13.3	0.749^∗
M:F	21 (9%): 206 (91%)	5 (15%): 28 (85%)	0.346^†

^∗ ttest

^† Chi square test.

Table 3.

Funduscopic findings in each subtype of lupus etinopathy

Retinopathy type	Funduscopic finding	No	(%)
Classic retinopathy	Hemorrhage	13	(61.9)
(N=21)	Cotton wool spot	13	(61.9)
	Focal vasculitis	2	(9.5)
	Hard exudate	1	(4.7)
Vaso occlusive	CRVO	2	(20)
retinopathy	BRVO	5	(50)
(N=10)	CRAO	1	(10)
	BRAO	1	(10)
	Diffuse obstruction	1	(10)
Others (N=2)		2

Table 4.

Difference of systemic manifestations between patients with retinopathy and without retinopathy

Systemic manifestations	No retinopathy N=148 (%)	Retinopathy N=30	p-value^∏
Rash	64 (43.2)	19 (63.3)	0.048^#
Photosensitivity	26 (17.6)	4 (13.3)	0.790
Mucosal ulcer	35 (23.6)	6 (20.0)	0.814
Arthritis	62 (41.9)	13 (43.3)	1.000
Serositis	26 (17.6)	8 (26.7)	0.307
Renal involvement^∗	63 (42.6)	20 (66.7)	0.026^＃
Neurological involvement^†	7 (4.7)	2 (6.7)	0.649
Hematologic abnormality^‡	103 (69.6)	17 (56.7)	0.201
Immunologic abnormality^§	120 (81.1)	26 (86.7)	0.606

^∗ Proteinuria > 500 mg/day, hematuria (RBC > 5/HPF), pyuria (WBC > 5/HPF) or cellular or granular casts

^† Seizure, organic brai syndrome, cranial nerve disorder, cerebral vascular accident, or psychosis

^‡ Hemolytic anemia, leukopenia (<4000/mm³) or lymphopeni (<1500/mm³)

^§ LE cell(+), Sm antibody (+), decreased C3/C4 level or increased dsDNA

^∏ Fisher's exact test.

^# p<0.05

Table 5.

Relationship between common autoantibodies found in SLE and lupus retinopathy

Autoantibodies	No retinopathy N(%)	All retinopathies N (%)	Classic retinopathy N (%)	occlusive retinopathy N (%)	p^∗	p^†	p^‡
APL^§	53 (30.1)	13 (48.1)	6 (37.5)	6 (66.7)	0.078	0.576	0.031^‡‡
LE cell	27 (44.3)	4 (40.0)	3 (42.9)	1 (50.0)	1.000	1.000	1.000
Ro / La^∏	67 (63.2)	10 (58.8)	7 (63.6)	3 (60.0)	0.790	1.000	1.000
Sm^＃	32 (27.8)	6 (33.3)	5 (45.5)	1 (20.0)	0.779	0.298	1.000
RNP^∗∗	30 (52.6)	5 (50.0)	5 (62.5)	0 (0)	1.000	0.716	0.237
RF^††	27 (19.3)	4 (25.0)	3 (21.4)	1 (100.0)	0.526	0.737	0.199

^∗ Fisher's exact test between “no retinopathy” and “all retinopathies”

^† Fisher's exact test between “no retinopathy” and “classic retinopathy”

^‡ Fisher's exact test between “no retinopathy” and “occlusive retinopathy”

^§ Antiphospholipid antibody: Lupus anticoagulant or anticardiolipine antibody

^∏ Anti-Ro (SS-A) antibodies/anti-La (SS-B) antibodies

^＃ Anti-Sm antibodies

^∗∗ Anti-snRNP antibodies

^†† Rheumatoid factor

^‡‡ p<0.05.

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