Studying the clinical, subclinical characteristics and treatment of retinal lesions in patients with systemic Lupus erythematosus

inal lesions in Lupus patients is about 10%.) d = 0.1 found n = 34.57 ≈ 35 eyes 2.2.3. Research facilities: including media Serving eye screening. Laboratory facilities at VNIO - Digital retinal fluorescent angiography machine (Carl Zeiss) - Optical coherence tomography machine (OCT 3- Carl Zeiss), Ultrasound B machine. Means of treatment of retinal lesions at VNIO - Retina laser machine - Room for intraocular injection, intraocular injection kit, Avastin medicine. - Surgical means Subclinical tests of SLE: Conducted at Labo Centers for Allergy Clinical Immunology, Biochemistry and Hematology at Bach Mai Hospital 2.2.4. Steps to conduct the research Research process The patient was diagnosed with Lupus Interview and eye screening. Optometry, intraocular pressure - pre-partial examination - fundoscopy If there is a lesions to the fundus B-scan  ultrasonography Optical coherence tomography (OCT) Fluorescence angiography Subclinical test of Lupus Research indicators on Lupus status, retinal condition before treatment Systemic treatment combined with ophthalmic treatment Research indicators on retinal condition, eyesight after treatment 2.2.4.1 Interview: All patients were asked to get information - Assessing the severity of Lupus according to SLEDAI: - Record all body test results, subjective signs at eyes 2.2.4.2 Screening to detect Retinal lesions at the eye - Optometry: Snellen vision chart, visual acuity test with corrective lenses. Vision results based on ICO report classification - Sydney 2002. Convert Snellen vision to logMAR vision table - Measurement of intraocular pressure, partial examination - Examination of the fundus: by direct ophthalmoscopy, Volk superfield glasses and 3-sided 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 the secretion size is less than 1/4 of optic disc area - Moderate level: secretion size from 1/4 to 1/2 area optic disc - Severe level: when secretion is large on 1/2 optic disc area + Retinal hemorrhage: assessing the location, morphological form (dot, candle or cloud), size and level of bleeding. According to Wisconsin, bleeding levels include " - 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: - Level 1: Blood vessels dilate slightly - Level 2: Shrink blood vessels with irregular diameter - Level 3: Severe when there is an image of a blood vessel, breaking or changing the direction of the blood vessel. + It may be accompanied by vascular lesions causing anemic retinopathy. * Occlusion of the retina: Evaluation of the embolization site, causing corresponding retinal perfusion is observed on fluorescent angiography, may include retinal neovascularization, neovascularization of optic nerve, vitreous hemorrhage, proliferation, retinal detachment contraction. + Choroid condition: + Vitreous condition: degree of transparency, cloudiness, hemorrhage vitreous + Macula: Anemia, edema macular region. + Status of optic disc: pink, suitable optic disc, concave, atrophic optic disc, neovascularization of optic disc. 2.2.4.3 The subclinical test in the eye * Fluorescent angiography: detected retinal vascular lesions: retinal vasculitis, retinal embolism, anemic retinopathy. + Anemic retinopathy area: Mild level: anemic area of less than 2 optic disc area Moderate level: from 2 to less than 5 optic disc area Severe level: anemic area of more than 5 optic disc areas + Abnormal fluorescence and numerous cases of retinal neovascularization + Other combined lesions such as anemia choroidal, anemia or edema macular * 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 Ds-DNA, 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 2-5 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. * Simple retinal occlusion group: First-hand treatment is Laser - If there is no complication of neovascular proliferation: laser indicated according to the level of anemic retinopathy: + Anemic Retinopathy <2 areas of papillae: monitoring + Anemic Retinopathy from 2-5 areas of papillae: Laser covered anemic area + Anemic Retinopathy> 5 areas of papillae: Laser peripheral peripheral retina close to 2 temporal arcs - 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. 2.2.5. Result evaluation 2.2.5.1 According to research indicators 2.2.5.2 Evaluation of specific results * Functional results: Subjective signs of the patient * Functional results Eye sight: Evaluating the changes in vision and visual acuity results after treatment - Good results: clinically the level of vision remains the same or increases - Bad results: clinically impaired vision or vision loss * Entity results Ophthalmoscopy - Good results: Retinal vasculitis reduced, no new neovascularization, no vitreous hemorrhage, old regressing neovascularization. - Bad results: Recurrent vasculitis retinal condition, new neovascularization, , vitreous body hemorrhage, retinal proliferation, complications of retinal detachment. 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 Assess complications during eye treatment * Final treatment results for Retinal lesions due to Lupus: evaluated according to two criteria: 1. Preserving and improving the eyesight 2. Preventing the complications * General results of the treatment process - Completely successful: When all of the following conditions are met: + Vision is preserved or increased compared to before treatment + No new neovascularization, regressing old neovascularization, no hemorrhage vitreous, no new anemic retinopathy area, anemic area replaced by laser scar. - Partially successful + Vision is preserved or reduced without losing sight + New neovascularization, vitreous body hemorrhage, new anemic area appeared, requiring additional treatment. There were no serious complications of embolic condition of retina such as: vitreous proliferation, retinal detachment. There is no glaucome neovascularization. + There are complications of treatment process in the eyes but not the serious complications. - Failed: When one of the following conditions is met: + Vision loss + Severe complications of retinal occlusion: severe vitreous body proliferation causing retinal detachment, loss of function + Glaucome neovascularization + There are severe complications of the treatment process 2.2.6. Data processing methods - The research data is processed on a computer with SPSS 15.0 software and cleaned before the processing. CHAPTER 3 RESEARCH RESULTS 3.1. CHARACTERISTICS OF STUDIED PATIENT GROUP: 31 PATIENTS 3.1.1. Gender: The male/female ratio is very different, female patients account for 87.1%, male only 4 patients account for 12.9%. 3.1.2. Age at the examination Chart 3.2: Age of patients at the examination 3.1.3. 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 anti-nuclear antibodies in the study group was 35.5%, antibodies to Ds-DNA 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 points Rate 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 period> 1 year 87,1% 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 3.2.2. Clinical characteristics 3.2.2.1 Retinal lesions forms Table 3.8: Forms of Retinal lesions Forms of Retinal lesions Number of eyes (n=52) Ratio % Retinal Vasculitis No retinal embolism 12 23,1 With retinal occlusion 14 26,9 Retinal occlusion merely does not cause vasculitis 26 50 3.2.2.2 Trauma positions of fundus 3.2.2.3 Merocrine secretion: found in 22 eyes Table 3.10: Levels of merocrine secretion and forms of Retinal lesions Level of merocrine secretion Lesion forms Total n = 22 Retinal Vasculitis Simple retinal occlusion No retinal embolism With retinal embolism Mild 2 (9,1%) 1 (4,5%) 1 (4,5%) 4 (18,1%) Moderate 2 (9,1%) 1 (4,5%) 0 3 (13,6%) Severe 3 (13,7%) 12 (54,6%) 0 15 (68,3%) Total 7 (31,9%) 14 (63,6%) 1 (4,5%) 22 (100%) 3.2.2.4 Retinal hemorrhage: found on 23 eyes. Mild and moderate retinal hemorrhage makes up the majority of 86.9%. The rate of retinal hemorrhage is high in the group of Retinal Vasculitis. 3.2.4. Subclinical characteristics: 3.2.3.1 Retinal Vasculitis status on fluorescent angiography: Table 3.12: Retinal vascular transformation according to lesion forms The degree of retinal vascular changes Lesion forms Total n=26 Retinal Vasculitis Simple retinal occlusion No retinal embolism With retinal embolism Mild 8 (30,8%) 2 (7,7%) 0 10 (38,5%) Moderate 4 (15,4%) 6 (23,1%) 0 10 (38,5%) Severe 0 6 (23%) 0 6 (23%) Total 12 (46,2%) 14 (53,8%) 0 26 (100%) Table 3.13: Trauma position of retinal vasculitis Position Number of eyes with retinal vasculitis (n = 26) Rate % Artery Small size (arterioles) 22 84,6 Large size (branches, central arteries of the retina) 10 38,5 Vein Small size 0 0 Large size (branches, central veins of the retina) 2 7,7 Capillary 15 57,7 3.2.3.2 Trauma position clogs retinal blood vessels Table 3.15: Trauma position of retinal occlusion Position Number of eyes with retinal embolism (n=40) Rate % Artery Small size (arterioles) 27 67,5 Large size (branches, central arteries of the retina) 18 45 Vein Small size 0 0 Large size (branches, central veins of the retina) 2 5 Capillary 22 55 3.2.3.3 The condition of anemic retinopathy in the research team: There were 39 eyes showing anemic retinopathy, in which moderate and severe anemic retinopathy accounted for the majority of cases 94.9%. 3.2.3.4 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. Table 3.18: Neovascularization and Anemic Retinopathy degree Degree of anemia Neovascularization Total Võng mạc Optic nerve Mild: < 2 S optic nerve 0 0 0 Moderate: 2-5 S optic nerve 9 (56,25%) 0 9 (56,25%) Severe: > 5 S optic nerve 5 (31,25%) 2 (12,5%) 7 (43,75%) Total 14 (87,5%) 2 (12,5%) 16 (100%) 3.2.4. Other combined lesions 3.2.4.1 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 Lesion forms Total Retinal Vasculitis Simple retinal occlusion Anemia choroidal 12 (66,7%) 2 (11,1%) 14 (77,8%) Secretion retinal detachment 1 (5,5%) 0 1 (5,5%) Central retinal vitiligo 0 0 0 Pigment epithelial lesion 3 (16,7%) 0 3 (16,7%) Total 16 (88,9%) 2 (11,1%) 18 (100%) 3.2.4.3 Optic nerve: No optic nerve inflammation. Atrophie of optic nerve accounts for 62.5%. Neovascularization of optic nerve found on 2 cases. 3.2.4.4 Macula Table 3.22: Macular lesions trong studied group Macular lesions Lesion forms Total Retinal Vasculitis Simple retinal occlusion Anemia macula 9 (33,3%) 2 (7,4%) 11 (40,7%) Macular edema 7 (25,9%) 1 (3,7%) 8 (29,6%) Thin central retinal atrophy 2 (7,4%) 5 (18,5%) 7 (25,9%) Neovascularization under the retina 0 1 (3,7%) 1 (3,7%) Macular poisoning due to drugs 0 0 0 Total 18 (66,7%) 9 (33,3%) 27 (100%) 3.2.5 Functions: 3.2.5.1. Vision before treatment of studied group The poor vision rate 20/200 accounts for up to 50% of cases before treatment. 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: 3.3.1.1 Initial treatment methods Table 3.26: Initial treatment methods in the group of Retinal Vasculitis Method Number of eyes Rate (n=26) Bolus 12 46,1 Bolus+laser 8 30,8 Bolus+laser+Avastin injection 6 23,1 3.3.1.2 Entity results: In vasculitis group, the rate of encountering merocrine secretion, hemorrhage, retinal vasculitis was high before treatment, this rate gradually decreased after Bolus treatment and ended at 6 months after treatment. There were no cases of neovascularization or retinopathy of proliferation at the time of examination in this form. 3.3.1.3 Complementary treatment of complications of neovascular proliferation Table 3.29: Complementary treatment in the Retinal Vasculitis group Forms Methods After 1 month After 3 months After 6 months After 9 months After 12 months Last time Vasculitis with retinal occlusion Bolus 1 0 0 0 0 0 Laser 13 10 4 3 0 0 Avastin injection 4 6 3 3 0 0 Surgery 0 1 1 2 5 2 3.3.1.4 Treatment methods Method Number of eyes Rate Bolus 12 46,2 Bolus + laser 2 7,7 Bolus + laser + Avastin ịnection 4 15,4 Bolus + laser + Surgery 1 3,8 Bolus + laser + Avastin + Surgery 7 26,9 3.3.1.5 Functional results Chart 3.4: Vision changes of Retinal Vasculitis group Vision improved at 1 month after Bolus however at 3-9 months vision was lesionsd more. There were no significant differences between the mean log-MAR visual value at the end of the follow-up compared to before treatment. Retinal Vasculitis group had 46.2% of cases with vision> 20/200 after treatment. 3.3.2. Treatment results in the Simple retinal occlusion group 3.3.2.1 Initial treatment methods Table 3.30: Initial treatment methods of retinal occlusion Methods Number of eyes Rate (n=26) Laser 15 57,7 Laser + Avastin injection 3 11,5 Avastin injection 2 7,7 Avastin injection+Vitreous body resection 1 3,8 Vitreous body resection 5 19,2 3.3.2.2 Entity results The Simple retinal occlusion group without the expression of retinal vasculitis had a high rate of anemic retinopathy before treatment of 96.2%, which gradually decreased and ended at 12 months with prophylaxis with retina laser. The pre-treatment neovascularization status of this group was 61.5%. 26.9% of cases with retinopathy increased during the examination. There was 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 Method Number of eyes Rate Laser 14 53,8 Laser + Avastin ịnection 3 11,5 Laser + Surgery 1 3,8 Avastin iniection 1 3,8 Avastin injection + Surgery 2 7,7 Surgery 5 19,2 3.3.2.5 Functional results Vision improved gradually over time of follow-up in the Simple retinal occlusion group, there was a statistically significant difference when assessed at the follow-up of 6 months compared to 3 months after treatment. Vision after treatment of this group improved significantly compared to before treatment Only 7.7% of cases had post-treatment vision in this group 20/200. Chart 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 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 Partially successful 15 (57,7%) 19 (73,1%) <0,05 Failed 2 (7,7%) 0 The rate of severe proliferation complications 13 (50%) 12 (46,2%) >0,05 3.3.4. General treatment results of studied group 3.3.4.1 Mechanical capacity: The symptoms of blurred vision improved in some cases after treatment, the visual acuity ratio reached> 20/200 after treatment in studied group was 61.5%, there was no case of complete vision loss.. 3.3.4.2 Function: Eyesight Chart 3.8: Comparison before and after treatment by vision group The results of vision after treatment are good if increase or stay the same, accounting for 69.3%, vision loss after treatment accounts for 30.7%. The average value of log-MAR vision varies according to the follow-up time, when there are differences in the 6-month and 3-month intervals between the average decrease in visual acuity. Comparison before treatment and end of monitoring had statistically significant improvement in visual acuity p <0.05. Chart 3.9: The change of average vision according to the log-MAR of studied group 3.3.4.3 Stroke due to treatment process in the eye: few 3.3.4.5 General results of the treatment process: Chart 3.10: General results of the treatment process CHAPTER 4 DISCUSSION 4.1. GENERAL CHARACTERISTICS OF THE STUDIED GROUP: The percentage of Retinal lesions is 5.46% of all screened cases. 4.1.1. Gender characteristics: The proportion of female patients accounted for the majority of 87.1%, male patients accounted for only 12.9%. 4.1.2. Characteristics of age at the examination The average age is 28.23 ± 11.76 (years) The most common age is from 16-45 years old, accounting for 71%, under 16 years old is 16.1% and no patients over 60 years old. The disease mainly affects young female patients of reproductive age and labor. 4.1.3. About the age of onset and the duration of treatment of Lupus The patients in the Retinal lesions group had an average age as well as the age of onset of disease was significantly different with p <0.005, the younger the average Lupus patients were, the earlier the age of onset the disease is more likely to encounter retinal lesions. 4.1.4. The systemic manifestations of Lupus Lupus disease manifests itself in the lesions of many body systems, in our studied group, the most common manifestations are symptoms in the skeletal system, skin with erythematous butterfly erythema, disc rash (64,5 %), the incidence of central nervous system lesions is 25.8%. 4.1.5. Changes in systemic tests: Very few cases of variability were noted. Comparing the test index in 2 groups of Lupus patients with retinal lesions and without retinal lesions, we did not see any significant difference in the average values of blood and electrolyte indices. 11 patients tested positive for ANA antibody 35.5% and 8 patients tested positive for Ds-DNA double-chain antibody accounted for 25.8%. The ratio of anti-nuclear antibodies, positive difference was statistically significant between 2 groups with and without Retinal lesions. 4.1.6. Severe level of Lupus By assessing under the SLEDAI scale, we recorded a high average SLEDAI score in studied group: 17.23 ± 4.8 points. 96.8% of patients with an SLEDAI score> 10 mean that the disease is at a level of severe activity. By comparing the severe level of the disease between the groups with retinal lesions and without retinal lesions, we found a statistically significant difference with p <0.05. Retinal lesions are often associated with a high level of systemic lupus activity and are a criterion for assessing the severity of the disease in 24 SLEDAI scoring criteria. 4.2. CLINICAL AND SUBCLINICAL CHARACTERISTICS OF THE RETINAL LESIONS Lupus retinopathy is an important marker in the progression of the disease. Retinal vascular lesions are the second most common lesions after corneal conjunctivitis due to dry eyes in Lupus patients. 4.2.1. Functional symptoms: The majority of patients in the studied group showed blurred vision, accounting for 94.2%. 4.2.2. Clinical characteristics on ophthalmoscopy The two main lesion forms encountered in the studied group include retinal vasculitis and simple retinal occlusion without vasculitis. Vasculitis without retinal occlusion accounted for 23.1%. 26.9% of cases with severe vasculitis accompanied by embolism caused anemic retinopathy. 50% of cases belong to the simple retinal occlusion group. 4.2.2.1 Merocrine secretion: Found on 22 eyes in the studied group accounted for 42.3%, this is one of the early manifestations, in the early stages characterized by due to Lupus microcirculation lesions. The percentage of encounter with merocrine secretion is mainly in the form of retinal vasculitis with the rate of 95.5%. This suggests that the merocrine secretion is one of the main manifestations of Retinal Vasculitis due to Lupus. 4.2.2.2 Retinal hemorrhage: 23 eyes with retinal hemorrhage manifesting accounted for 44.2% The highest hemorrhage rate in vasculitis group with retinal occlusion accounts for 60.8%. 4.2.3. Subclinical characteristics: 4.2.3.1 Inflammation of the retina blood vessels: Initially, the image changed shape, the blood vessels shrunk, narrowed to localized sections, the diameter was irregular, there were images of blood vessels, inflammation around the walls of the vessels. Severe retinal vasculitis lesions may be accompanied by occlusion with images of dry, white fibrous branches of the branches.100% of cases of retinal vasculitis with vitreous clearly, in lesions are primarily seen in arteries of size small (84.6%). 4.2.3.2 Embolism causing anemic retinopathy: Blockage of arteries, large or small, causes retinal necrosis in the respective areas. Location of retinal occlusion is mainly in small sized blood vessels, arterioles (67.5%). 4.2.3.3 The condition of Anemic Retinopathy: On fluorescent angiography, it is assessed