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.