Discussion:
We report here two cases of retinal vasculitis (RV) occurring on young adult satisfying the 2010 ACR/EULAR Criteria for RA diagnosis.1
The two patients were younger comparing to the reported cases in literature noticing that RV occurred between the fifth and the sixth decade of life 2 34 5 . Disease duration was 8 years for the first case and 4 years for the second one otherwise, disease duration was more then 10 years in the most reported cases in literature except for one case in which RA was revealed few months before RV development 3 4 5. Our patients did not have extra-articular manifestations including diffuse pulmonary interstitial fibrosis, pleuritis, pericarditis, muscular atrophy, leg edema and rheumatoid nodules. Also they did not show any feature of rheumatoid vasculitis manifested as petechiae, purpura, digital infarcts, gangrene, livedo reticularis, and lower extremity ulceration. The common ocular complications of RA including episcleritis, scleritis and peripheral ulcerative keratitis were not noted in our patients’ clinical course. Retinal vasculitis associated with RA is rarely reported 6 . Since then, other potential etiologies of retinal vasculitis were suspected. Intensive investigation revealed no evidence of infection (Tuberculosis, EBV, CMV, toxoplasmosis, syphilis, Lyme disease and cat scratch disease), inflammatory or autoimmune diseases (Systemic vasculitis, SLE or antiphospholipid antibody syndrome) 7 . In the two cases, retinal vasculitis occurred concomitantly with a flare of RA as shown by a positive test for CRP and elevated ESR with high DAS28. Therefore, we cautiously hypothesize that RA led to RV development. RA is a systemic inflammatory rheumatic disease with extra-articular manifestations and rheumatoid vasculitis can accompany long-standing disease (in less than 1% of RA patients) 2 .The signs of rheumatoid vasculitis vary and may include peripheral neuropath, visceral ischemia and various skin lesions as purpura, skin ulceration and digital gangrenes. Rheumatoid vasculitis may also affect the retinal vessels. Because epidemiologic data and retinal vasculitis case reports in patients with RA are lacking, the pathogenetic association between RV and RA could not be fluently assessed 2 . It’s reported that retinal vasculitis related to RA, usually occurs in nodular disease, with high titres of classical IgM rheumatoid factor and are often associated to Infarcts in nailfold capillaries, weight loss and general malaise 8 9. Our patients did not have all these features except a high titer of rheumatoid factor noted in the first case. In contrast to what is previously reported, it is enough noticeable that our two patients with active RA developed diffuse inflammation of the retinal capillaries in the absence of systemic vasculitis. Our literature review identified that an association between RA disease activity and retinal vasculitis was presented in a report suggesting that suppressing RA-related inflammation improves vascular health 10. Another report showed that orbital blood flow velocity in RA patients is lower than in healthy controls suggesting that systemic inflammation may also affect the ocular vessels 11. In our current cases, we conjecture that retinal vasculitis development may reflect long-standing subclinical systemic inflammation. Timing of the retinal vasculitis and the observed clinical improvement after adequate inflammation control using corticosteroids or immunomodulatory therapy, suggest that the retinal changes were a direct consequence of their active rheumatoid disease. However, further research is needed to investigate pathophysiologic processes of retinal vasculitis in RA patients.
Conclusion : From these two observations, we concluded that the RV remain rare in the course of RA. However, retina should be examined for evidence of vasculitis in rheumatoid disease, and that collaborative efforts between the ophthalmologists and rheumatologists involved in the evaluation and treatment of patients with RA are essential to effectively manage any ocular complications that may arise.