Microvascular Research 97 (2015) 31–36
Contents lists available at ScienceDirect
Microvascular Research journal homepage: www.elsevier.com/locate/ymvre
Choroidal impairment and macular thinning in patients with systemic sclerosis: The acute study Francesca Ingegnoli a,⁎, Roberta Gualtierotti a, Luisa Pierro b, Claudia Del Turco b, Elisabetta Miserocchi c, Tommaso Schioppo a, Pier Luigi Meroni a, on behalf of the, ACUTE study group Co-authors of the ACUTE (Assessement of Choroidal and macUlar Thickness in systEmic sclerosis) study group (in alphabetical order):Marco Gagliardi 1, Giulio Modorati 2, Giuseppe Querques 1 1 2 a b c
Department of Ophthalmology, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, Milano, Italy Ocular immunology and Uveitis Service, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, Milano, Italy Division of Rheumatology, Istituto Gaetano Pini, Department of Clinical Sciences & Community Health, University of Milano, Piazza cardinal Ferrari 1, Milano, Italy Department of Ophthalmology, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, Milano, Italy Ocular immunology and Uveitis Service, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, Milano, Italy
a r t i c l e
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Article history: Accepted 23 August 2014 Available online 26 September 2014 Keywords: Raynaud's phenomenon Systemic sclerosis SD-OCT Choroid Macula Eye Microcirculation Connective tissue disease Screening
a b s t r a c t Raynaud's phenomenon (RP) is a reversible vasospastic response of the extremities to cold or emotion, and can be the first manifestation or may be present before the development of an overt systemic sclerosis (SSc). The disturbance of the balance between vasodilation and vasoconstriction is not limited to the peripheral microcirculation of the skin, but it is also observed in other organs, such as the choroidal plexus of the eye. We aimed to examine the choroidal thickness (CT), the macular thickness and ganglion cell complex (GCC) average in thirty consecutive patients, without visual symptoms, classified as primary RP (pRP), RP secondary to suspected SSc, and overt SSc. All the patients underwent rheumatologic and ophthalmologic examination, capillaroscopy, test for anti-nuclear antibodies, anti-dsDNA, and anti-extractable nuclear antigens. Ophthalmologic examination included: best corrected visual acuity; slit lamp biomicroscopy; intraocular pressure measurements, fundus examination, and Spectral Domain-Optical Coherence Tomography (SD-OCT) with enhanced depth imaging scan system. Twenty-seven healthy subjects similar for gender and age were analyzed. In pRP, CT was significantly thinner than controls in the outer nasal and temporal regions. In secondary RP, the inner and outer nasal areas were significantly thinner than controls. In SSc, the central, inner inferior, inner nasal, inner superior, outer temporal, outer inferior, and outer nasal regions were significantly thinner than controls. A decreasing trend of central foveal thickness was noted. All the patients had GCC average significantly lower than controls. A thinning of choroidal and macular thickness, as well as of GCC was observed in patients with pRP and becomes more severe and extensive in RP secondary to suspected SSc and overt SSc. To our knowledge, this is the first study to analyze the choroidal features using SD-OCT in RP. These data may be clinically useful in suggesting an early involvement of ocular microcirculation with significant reduction of choroidal perfusion. © 2014 Elsevier Inc. All rights reserved.
Introduction Raynaud's phenomenon (RP) is an exaggerated vasospastic response of the extremities to cold or emotion. RP can be either primary (pRP), a ⁎ Corresponding author at: Division of Rheumatology, Piazza Cardinal Ferrari, 1 20122 Milano, Italy. E-mail addresses: [email protected] (F. Ingegnoli), [email protected] (R. Gualtierotti), [email protected] (L. Pierro), [email protected] (C. Del Turco), [email protected] (E. Miserocchi), [email protected] (T. Schioppo), [email protected] (P.L. Meroni), [email protected] (M. Gagliardi), [email protected] (G. Modorati), [email protected] (G. Querques).
http://dx.doi.org/10.1016/j.mvr.2014.08.008 0026-2862/© 2014 Elsevier Inc. All rights reserved.
benign idiopathic condition that does not progress into any further disease, or secondary to many non-rheumatic and rheumatic conditions (Herrick, 2012). Among the latter, RP occurs in almost all patients with systemic sclerosis (SSc), and it usually predates the onset of systemic clinical signs of tissue fibrosis (Herrick, 2012). It is generally accepted that SSc is characterized by prominent vascular involvement that is not limited to the peripheral microcirculation of the skin, but is also observed in the heart, lungs, kidneys, gastro-intestinal tract and eyes (Matucci-Cerinic et al., 2013). Many ocular manifestations have been described involving both anterior and posterior segment, as well as the orbit, and the extra-ocular muscles, although most of these are small case series or case reports (Tailor et al., 2009).
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In particular, histological studies in patients with SSc have demonstrated that choroidal vessels are grossly affected and present endothelial cell damage, basement membrane thickening and absence of pericytes (Farkas et al., 1972), which overall can contribute to the impaired choroidal circulation shown by fundus fluorescein angiography, an invasive technique (Serup et al., 1987). In addition, abnormal neurogenic control of choroidal vascular tone has been reported in SSc patients. Ocular vasospasm may induce optic nerve damage, thus contributing to normal-tension glaucoma which is reported to have an increased prevalence in SSc (Allanore et al., 2004). Moreover, in patients with SSc, normal-tension glaucoma has been related to the observation of nail bed hemorrhages observed by capillaroscopy, whereas other nailfold capillary abnormalities, such as giant capillaries or avascular areas, are not related to retinal vascular changes observed in the ocular fundi (Bozic et al., 2010; Park et al., 2011; Ushiyama et al., 2003). In the early phase of the disease, these eye abnormalities are generally overlooked in a regular eye examination because they are not necessarily associated with impaired visual acuity. Against this background, we designed the ACUTE (Assessement of Choroidal and macUlar Thickness in systEmic sclerosis) study in which a cohort of patients with RP at the first rheumatologic evaluation were studied. Our specific objectives were to examine the choroidal and macular thickness (CT and MT) and ganglion cell complex (GCC) average by Spectral Domain-Optical Coherence Tomography (SD-OCT), and to determine whether these parameters differ between patients with pRP, RP suspected secondary to SSc, overt SSc and healthy controls. Materials and methods Patient selection Between February 2011 and May 2012, 30 consecutive adults with RP at the first rheumatologic evaluation and without visual symptoms were recruited at the Rheumatology Division of the University of Milano (Milano, Italy). In order to eliminate myopic patients that present a thin choroidal thickness (Flores-Moreno et al., 2014), enrolled patients with RP had to have an axial length of 24 ± 0.5 mm. RP was defined as an episodic, reversible vasospastic ischemia of the digits upon exposure to cold and/or in association with emotional stress, and characterized by blanching, possibly followed by cyanosis and postischemic red flushing upon rewarming. The episodes may have involved biphasic or triphasic color changes, and could have been accompanied by varying degrees of paresthesia, numbness or pain (Herrick, 2012). The study was approved by the ethics committee, and informed consent was obtained from all patients. Ophthalmologic assessment Enrolled patients underwent a complete ocular examination at San Raffaele Scientific Institute, Milano, Italy. The ocular examination in both eyes included: best-corrected visual acuity, slit lamp biomicroscopy, intraocular pressure measurements, fundus examination, and SD-OCT. All patients were examined to rule out the presence of any ocular disease. CT was assessed using the Zeiss Cirrus high definition (HD)-OCT with enhanced depth imaging (EDI) scan system. The scans were conducted in the macular region by using horizontal and vertical sections of the HD 5 line raster analysis. A single expert grader, blind to patients' subgroup identity, manually measured CT, by using the caliper tool of the software, from the external limit of Bruch's membrane to the innermost layer of the sclera, at 9 points (in the subfoveal, superior, inferior, nasal and temporal regions at intervals of 0.5 mm up to 1 mm from the fovea). The measures of MT in the central point, named foveal thickness (FT), and GCC average were obtained automatically by using the Macular Cube 518 × 128 analysis. Twenty-seven healthy subjects of the same ethnic group, and similar to the patients' group for gender and age were analyzed as control
group. Their SD-OCT features were analyzed as mentioned in the above paragraph. Inclusion criteria for healthy subjects were an unremarkable ophthalmologic pathological history, best corrected visual acuity of 20/20 or better, spherical refraction between + 2.0 to − 2.0 diopters, axial length ≤ 24 mm, normal optic nerve with no neuro-retinal rim alterations, cup-to-disk greater than 0.2, normal anterior chamber with open angle, normal macular region, normal vessels and a normal SD-OCT scan. Rheumatologic assessment Patients underwent complete clinical examination to rule out any underlying cause of secondary RP (i.e. connective tissue diseases, current drug use, exposure to toxic agents, history of use of vibrating tools, thoracic outlet syndrome). Serum was collected at the time of clinical assessment and stored at −80 °C until assayed. The samples were tested for: anti-nuclear antibodies (ANA) by indirect immunofluorescence on HEp2 cells, considering positive those samples with a dilution higher than 1:80, anti-dsDNA by ELISA, anti-extractable nuclear antigens (anti-ENA) by ELISA (Phadia, Freiburg, Germany) and DotBlot (EUROLINE Systemic Sclerosis and Myositis profile IgG EUROIMMUN AG Luebeck, Germany). Nailfold capillaroscopy was performed using a video-capillaroscopy equipment (Videocap, DS-Medica, Milan, Italy) with optic probe 200×. Images were captured, coded, and stored through a Videocap software (Ingegnoli et al., 2009, 2013a, 2013b). Based on this set of diagnostic examination and investigation, patients with RP were classified as: pRP (i.e. normal capillaroscopy, negative ANA and anti-ENA, in the absence of any symptoms/signs suggestive of connective tissue diseases); RP secondary to suspected SSc (i.e. abnormal capillaroscopy or positive ANA with or without anti-ENA positivity, and without any symptoms/signs suggestive for SSc); SSc (van den Hoogen et al., 2013). Data analysis One-way ANOVA in rank transformation was used to analyze differences in means between the subgroups. Multiple post hoc pairwise comparisons were then performed, taking into account the appropriate significance level for each comparison (Bonferroni method). Results Of the 30 patients enrolled (90% females), 8 (16 eyes) were classified as pRP (median age 52.5 yrs), 12 (24 eyes) as SSc (median age 56.5 yrs), and 10 (20 eyes) as RP secondary to suspected SSc (median age 54 yrs). ANAs were positive in nearly all patients with SSc (91.6%). At enrollment, only 2 patients were receiving calcium channel blockers for RP. Slit lamp biomicroscopy was within normal range in all patients, as well as the mean best-corrected visual acuity and the mean intraocular pressure measurement (mean 14 mm Hg). Analysis of the choroidal thickness The choroidoscleral boundary was clearly identified in 101/104 (97.1%) of eyes imaged with Cirrus EDI-HD-OCT. The mean subfoveal CT was 313.2 μm (range 267–348) in healthy subjects, 273.9 μm (range 229.8–306) in pRP, 275.1 μm (range 254–310.5) in RP suspected secondary to SSc, 250.5 μm (range 189.8–314.3) in SSc. Mean, median and interquartile range of CT values in different subgroups are summarized in Fig. 1. Differences among CT mean values were analyzed by one-way ANOVA. Significant differences between subgroups, with decreases of values from healthy controls to SSc, were observed for the central CT (p = 0.01), the inner nasal (p = 0.001), superior (p = 0.02) and inferior (p = 0.03) areas, as well as for the outer nasal (p b 0.001), temporal
F. Ingegnoli et al. / Microvascular Research 97 (2015) 31–36
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RP: Raynaud phenomenon; CT: choroidal thickness; FT: foveal thickness; GCC: ganglion cell complex. Fig. 1. Measurements of choroidal and macular thickness by spectral domain-optical coherence tomography. RP: Raynaud phenomenon; CT: choroidal thickness; FT: foveal thickness; GCC: ganglion cell complex.
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(p b 0.001), and inferior (p = 0.01) regions (Fig. 2). Decreasing CT values, from healthy controls to SSc, were noted for the inner temporal and outer superior regions, however they were not significant. The multiple comparison among disease subgroups showed that in pRP, CT was significantly thinner than healthy controls in the outer nasal (p = 0.03) and outer temporal (p = 0.01) regions. In patients with RP secondary to suspected SSc, the inner and outer nasal areas were significantly thinner than healthy controls (p = 0.03 and p = 0.0001, respectively). In SSc, most of the choroidal regions were significantly thinner than healthy controls: central (p = 0.008), inner inferior (p = 0.02), inner nasal (p = 0.0004), inner superior (p = 0.03), outer temporal (p = 0.0002), outer inferior (p = 0.01), outer nasal (p b 0.0001). Analysis of the macular thickness The mean central FT was 275.2 μm (range 260–296) in healthy subjects, 261.7 μm (range 244–281.5) in pRP, 262.8 μm (range 252.8–280.8) in RP suspected secondary to SSc, 260.3 μm (range 246.8–275.5) in SSc. Mean, median and interquartile range of central FT in different subgroups are summarized in Fig. 1. A trend toward a decrease in central FT was seen in all the patient subgroups, although not reaching significance. Analysis of ganglion cell complex average Average GCC was 94.3 μm (range 91–97.3) in healthy controls, 85.2 μm (range 82.7–88.2) in primary RP, 84.2 μm (range 78.2–90.7) in RP suspected secondary to SSc, 83 μm (range 79.7–86.5) in SSc (Figs. 1 and 3). By ANOVA, significant difference between subgroups was observed for the GCC average (p b 0.0001). In particular, multiple comparison analysis showed that patients with pRP, RP secondary to suspected SSc and SSc had GCC average significantly lower than healthy controls (p b 0.0001 in all comparisons). Discussion In this study, an overall thinning of choroidal layer has been observed in patients with RP, with progressive extension of thinning
from pRP to SSc. These findings are consistent with an impairment of choroidal perfusion, as well as the presence of an early involvement of ocular microcirculation, since the very early phase of a scleroderma spectrum disease. This process likely begins from the external macular regions (outer nasal and temporal) in pRP, and becomes progressively more severe and extensive in overt SSc. Recent research on healthy subjects supports the view that subfoveal CT and ocular perfusion pressure are related, suggesting that subfoveal CT may be considered an indirect index of ocular perfusion status (Kim et al., 2012). However, the implications of the in vivo CT thinning shown by OCT in the absence of visual symptoms still remain to be defined. By contrast, the status of the choroid plexus seems to play a key role in visual symptoms of other conditions such as choroidal atrophy, myopic chorioretinal atrophy, central serous chorioretinopathy, chorioretinal inflammatory diseases, and tumors (Lehtinen et al., 2013). Furthermore, a thinning of CT has been related to a decreased blood flow in the choriocapillaris in patients with diabetes and untreated systemic arterial hypertension (Bourke et al., 2004; Querques et al., 2012; Regatieri et al., 2012). Choroidal perfusion impairment is of much significance in the foveal region, as in this area the retinal vascular supply is lacking. Our results showed an overall reduction of the central FT in primary and secondary RP, even if the decreasing trend did not reach statistical significance. These data are in keeping with previous studies that reported abnormality of the choroidal vasculature in SSc by fluorescein angiography (Farkas et al., 1972; Grennan and Forrester, 1977; Serup et al., 1987). This may be related to the lack of the internal elastic membrane and a nerve supply to the retinal arteries that may render these vessels less sensitive to the effects of SSc as compared to the choroidal vessels which have a nerve supply and also have pericytes (Tailor et al., 2009). Another key finding was the significant decrease of GCC average in both primary and secondary RP compared to healthy controls. The GCC represents the internal layer of the retina that elaborates the electric signal deriving from the light stimuli, and drives them to the central nervous system via the nerve fiber layer and the optic nerve. The GCC is much affected by the mechanical damage operated by increased intraocular pressure, as occurs in glaucoma. Our data of GCC changes in RP population may be linked to the potential normal-tension glaucoma outbreak in late phases of the disease, as a higher incidence of normaltension glaucoma was reported in SSc population (Allanore et al., 2004).
A
B
C
D
Fig. 2. The fundus photography including horizontal scan marks of a patient with Raynaud's phenomenon secondary to suspected systemic sclerosis (A.) and a healthy subject (B.). The related OCT images show a thinning of the choroidal thickness measure in the patients with secondary Raynaud's phenomenon (C.) compared to the healthy subject (D.).
F. Ingegnoli et al. / Microvascular Research 97 (2015) 31–36
A
35
B
*
Fig. 3. Measurement of ganglion cells complex (GCC) thickness in 6 sectors (disk) and related average value by HD-OCT. GCC layer indicated by white star (*) is automatically segmented and measured by a specific analysis of the 512 × 128 Macular Cube scanning. As shown, the average GCC value is lower in the patient with Raynaud's phenomenon secondary to suspected systemic sclerosis (A.) than in a healthy subject (B.).
This is the first study in which SD-OCT was used in patients with pRP and SSc. Over recent years until nowadays, the study of the posterior pole of the eye was performed by retinography using different filters to enhance the contrast between structures, while the study of the in vivo ocular microcirculation was done by fluorescein or indocyanine green angiography with contrast medium injection. By contrast, SD-OCT is an in vivo non-invasive technique that has revolutionized the ophthalmic clinical practice, as it allows rapid and repeatable imaging of the retina and of the choroid, with no need to dilate pupils. SD-OCT has now become almost complementary to indirect biomicroscopy, since it operates a tomographic study of retina and choroid and visualizes the relations between layers providing excellent morphologic details. Visualization of choroid is a recent technological advance in the field of OCT imaging. It should be emphasized that choroidal thickness measurement is to be obtained manually and that the accuracy of segmentation depends on the good visualization and recognition of the choroidoscleral boundary, that is supposed to be more difficult in the cases when CT is much thicker, such as normal eyes (Branchini et al., 2012). In order to support an accurate segmentation, we performed all imaging with EDI technology and after pupil dilation; all the measurement were performed by a single expert grader. In our study, EDIOCT technology allowed a clear visualization of choroidoscleral interface in 97.1% of cases, which is in line with previous data reported on SD-OCT systems by Branchini et al. (2012). Cirrus HD-OCTih has shown to provide good reproducibility of choroidal measurement compared to other SD-OCT systems, even to those employing higher frames averaging technologies (Branchini et al., 2012). Nevertheless there are concerns regarding reliability of choroidal imaging in the Cirrus 800 nm wavelength band respect to imaging systems that use longerwavelength light source, such as swept-source OCT. It was recently demonstrated that swept-source OCT systems permit an enhanced visualization of choroid layer compared to 800 nm wavelength band Cirrus OCT imaging, by allowing a deeper penetration of light through tissues, but no significant difference was found in the choroidal thickness measurement in any compared scan line between the two instruments (Adhi et al., 2014). Further recent technological advance is based on a tracking system that allows image repetition with a pointto-point approach, thus OCT is used successfully for screening and follow-up of many ocular conditions. One limitation of this study includes the small group of patients in each group. It should be emphasized that this was a pilot study. To our knowledge, there are no published studies using SD-OCT to assess eye
vascular impairment in pRP and SSc. Therefore, further studies are required, but these results support the use of this non-invasive technique as part of the overall assessment of these patients. It is noteworthy that, according to our results, patients with primary or secondary RP do not have impaired visual acuity. As a consequence, physicians should be aware that these ocular abnormalities highlighted with SD-OCT are an overlooked clinical entity and missed in the course of a regular eye examination. Therefore, we suggest that this examination should be considered since the early phase of the disease. In conclusion, these data support the hypothesis of the usefulness of the application of this non-invasive technique in monitoring patients with RP, with the aim of improving diagnostic accuracy to assess the potential risk of developing severe glaucomatous damage over the course of the disease.
References Adhi, M., et al., 2014. Choroidal analysis in healthy eyes using swept-source optical coherence tomography compared to spectral domain optical coherence tomography. Am. J. Ophthalmol. 157 (1272–1281), e1. Allanore, Y., et al., 2004. Increased prevalence of ocular glaucomatous abnormalities in systemic sclerosis. Ann. Rheum. Dis. 63, 1276–1278. Bourke, K., et al., 2004. Hypertensive choroidopathy. J. Clin. Hypertens. (Greenwich) 6, 471–472. Bozic, M., et al., 2010. Is nail fold capillaroscopy useful in normotensive and primary open angle glaucoma? A pilot study. Curr. Eye Res. 35, 1099–1104. Branchini, L., et al., 2012. Reproducibility of choroidal thickness measurements across three spectral domain optical coherence tomography systems. Ophthalmology 119, 119–123. Farkas, T.G., et al., 1972. The choroidopathy of progressive systemic sclerosis (scleroderma). Am. J. Ophthalmol. 74, 875–886. Flores-Moreno, I., et al., 2014. The relationship between retinal and choroidal thickness and visual acuity in highly myopic eyes. Br. J. Ophthalmol. 98, 143–144. Grennan, D.M., Forrester, J., 1977. Involvement of the eye in SLE and scleroderma. A study using fluorescein angiography in addition to clinical ophthalmic assessment. Ann. Rheum. Dis. 36, 152–156. Herrick, A.L., 2012. The pathogenesis, diagnosis and treatment of Raynaud phenomenon. Nat. Rev. Rheumatol. 8, 469–479. Ingegnoli, F., et al., 2013a. Nailfold capillaroscopy in systemic sclerosis: data from the EULAR scleroderma trials and research (EUSTAR) database. Microvasc. Res. 89, 122–128. Ingegnoli, F., et al., 2013b. Nailfold capillary patterns in healthy subjects: a real issue in capillaroscopy. Microvasc. Res. 90, 90–95. Ingegnoli, F., et al., 2009. Feasibility of different capillaroscopic measures for identifying nailfold microvascular alterations. Semin. Arthritis Rheum. 38, 289–295. Kim, M., et al., 2012. Association between choroidal thickness and ocular perfusion pressure in young, healthy subjects: enhanced depth imaging optical coherence tomography study. Invest. Ophthalmol. Vis. Sci. 53, 7710–7717. Lehtinen, M.K., et al., 2013. The choroid plexus and cerebrospinal fluid: emerging roles in development, disease, and therapy. J. Neurosci. 33, 17553–17559.
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Matucci-Cerinic, M., et al., 2013. Review: evidence that systemic sclerosis is a vascular disease. Arthritis Rheum. 65, 1953–1962. Park, H.Y., et al., 2011. Nail bed hemorrhage: a clinical marker of optic disc hemorrhage in patients with glaucoma. Arch. Ophthalmol. 129, 1299–1304. Querques, G., et al., 2012. Enhanced depth imaging optical coherence tomography in type 2 diabetes. Invest. Ophthalmol. Vis. Sci. 53, 6017–6024. Regatieri, C.V., et al., 2012. Choroidal thickness in patients with diabetic retinopathy analyzed by spectral-domain optical coherence tomography. Retina 32, 563–568. Serup, L., et al., 1987. Fundus fluorescein angiography in generalized scleroderma. Ophthalmic Res. 19, 303–308.
Tailor, R., et al., 2009. Ocular manifestations of scleroderma. Surv. Ophthalmol. 54, 292–304. Ushiyama, O., et al., 2003. Retinal findings in systemic sclerosis: a comparison with nailfold capillaroscopic patterns. Ann. Rheum. Dis. 62, 204–207. van den Hoogen, F., et al., 2013. 2013 classification criteria for systemic sclerosis: an American College of Rheumatology/European League against Rheumatism collaborative initiative. Arthritis Rheum. 65, 2737–2747.
Contents lists available at ScienceDirect
Microvascular Research journal homepage: www.elsevier.com/locate/ymvre
Choroidal impairment and macular thinning in patients with systemic sclerosis: The acute study Francesca Ingegnoli a,⁎, Roberta Gualtierotti a, Luisa Pierro b, Claudia Del Turco b, Elisabetta Miserocchi c, Tommaso Schioppo a, Pier Luigi Meroni a, on behalf of the, ACUTE study group Co-authors of the ACUTE (Assessement of Choroidal and macUlar Thickness in systEmic sclerosis) study group (in alphabetical order):Marco Gagliardi 1, Giulio Modorati 2, Giuseppe Querques 1 1 2 a b c
Department of Ophthalmology, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, Milano, Italy Ocular immunology and Uveitis Service, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, Milano, Italy Division of Rheumatology, Istituto Gaetano Pini, Department of Clinical Sciences & Community Health, University of Milano, Piazza cardinal Ferrari 1, Milano, Italy Department of Ophthalmology, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, Milano, Italy Ocular immunology and Uveitis Service, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, Milano, Italy
a r t i c l e
i n f o
Article history: Accepted 23 August 2014 Available online 26 September 2014 Keywords: Raynaud's phenomenon Systemic sclerosis SD-OCT Choroid Macula Eye Microcirculation Connective tissue disease Screening
a b s t r a c t Raynaud's phenomenon (RP) is a reversible vasospastic response of the extremities to cold or emotion, and can be the first manifestation or may be present before the development of an overt systemic sclerosis (SSc). The disturbance of the balance between vasodilation and vasoconstriction is not limited to the peripheral microcirculation of the skin, but it is also observed in other organs, such as the choroidal plexus of the eye. We aimed to examine the choroidal thickness (CT), the macular thickness and ganglion cell complex (GCC) average in thirty consecutive patients, without visual symptoms, classified as primary RP (pRP), RP secondary to suspected SSc, and overt SSc. All the patients underwent rheumatologic and ophthalmologic examination, capillaroscopy, test for anti-nuclear antibodies, anti-dsDNA, and anti-extractable nuclear antigens. Ophthalmologic examination included: best corrected visual acuity; slit lamp biomicroscopy; intraocular pressure measurements, fundus examination, and Spectral Domain-Optical Coherence Tomography (SD-OCT) with enhanced depth imaging scan system. Twenty-seven healthy subjects similar for gender and age were analyzed. In pRP, CT was significantly thinner than controls in the outer nasal and temporal regions. In secondary RP, the inner and outer nasal areas were significantly thinner than controls. In SSc, the central, inner inferior, inner nasal, inner superior, outer temporal, outer inferior, and outer nasal regions were significantly thinner than controls. A decreasing trend of central foveal thickness was noted. All the patients had GCC average significantly lower than controls. A thinning of choroidal and macular thickness, as well as of GCC was observed in patients with pRP and becomes more severe and extensive in RP secondary to suspected SSc and overt SSc. To our knowledge, this is the first study to analyze the choroidal features using SD-OCT in RP. These data may be clinically useful in suggesting an early involvement of ocular microcirculation with significant reduction of choroidal perfusion. © 2014 Elsevier Inc. All rights reserved.
Introduction Raynaud's phenomenon (RP) is an exaggerated vasospastic response of the extremities to cold or emotion. RP can be either primary (pRP), a ⁎ Corresponding author at: Division of Rheumatology, Piazza Cardinal Ferrari, 1 20122 Milano, Italy. E-mail addresses: [email protected] (F. Ingegnoli), [email protected] (R. Gualtierotti), [email protected] (L. Pierro), [email protected] (C. Del Turco), [email protected] (E. Miserocchi), [email protected] (T. Schioppo), [email protected] (P.L. Meroni), [email protected] (M. Gagliardi), [email protected] (G. Modorati), [email protected] (G. Querques).
http://dx.doi.org/10.1016/j.mvr.2014.08.008 0026-2862/© 2014 Elsevier Inc. All rights reserved.
benign idiopathic condition that does not progress into any further disease, or secondary to many non-rheumatic and rheumatic conditions (Herrick, 2012). Among the latter, RP occurs in almost all patients with systemic sclerosis (SSc), and it usually predates the onset of systemic clinical signs of tissue fibrosis (Herrick, 2012). It is generally accepted that SSc is characterized by prominent vascular involvement that is not limited to the peripheral microcirculation of the skin, but is also observed in the heart, lungs, kidneys, gastro-intestinal tract and eyes (Matucci-Cerinic et al., 2013). Many ocular manifestations have been described involving both anterior and posterior segment, as well as the orbit, and the extra-ocular muscles, although most of these are small case series or case reports (Tailor et al., 2009).
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In particular, histological studies in patients with SSc have demonstrated that choroidal vessels are grossly affected and present endothelial cell damage, basement membrane thickening and absence of pericytes (Farkas et al., 1972), which overall can contribute to the impaired choroidal circulation shown by fundus fluorescein angiography, an invasive technique (Serup et al., 1987). In addition, abnormal neurogenic control of choroidal vascular tone has been reported in SSc patients. Ocular vasospasm may induce optic nerve damage, thus contributing to normal-tension glaucoma which is reported to have an increased prevalence in SSc (Allanore et al., 2004). Moreover, in patients with SSc, normal-tension glaucoma has been related to the observation of nail bed hemorrhages observed by capillaroscopy, whereas other nailfold capillary abnormalities, such as giant capillaries or avascular areas, are not related to retinal vascular changes observed in the ocular fundi (Bozic et al., 2010; Park et al., 2011; Ushiyama et al., 2003). In the early phase of the disease, these eye abnormalities are generally overlooked in a regular eye examination because they are not necessarily associated with impaired visual acuity. Against this background, we designed the ACUTE (Assessement of Choroidal and macUlar Thickness in systEmic sclerosis) study in which a cohort of patients with RP at the first rheumatologic evaluation were studied. Our specific objectives were to examine the choroidal and macular thickness (CT and MT) and ganglion cell complex (GCC) average by Spectral Domain-Optical Coherence Tomography (SD-OCT), and to determine whether these parameters differ between patients with pRP, RP suspected secondary to SSc, overt SSc and healthy controls. Materials and methods Patient selection Between February 2011 and May 2012, 30 consecutive adults with RP at the first rheumatologic evaluation and without visual symptoms were recruited at the Rheumatology Division of the University of Milano (Milano, Italy). In order to eliminate myopic patients that present a thin choroidal thickness (Flores-Moreno et al., 2014), enrolled patients with RP had to have an axial length of 24 ± 0.5 mm. RP was defined as an episodic, reversible vasospastic ischemia of the digits upon exposure to cold and/or in association with emotional stress, and characterized by blanching, possibly followed by cyanosis and postischemic red flushing upon rewarming. The episodes may have involved biphasic or triphasic color changes, and could have been accompanied by varying degrees of paresthesia, numbness or pain (Herrick, 2012). The study was approved by the ethics committee, and informed consent was obtained from all patients. Ophthalmologic assessment Enrolled patients underwent a complete ocular examination at San Raffaele Scientific Institute, Milano, Italy. The ocular examination in both eyes included: best-corrected visual acuity, slit lamp biomicroscopy, intraocular pressure measurements, fundus examination, and SD-OCT. All patients were examined to rule out the presence of any ocular disease. CT was assessed using the Zeiss Cirrus high definition (HD)-OCT with enhanced depth imaging (EDI) scan system. The scans were conducted in the macular region by using horizontal and vertical sections of the HD 5 line raster analysis. A single expert grader, blind to patients' subgroup identity, manually measured CT, by using the caliper tool of the software, from the external limit of Bruch's membrane to the innermost layer of the sclera, at 9 points (in the subfoveal, superior, inferior, nasal and temporal regions at intervals of 0.5 mm up to 1 mm from the fovea). The measures of MT in the central point, named foveal thickness (FT), and GCC average were obtained automatically by using the Macular Cube 518 × 128 analysis. Twenty-seven healthy subjects of the same ethnic group, and similar to the patients' group for gender and age were analyzed as control
group. Their SD-OCT features were analyzed as mentioned in the above paragraph. Inclusion criteria for healthy subjects were an unremarkable ophthalmologic pathological history, best corrected visual acuity of 20/20 or better, spherical refraction between + 2.0 to − 2.0 diopters, axial length ≤ 24 mm, normal optic nerve with no neuro-retinal rim alterations, cup-to-disk greater than 0.2, normal anterior chamber with open angle, normal macular region, normal vessels and a normal SD-OCT scan. Rheumatologic assessment Patients underwent complete clinical examination to rule out any underlying cause of secondary RP (i.e. connective tissue diseases, current drug use, exposure to toxic agents, history of use of vibrating tools, thoracic outlet syndrome). Serum was collected at the time of clinical assessment and stored at −80 °C until assayed. The samples were tested for: anti-nuclear antibodies (ANA) by indirect immunofluorescence on HEp2 cells, considering positive those samples with a dilution higher than 1:80, anti-dsDNA by ELISA, anti-extractable nuclear antigens (anti-ENA) by ELISA (Phadia, Freiburg, Germany) and DotBlot (EUROLINE Systemic Sclerosis and Myositis profile IgG EUROIMMUN AG Luebeck, Germany). Nailfold capillaroscopy was performed using a video-capillaroscopy equipment (Videocap, DS-Medica, Milan, Italy) with optic probe 200×. Images were captured, coded, and stored through a Videocap software (Ingegnoli et al., 2009, 2013a, 2013b). Based on this set of diagnostic examination and investigation, patients with RP were classified as: pRP (i.e. normal capillaroscopy, negative ANA and anti-ENA, in the absence of any symptoms/signs suggestive of connective tissue diseases); RP secondary to suspected SSc (i.e. abnormal capillaroscopy or positive ANA with or without anti-ENA positivity, and without any symptoms/signs suggestive for SSc); SSc (van den Hoogen et al., 2013). Data analysis One-way ANOVA in rank transformation was used to analyze differences in means between the subgroups. Multiple post hoc pairwise comparisons were then performed, taking into account the appropriate significance level for each comparison (Bonferroni method). Results Of the 30 patients enrolled (90% females), 8 (16 eyes) were classified as pRP (median age 52.5 yrs), 12 (24 eyes) as SSc (median age 56.5 yrs), and 10 (20 eyes) as RP secondary to suspected SSc (median age 54 yrs). ANAs were positive in nearly all patients with SSc (91.6%). At enrollment, only 2 patients were receiving calcium channel blockers for RP. Slit lamp biomicroscopy was within normal range in all patients, as well as the mean best-corrected visual acuity and the mean intraocular pressure measurement (mean 14 mm Hg). Analysis of the choroidal thickness The choroidoscleral boundary was clearly identified in 101/104 (97.1%) of eyes imaged with Cirrus EDI-HD-OCT. The mean subfoveal CT was 313.2 μm (range 267–348) in healthy subjects, 273.9 μm (range 229.8–306) in pRP, 275.1 μm (range 254–310.5) in RP suspected secondary to SSc, 250.5 μm (range 189.8–314.3) in SSc. Mean, median and interquartile range of CT values in different subgroups are summarized in Fig. 1. Differences among CT mean values were analyzed by one-way ANOVA. Significant differences between subgroups, with decreases of values from healthy controls to SSc, were observed for the central CT (p = 0.01), the inner nasal (p = 0.001), superior (p = 0.02) and inferior (p = 0.03) areas, as well as for the outer nasal (p b 0.001), temporal
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RP: Raynaud phenomenon; CT: choroidal thickness; FT: foveal thickness; GCC: ganglion cell complex. Fig. 1. Measurements of choroidal and macular thickness by spectral domain-optical coherence tomography. RP: Raynaud phenomenon; CT: choroidal thickness; FT: foveal thickness; GCC: ganglion cell complex.
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(p b 0.001), and inferior (p = 0.01) regions (Fig. 2). Decreasing CT values, from healthy controls to SSc, were noted for the inner temporal and outer superior regions, however they were not significant. The multiple comparison among disease subgroups showed that in pRP, CT was significantly thinner than healthy controls in the outer nasal (p = 0.03) and outer temporal (p = 0.01) regions. In patients with RP secondary to suspected SSc, the inner and outer nasal areas were significantly thinner than healthy controls (p = 0.03 and p = 0.0001, respectively). In SSc, most of the choroidal regions were significantly thinner than healthy controls: central (p = 0.008), inner inferior (p = 0.02), inner nasal (p = 0.0004), inner superior (p = 0.03), outer temporal (p = 0.0002), outer inferior (p = 0.01), outer nasal (p b 0.0001). Analysis of the macular thickness The mean central FT was 275.2 μm (range 260–296) in healthy subjects, 261.7 μm (range 244–281.5) in pRP, 262.8 μm (range 252.8–280.8) in RP suspected secondary to SSc, 260.3 μm (range 246.8–275.5) in SSc. Mean, median and interquartile range of central FT in different subgroups are summarized in Fig. 1. A trend toward a decrease in central FT was seen in all the patient subgroups, although not reaching significance. Analysis of ganglion cell complex average Average GCC was 94.3 μm (range 91–97.3) in healthy controls, 85.2 μm (range 82.7–88.2) in primary RP, 84.2 μm (range 78.2–90.7) in RP suspected secondary to SSc, 83 μm (range 79.7–86.5) in SSc (Figs. 1 and 3). By ANOVA, significant difference between subgroups was observed for the GCC average (p b 0.0001). In particular, multiple comparison analysis showed that patients with pRP, RP secondary to suspected SSc and SSc had GCC average significantly lower than healthy controls (p b 0.0001 in all comparisons). Discussion In this study, an overall thinning of choroidal layer has been observed in patients with RP, with progressive extension of thinning
from pRP to SSc. These findings are consistent with an impairment of choroidal perfusion, as well as the presence of an early involvement of ocular microcirculation, since the very early phase of a scleroderma spectrum disease. This process likely begins from the external macular regions (outer nasal and temporal) in pRP, and becomes progressively more severe and extensive in overt SSc. Recent research on healthy subjects supports the view that subfoveal CT and ocular perfusion pressure are related, suggesting that subfoveal CT may be considered an indirect index of ocular perfusion status (Kim et al., 2012). However, the implications of the in vivo CT thinning shown by OCT in the absence of visual symptoms still remain to be defined. By contrast, the status of the choroid plexus seems to play a key role in visual symptoms of other conditions such as choroidal atrophy, myopic chorioretinal atrophy, central serous chorioretinopathy, chorioretinal inflammatory diseases, and tumors (Lehtinen et al., 2013). Furthermore, a thinning of CT has been related to a decreased blood flow in the choriocapillaris in patients with diabetes and untreated systemic arterial hypertension (Bourke et al., 2004; Querques et al., 2012; Regatieri et al., 2012). Choroidal perfusion impairment is of much significance in the foveal region, as in this area the retinal vascular supply is lacking. Our results showed an overall reduction of the central FT in primary and secondary RP, even if the decreasing trend did not reach statistical significance. These data are in keeping with previous studies that reported abnormality of the choroidal vasculature in SSc by fluorescein angiography (Farkas et al., 1972; Grennan and Forrester, 1977; Serup et al., 1987). This may be related to the lack of the internal elastic membrane and a nerve supply to the retinal arteries that may render these vessels less sensitive to the effects of SSc as compared to the choroidal vessels which have a nerve supply and also have pericytes (Tailor et al., 2009). Another key finding was the significant decrease of GCC average in both primary and secondary RP compared to healthy controls. The GCC represents the internal layer of the retina that elaborates the electric signal deriving from the light stimuli, and drives them to the central nervous system via the nerve fiber layer and the optic nerve. The GCC is much affected by the mechanical damage operated by increased intraocular pressure, as occurs in glaucoma. Our data of GCC changes in RP population may be linked to the potential normal-tension glaucoma outbreak in late phases of the disease, as a higher incidence of normaltension glaucoma was reported in SSc population (Allanore et al., 2004).
A
B
C
D
Fig. 2. The fundus photography including horizontal scan marks of a patient with Raynaud's phenomenon secondary to suspected systemic sclerosis (A.) and a healthy subject (B.). The related OCT images show a thinning of the choroidal thickness measure in the patients with secondary Raynaud's phenomenon (C.) compared to the healthy subject (D.).
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A
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B
*
Fig. 3. Measurement of ganglion cells complex (GCC) thickness in 6 sectors (disk) and related average value by HD-OCT. GCC layer indicated by white star (*) is automatically segmented and measured by a specific analysis of the 512 × 128 Macular Cube scanning. As shown, the average GCC value is lower in the patient with Raynaud's phenomenon secondary to suspected systemic sclerosis (A.) than in a healthy subject (B.).
This is the first study in which SD-OCT was used in patients with pRP and SSc. Over recent years until nowadays, the study of the posterior pole of the eye was performed by retinography using different filters to enhance the contrast between structures, while the study of the in vivo ocular microcirculation was done by fluorescein or indocyanine green angiography with contrast medium injection. By contrast, SD-OCT is an in vivo non-invasive technique that has revolutionized the ophthalmic clinical practice, as it allows rapid and repeatable imaging of the retina and of the choroid, with no need to dilate pupils. SD-OCT has now become almost complementary to indirect biomicroscopy, since it operates a tomographic study of retina and choroid and visualizes the relations between layers providing excellent morphologic details. Visualization of choroid is a recent technological advance in the field of OCT imaging. It should be emphasized that choroidal thickness measurement is to be obtained manually and that the accuracy of segmentation depends on the good visualization and recognition of the choroidoscleral boundary, that is supposed to be more difficult in the cases when CT is much thicker, such as normal eyes (Branchini et al., 2012). In order to support an accurate segmentation, we performed all imaging with EDI technology and after pupil dilation; all the measurement were performed by a single expert grader. In our study, EDIOCT technology allowed a clear visualization of choroidoscleral interface in 97.1% of cases, which is in line with previous data reported on SD-OCT systems by Branchini et al. (2012). Cirrus HD-OCTih has shown to provide good reproducibility of choroidal measurement compared to other SD-OCT systems, even to those employing higher frames averaging technologies (Branchini et al., 2012). Nevertheless there are concerns regarding reliability of choroidal imaging in the Cirrus 800 nm wavelength band respect to imaging systems that use longerwavelength light source, such as swept-source OCT. It was recently demonstrated that swept-source OCT systems permit an enhanced visualization of choroid layer compared to 800 nm wavelength band Cirrus OCT imaging, by allowing a deeper penetration of light through tissues, but no significant difference was found in the choroidal thickness measurement in any compared scan line between the two instruments (Adhi et al., 2014). Further recent technological advance is based on a tracking system that allows image repetition with a pointto-point approach, thus OCT is used successfully for screening and follow-up of many ocular conditions. One limitation of this study includes the small group of patients in each group. It should be emphasized that this was a pilot study. To our knowledge, there are no published studies using SD-OCT to assess eye
vascular impairment in pRP and SSc. Therefore, further studies are required, but these results support the use of this non-invasive technique as part of the overall assessment of these patients. It is noteworthy that, according to our results, patients with primary or secondary RP do not have impaired visual acuity. As a consequence, physicians should be aware that these ocular abnormalities highlighted with SD-OCT are an overlooked clinical entity and missed in the course of a regular eye examination. Therefore, we suggest that this examination should be considered since the early phase of the disease. In conclusion, these data support the hypothesis of the usefulness of the application of this non-invasive technique in monitoring patients with RP, with the aim of improving diagnostic accuracy to assess the potential risk of developing severe glaucomatous damage over the course of the disease.
References Adhi, M., et al., 2014. Choroidal analysis in healthy eyes using swept-source optical coherence tomography compared to spectral domain optical coherence tomography. Am. J. Ophthalmol. 157 (1272–1281), e1. Allanore, Y., et al., 2004. Increased prevalence of ocular glaucomatous abnormalities in systemic sclerosis. Ann. Rheum. Dis. 63, 1276–1278. Bourke, K., et al., 2004. Hypertensive choroidopathy. J. Clin. Hypertens. (Greenwich) 6, 471–472. Bozic, M., et al., 2010. Is nail fold capillaroscopy useful in normotensive and primary open angle glaucoma? A pilot study. Curr. Eye Res. 35, 1099–1104. Branchini, L., et al., 2012. Reproducibility of choroidal thickness measurements across three spectral domain optical coherence tomography systems. Ophthalmology 119, 119–123. Farkas, T.G., et al., 1972. The choroidopathy of progressive systemic sclerosis (scleroderma). Am. J. Ophthalmol. 74, 875–886. Flores-Moreno, I., et al., 2014. The relationship between retinal and choroidal thickness and visual acuity in highly myopic eyes. Br. J. Ophthalmol. 98, 143–144. Grennan, D.M., Forrester, J., 1977. Involvement of the eye in SLE and scleroderma. A study using fluorescein angiography in addition to clinical ophthalmic assessment. Ann. Rheum. Dis. 36, 152–156. Herrick, A.L., 2012. The pathogenesis, diagnosis and treatment of Raynaud phenomenon. Nat. Rev. Rheumatol. 8, 469–479. Ingegnoli, F., et al., 2013a. Nailfold capillaroscopy in systemic sclerosis: data from the EULAR scleroderma trials and research (EUSTAR) database. Microvasc. Res. 89, 122–128. Ingegnoli, F., et al., 2013b. Nailfold capillary patterns in healthy subjects: a real issue in capillaroscopy. Microvasc. Res. 90, 90–95. Ingegnoli, F., et al., 2009. Feasibility of different capillaroscopic measures for identifying nailfold microvascular alterations. Semin. Arthritis Rheum. 38, 289–295. Kim, M., et al., 2012. Association between choroidal thickness and ocular perfusion pressure in young, healthy subjects: enhanced depth imaging optical coherence tomography study. Invest. Ophthalmol. Vis. Sci. 53, 7710–7717. Lehtinen, M.K., et al., 2013. The choroid plexus and cerebrospinal fluid: emerging roles in development, disease, and therapy. J. Neurosci. 33, 17553–17559.
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F. Ingegnoli et al. / Microvascular Research 97 (2015) 31–36
Matucci-Cerinic, M., et al., 2013. Review: evidence that systemic sclerosis is a vascular disease. Arthritis Rheum. 65, 1953–1962. Park, H.Y., et al., 2011. Nail bed hemorrhage: a clinical marker of optic disc hemorrhage in patients with glaucoma. Arch. Ophthalmol. 129, 1299–1304. Querques, G., et al., 2012. Enhanced depth imaging optical coherence tomography in type 2 diabetes. Invest. Ophthalmol. Vis. Sci. 53, 6017–6024. Regatieri, C.V., et al., 2012. Choroidal thickness in patients with diabetic retinopathy analyzed by spectral-domain optical coherence tomography. Retina 32, 563–568. Serup, L., et al., 1987. Fundus fluorescein angiography in generalized scleroderma. Ophthalmic Res. 19, 303–308.
Tailor, R., et al., 2009. Ocular manifestations of scleroderma. Surv. Ophthalmol. 54, 292–304. Ushiyama, O., et al., 2003. Retinal findings in systemic sclerosis: a comparison with nailfold capillaroscopic patterns. Ann. Rheum. Dis. 62, 204–207. van den Hoogen, F., et al., 2013. 2013 classification criteria for systemic sclerosis: an American College of Rheumatology/European League against Rheumatism collaborative initiative. Arthritis Rheum. 65, 2737–2747.
