History of Present Illness
A 42-year-old African American gentleman returned for routine follow-up, without any new visual complaints. He was diagnosed with systemic lupus erythematosus (SLE) in his 20s and had several episodes of “uveitis” in both eyes (OU) that required treatment with oral and topical medications. Nevertheless, he slowly had gradual progression of visual loss, OU, right eye greater than left eye (OD > OS). He received previous sector panretinal photocoagulation for ischemic retinal disease OD.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/80 | 20/30 |
| Intraocular pressure (IOP) | 12 | 12 |
| Sclera/conjunctiva | Within normal limits (WNL) | WNL |
| Cornea | Clear | Clear |
| Anterior chamber (AC) | No cell or flare | No cell or flare |
| Iris | No iris neovascularization (NV) | No iris NV |
| Lens | Mild nuclear sclerosis | Mild nuclear sclerosis |
| Vitreous cavity | No cells | No cells |
| Retina/optic nerve | Normal optic disc. Fibrosed retinal NV frond along superotemporal (ST) arcade. Light laser photo-coagulation scars in superotemporal quadrant (STQ) of retina | Marked attenuation of retina arterial vasculature with arteriovenous (AV) nicking. |
Questions to Ask
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What complications have you had because of SLE?
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Did you receive laser treatment to both eyes?
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Are you on medication for your SLE and/or complications from the disease?
He responds that he had been told that he developed occlusive retinal vasculitis with retinal neovascularization (NV) in the OD that required laser treatment. He denied laser treatment to the OS. He added that he was on chronic dialysis because of lupus nephritis and taking azathioprine 100 mg every morning.
Assessment
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Retina vascular ischemia OU in a patient with SLE
Differential Diagnosis
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Behçet disease
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Syphilis
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Polyarteritis nodosa
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Takayasu disease
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Granulomatosis with polyangiitis
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Severe hypertensive retinopathy
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Proliferative diabetic retinopathy
Working Diagnosis
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SLE occlusive retinal vasculopathy OU (OD > OS)
Although the patient’s retinopathy may also show changes of systemic hypertension secondary to chronic renal disease, it is not the primary cause of his retinal occlusive disease and NV. Additionally, he experienced medication-induced diabetes mellitus because he was maintained on systemic prednisone before other immunomodulatory therapy (IMT) for his SLE, and his retina does not show the hallmark changes of diabetic retinopathy.
Testing
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Consultation with nephrology for evaluation of his lupus nephritis and current systemic evaluation of SLE. Appropriate laboratory tests will be ordered by that service.
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Fundus autofluorescence (FAF) ( Fig. 73.1 )
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