Nghiên cứu đặc điểm lâm sàng, cận lâm sàng và kết quả điều trị các tổn thương võng mạc trên bệnh nhân lupus ban đỏ hệ thống tt tiếng anh

1
INTRODUCTION
Systemic lupus erythematosus (SLE) is the most common disease in
the autoimmune disease group. The disease stands out with diverse lesions in
many organs, internal organs, chronic progression over many years, alternating
many exacerbations that greatly affect the quality of life of patients even
leading to death.
The ophthalmic manifestations in Lupus can threaten the vision and
impair the patient’s life quality, which is also an indicator of advanced systemic
disease. In Vietnam, there are currently no reports of eye injuries caused by the
pathological process of Lupus, especially the fundus lesions. So we proceed to
the topic: “Studying the clinical, subclinical characteristics and treatment
of retinal lesions in patients with systemic Lupus erythematosus” with the
two following goals:
1. Describing the clinical and subclinical characteristics of retinal
lesions in Lupus patients
2. Assessing the results of treatment of retinal lesions in patients with
systemic lupus erythematosus.
NEW CONTRIBUTIONS OF THE THESIS
This is the first study in Vietnam on retinal lesions caused by Lupus,
assessing the forms of retinal lesions caused by Lupus, the severity of injuries
as well as the risk of losing sight of patients. , thereby proposing systematic and
periodic eye examinations for patients for early detection and timely treatment
of eye lesions caused by Lupus. This study assesses the results of treatment of
retinal lesions, thereby proposing a treatment regimen as well as selecting
treatment methods appropriate to each morphology and extent of lesions,
contributing to preserving the function of vision. awareness for Lupus patients,
improving the quality of life for patients as well as reducing the burden on
families and society. Partly elucidating the mechanism of lesions, the
relationship between visceral lesions in Lupus and eye lesions will contribute to
improving the effectiveness of treatment coordination between

Ophthalmologists and physicians of Clinical Allergy - Immunology.
STRUCTURE OF THE THESIS
The thesis is 155 pages long, consisting of the following sections: Introduction
(2 pages), Chapter 1: Literature Overview (45 pages), Chapter 2: Research
subjects and methods (28 pages); Chapter 3: Research results (32 pages);
Chapter 4: Discussion (47 pages); Conclusion (2 pages); Recommendations (1
page). In the thesis, there are 41 tables, 10 charts and 19 photos. There are 102
references (11 documentsin Vietnamese and 91 documents in English).


2
CHAPTER 1
LITERATURE OVERVIEW
1.1. SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
1.1.1. Definitions: Lupus is a disease with multiple organ lesions in which the
autoimmune mechanism plays the most important role in the pathogenesis
mechanism. It is characterized by the production of autoantibodies against the
components of the nucleus of the cell itself, multi-organ lesions, multiple acute
progression, alternating with regressions of the disease. Lupus is more common
in women, especially in reproductive and working age.
1.1.2. The diagnostic criteria for Lupus: According to SLICC (2012)
1.1.3. Assessing the severity of systemic lupus erythematosus: Based on the
SLEDAI scale, classified as follows: Mild and moderate disease SLEDAI ≤ 10,
severe disease when SLEDAI> 10.
1.1.5. The relationship between the pathological process of Lupus and the
patterns of ocular lesions:
- Ocular legions and immune disorders that form autoantibodies against organs
- Disorders of coagulation cause vascular complications
- Reducing blood cell lines causing lesions to retina, optic nerve
-Glomerular lesions causes hypertension - nephrotic syndrome with

atherosclerosis and ophthalmic manifestations
- Autoimmune mechanism of diabetes and ocular lesions
- Ocular lesions due to the treatment of Lupus with corticoides, synthetic antimalarial drug.
1.2. CLINICAL CHARACTERISTICS OF RETINAL LESIONS IN LUPUS
1.2.1. The morphologies of retinal vascular lesions
1.2.1.1 Retinal Vasculitis:
* Retinal Vasculitis without retinal embolism: more common in
microcircular lesions, typically with the presence of cotton nodules (8-24%),
retinal hemorrhages, changes in blood vessel shape, common in small arteries.
* Retinal Vasculitis with retinal embolism: is a retinal vascular disease
due to inflammation of small arteries, arterioles accompanied by occlusive
complications, retinal anemia, this is the main and very serious clinical
manifestation of the disease, with symptoms such as: nodules cotton,
superficial retinal hemorrhage (see 5-10%), small arterioles (13.2%), clear
vascular cages, resident retinal edema or dissemination due to rupture retinal


3
blood barrier.
1.2.1.2. Blockage of large blood vessels of the retina: more rarely, with
manifestation of occlusion or total occlusion of the central retinal vein causing
severe retinal anemia, very common in the presence of antiphospholipid
syndrome (APS). Lupus retinopathy has varying degrees of anemia, and the
width of the anemia is proportional to the degree of visual impairment.
Vascular occlusion causes severe retinal anemia, which can be accompanied by
complications of new neovascularization.
1.2.2. The degrees of retinal lesions due to Lupus: consisting of 3 levels
- Localized retinal ischemia
- Blockage of large blood vessels causes severe retinal anemia
- Retinopathy of proliferation

1.2.3. Combined lesions:
- Choroidal lesions: more common with choroidal anemia
- Most inflammation lesions in retinal vein occlusion due to Lupus have clearly
vitreous. Hemorrhagic vitreous is common in cases of complications of
neovascular proliferation.
- Macular lesions: common condition is edema and anemia in macular region.
- Rare optic nerve lesions (1%), manifesting edema optic nerve and optic nerve
anemia in front or back.
1.3. SUBCLINICAL TESTS
Ophthalmoscopy allows the evaluation of specific lesions of inflammation
in retinal vein occlusion due to Lupus. Fluorescent angiography, optical
coherence tomography- OCT and ultrasound mode B techniques play an
important role in detecting and evaluating retinal lesions and monitoring
treatment.
1.4. Differential diagnosis: with causes of Retinal Vasculitis in general
1.5. TREATMENT METHODS
1.5.1. Systemic treatment: The main purpose is to suppress immune-acting
activities, reducing the concentration of autoantibodies that fight off organs.
Corticoides is the first-line treatment option and is the shortest treatment
available for due to Lupus systemic vasculitis as well as retinal Vasculitis in the
eyes. Corticoides treatment or have severe side effects. Synthetic anti-malarial
drugs such as Chloroquine, Hydroxychloroquine (HCQ) have the effect of
reducing future outbreaks, preventing relapses and the progression of Lupus
disease. Other drugs: anti-platelet aggregation drugs, anticoagulants, exchange


4
plasma.
1.5.2. Local treatment: The main purpose is to prevent complications caused
by embolic condition, contributing to preserving vision for Lupus patients..

1.5.2.1. Retina laser: This is the first treatment option for complications of
embolism that causes anemic retinopathy due to Lupus.
Laser designation according to the degree of anemic retinopathy:
- Light anemic retinopathy under 2 optic disc area: track
- Anemic retinopathy averages from 2 to less than 5 optic disc areas: the
laser covers the entire anemic area.
- Anemic retinopathy weighing over 5 optic disc areas: whole peripheral
retina laser to near the temporal arc (PRP)
- Retinal neovascularization in peripheral: find the starting position of
neovascularization so that the laser then the entire retinal laser region is
anemic, in case of neovascularization and optic nerve, the risk of vitreous
body hemorrhage must be combined with intraocular injection with Avastin
1.5.2.2. Anti-VEGF (Avastin)
Anti-VEGF drugs are effective in preventing and treating complications of
neovascular proliferation of the retina due to Lupus, which inhibits retinal
neovascularization and limits the spread of existing neovascularization.
Bevacizumab (Avastin) is a monoclonal antibody designated intraocular
injection to treat retinal neovascularization, neovascularization and optic nerve
complications with a dose of 1.25mg / 0.05ml.
Indications for injection Avastin in cases:
- In the case of thrombophlebitis causes severe anemic retinopathy risk of
high neovascular proliferation,
- Neovascularization of optic nerve have a risk of heamorrhagic vitreous
- Neovascularization of the macular, macular edema
1.5.2.3. Resection of vitreous body
Prescription: treatment of proliferation complications, retinal detachment,
haemorrhagic vitreous due to neovascularization of optic nerve.
1.5.2.4. Other treatments: adapted on the spot
The combination of systemic and ophthalmic treatment is the key to reducing
serious eye complications, preserving vision function for patients.

5
CHAPTER 2
RESEARCH SUBJECTS AND METHODS
2.1. RESEARCH SUBJECTS
- Patients coming for outpatient examination at the Examination Department
of Bach Mai Hospital and VNIO are diagnosed to identify Lupus according to
SLICC 2012 with retinal lesions in the eyes.
- Research period from June 2013 to June 2017
- Research location: Examination Department of Bach Mai Hospital and
VNIO.
2.1.1. Criteria for selecting a patient: Patients diagnosed with Lupus
according to SLICC 2012 will be screened for retinal lesions at the eye.
2.1.2. Exclusion criteria
+ Patient has ocular trauma due to previous injury.
+ Patients do not agree to participate in the study.
+ The patient participated in the study at the previous selection.
2.2. RESEARCH METHODS
2.2.1. Research design: Clinical intervention, prospective, no control group.
2.2.2. Sample size: Applied the formula for calculating sample sizes using
WHO sample software
p (1 − p )
n = Z 21−α / 2
d2
In which:
n is the needed minimum sample size
Z (1-α/2) =1.96 (95% reliability, α=0,05)
p = 0.1 (The rate of retinal 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


6
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

Fluorescence
angiography

Optical coherence
tomography (OCT)

B-scan
ultrasonography

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:


7
* 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:
o Mild level: anemic area of less than 2 optic disc area
o Moderate level: from 2 to less than 5 optic disc area
o Severe level: anemic area of more than 5 optic disc areas


8
+ 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


9
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


10
+ 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


11
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
87,1%
period> 1 year
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
Ratio
eyes (n=52)
%
No retinal embolism
12
23,1
Retinal Vasculitis
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
Lesion forms
Total
merocrine
n
= 22
Retinal Vasculitis
Simple
secretion
retinal
No retinal

With retinal
occlusion
embolism
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


12
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
Lesion forms
of retinal
Total
Retinal Vasculitis
Simple
vascular
n=26
retinal
No retinal
With retinal
changes
occlusion
embolism
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
Rate
retinal vasculitis (n = 26)
%
Small size (arterioles)
22
84,6
Artery Large size (branches, central
10
38,5
arteries of the retina)
Small size
0
0
Vein
Large size (branches, central
2
7,7
veins of the retina)
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 Rate %
retinal embolism
(n=40)
Small size (arterioles)
27
67,5
Artery Large size (branches, central
18
45
arteries of the retina)
Small size
0
0
Vein
Large size (branches, central
2
5
veins of the retina)
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

13
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
0
0
0
Mild: < 2 S optic nerve
9 (56,25%)
0
9 (56,25%)
Moderate: 2-5 S optic nerve
5 (31,25%)
2 (12,5%)
7 (43,75%)
Severe: > 5 S optic nerve
14
(87,5%)
2
(12,5%)

16 (100%)
Total
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
Anemia choroidal
Secretion retinal detachment
Central retinal vitiligo
Pigment epithelial lesion
Total

Lesion forms
Retinal
Simple retinal
Vasculitis
occlusion
12 (66,7%)
2 (11,1%)
1 (5,5%)
0
0
0
3 (16,7%)
0
16 (88,9%)
2 (11,1%)

Total
14 (77,8%)
1 (5,5%)
0
3 (16,7%)
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
Anemia macula
Macular edema
Thin central retinal atrophy
Neovascularization under the

Lesion forms
Retinal
Simple retinal
Vasculitis
occlusion
9 (33,3%)
2 (7,4%)
7 (25,9%)
1 (3,7%)
2 (7,4%)
5 (18,5%)
0
1 (3,7%)

Total
11 (40,7%)
8 (29,6%)
7 (25,9%)
1 (3,7%)


14
retina
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 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
After 1 After 3 After 6 After 9 After 12 Last
Forms
Methods
month months months months months time
Vasculitis
Bolus
1
0
0
0
0
0
with retinal Laser

13
10
4
3
0
0
occlusion
Avastin
4
6
3
3
0
0
injection
Surgery
0
1
1
2
5
2
3.3.1.4 Treatment methods
Method
Bolus
Bolus + laser
Bolus + laser + Avastin ịnection
Bolus + laser + Surgery
Bolus + laser + Avastin + Surgery

Number of eyes
12
2
4
1
7

Rate
46,2
7,7
15,4
3,8
26,9


15
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 logMAR 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


16
Avastin iniection
Avastin injection + Surgery
Surgery

1
2
5

3,8
7,7
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 77% of cases have visual acuity> 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 <0.05. The percentage of patients
with visual acuity> 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
Group of
P
retinal
retinal
vasculitis
occlusion
Completely successful
9 (34,6%)
7 (26,9%)
>0,05
Partially successful
Failed
The rate of severe proliferation

15 (57,7%)
2 (7,7%)
13 (50%)

19 (73,1%)
0
12 (46,2%)

<0,05
>0,05


17
complications
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


18
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 1645 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


19
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


20
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 according to 3 mild, moderate and severe levels, in which the level
of severe anemia is greater than 5 optic nerve areas, accounting for the highest
rate of 51.3%.
4.2.3.4 Retinal neovascularization and optic nerve before treatment: Severe
retinal occlusion causes extensive Anemic Retinopathy that can lead to
complications of retinopathy.
4.2.4. Other combined lesions
4.2.4.1 The condition of vitreous body: The majority of Lupus retinal lesions
patients in the study had vitreous clearly in 84.6%.
4.2.4.2 Choroidal lesions:
- Choroidal anemia was found in 14 cases (77.8%). Most commonly seen
the lesion choroidal in group retinal vasculitis.
- We only encountered one case of secretion retinal detachment,

accounting for 5.5%
4.2.4.3 Optic nerve lesions
There are two cases of optic nerve anemia coordinated with retinal lesions
due to occlusion of small arteries nourishing optic nerve (12.5%). We had 2
eyes with optic nerve edema due to central retinal vein occlusion accounted for
12.5%.
Percentage of patients in the study with neuropsychiatric manifestations
such as epilepsy, convulsions, headache, paralysis ½ people met in 8 cases,
including 2 cases of patients died due to complications of mental illness Central
seizures (epilepsy) during monitoring. A case of stroke in the brain blood
vessel, paralyzed ½ person.
4.2.4.4 Macular lesions
11 cases showed anemia in macular region (accounting for 40.7%).
Macular edema occurs in 29.6% of cases, all are the result of embolic condition
and mainly in the retinal vasculitis group. Progressing to degeneration, atrophy
of the central retinal area due to lack of nutrition.
4.2.5 Functions:
4.2.5.1 Vision before treatment: Up to 73.1% of the cases were not blind and
none were completely blind. Prevalence of vision> 20/200 accounts for 50% of
pre-treatment cases.
4.2.5.2. Classified by lesion forms and degree of anemia


21
Retinal vasculitis group without embolization: cases with vision> 20/200
accounted for 83.3%. In contrast, in the vasculitis group associated with
thrombosis causing anemic retinopathy, up to 50% of cases have visual lesions
<1m finger count. This rate was 23.1% in the group with retinal embolism
alone without vasculitis. Anemic retinopathy level is also one of the factors
causing visual lesions.

4.3. TREATMENT RESULTS OF RETINAL LESIONS
4.3.1. Treatment results in the group of Retinal Vasculitis (n=26)
100% of cases were treated with high-dose intravenous bolus Corticoides
then, if accompanied by embolism causing Anemic Retinopathy on fluorescent
angiography, patients will be assigned to retina laser anemic area treatment.
23.1% of cases must be indicated in combination with retina laser and
intraocular injection Avastin for prophylactic neovascular proliferation.
4.3.1.1 Entity results
+ The status of exudative, retinal hemorrhage (microcirculation lesions) at 6
months is no longer observed the excudative, retinal hemorrhage lesions on
patients' eyes.
+ Retinal vasculitis status: 100% of cases in this group with manifestations
of retinal vasculitis were prescribed bolus intravenous infusion for 3 days, after
treatment of vasculitis reduced significantly, at 6 months there were no images.
vasculitis
+ Embolic condition, anemic retinopathy causing neovascularization
complications: not much improved. Manifesting at 1 month and 3 months, the
rate of embolism and anemic retinopathy is still low, accounting for a large
proportion, this rate only decreases at 6 and 9 months, 2 cases with neovascular
glaucoma have to be indicated optically, accounted for 7.7%.
4.3.1.2. Functional results: There was no statistically significant difference
between the mean log-MAR visual acuity at the end of follow-up compared to
before treatment. Vision improved after 1 month due to the effect of systemic
treatment with Bolus. The rate of vision vision> 20/200 in this group after
treatment is 46.2%.
4.3.2. Treatment results in the Simple retinal occlusion group n = 26
18 cases were assigned a retina laser anemic area at the beginning, 11.5%
had to appoint retina laser with intraocular injection Avastin. 23% of cases
require surgery due to complications.
4.3.2.1. Entity results

+ Embolic condition, anemic retinopathy: Embolic condition, anemic
retinopathy as well as retinal neovascularization descend and stabilize. Fifteen


22
cases of laser treatment alone had stable retinal condition through monitoring
(accounting for 57.7%). The remaining cases must be supplemented with
intravenous or surgical Avastin injection.
+ The status of neovascularization: found at the time of screening is
different from the group with retinal vasculitis when no neovascular
proliferation cases before treatment. Neovascular glaucoma is not seen.
4.3.2.2. Functional results: Vision improved gradually over time following
treatment in the simple retinal occlusion group. The post-treatment visual
acuity was significantly improved with statistically significant difference
compared with before treatment with p <0.05. 76.9% of cases in this group had
post-treatment visual acuity> 20/200, 7.7% of cases had poor eyesight
4.3.3. Therapeutic efficacy in two groups
4.3.3.1. Vision results: Good vision results in both groups were similar.
However, the percentage of eyes with postoperative visual acuity> 20/200 in 2
groups has a statistically significant difference with p <0.05. 2 cases of
neovascular glaucoma with poor eye shadow of 0.2 m were belonging to the
retinal vasculitis group with occlusion.
4.3.3.2. Success rate: There was no difference in 2 groups
4.3.4. General treatment results of studied group
4.3.4.1. Mechanical capacity: In some cases after treatment, blurred vision
improved, 61.5% of cases had vision> 20/200 after treatment.
4.3.4.2. Functions: The proportion of patients with postoperative visual
acuity> 20/200 was 61.5% increase compared to before treatment, good posttreatment visual acuity was found at 69.3%. The average visual acuity
according to log-MAR before and after treatment at the end of the follow-up

was statistically significant with p <0.05 in the direction of visual acuity with
improvement after treatment.
4.3.4.3. Optic nerve and macular lesions after treatment
Degenerative atrophy of the central retina area accounted for 26.9%. The
rate of optic nerve atrophy increased from 19.2% before treatment to 40.4%
after treatment. These 2 sequelae are also one of the factors causing visual
lesions in Lupus patients.
4.3.4.4. The stroke caused by eye treatment: few
4.4.4.5. General results of the treatment process
- The overall success rate was found in 16 cases, 30.8%.


23
-The failure rate in 2 cases with complications of anemia, glaucome
neovascularization accounted for 3.8%.
- The remaining cases are classified as partially successful treatment results
in 31 cases accounting for 65.4%.
4.4.4.6. Factors affecting treatment results: Age, severe level of disease,
presence of antinuclear antibodies, forms and extent of lesions.
CONCLUSION
1. Clinical and subclinical characteristics of retinal lesions due to Lupus:
-Found on young female patients, of reproductive and working age, often
with early onset of illness. Retinal lesions are an indicator of disease activity.
-Two main forms: Retinal vasculitis accounts for 50% of cases in which
23.1% does not include retinal embolism, 26.9% is accompanied by embolism,
characterized by microcirculation lesions, inflammation around the walls of
blood vessels. Simple retinal occlusion was found in 26 cases.
-Exudative 42.3%, hemorrhage 44.2%, retinal vascular changes due to
inflammation account for 50%. Occlusion accounts for 76.9%, anemic
retinopathy is 75%. 30.8% of all neovascular proliferation cases belong to

simple retinal occlusion group.
-Vasculitis and retinal vasculature are mainly found in small arteries with
vitreous clearly.
-The combined lesions include anemia choroidal 26.9%, macular anemia
21.1%, macular edema encountered in 15.4%. Most are found in retinal
vasculitis forms.
2. Treatment results for Retinal lesions due to Lupus: Applied the treatment
regimen for the forms and levels of retinal lesions.
2.1. Results of treatment in the Retinal Vasculitis group
- Exudative, hemorrhage, retinal vasculitis completely ceased at 6 months.
New anemic area, retinal neovascularization, neovascularization of optic nerve
were high at 3-9 months of follow-up. Vision improved after Bolus but tended
to decrease at 3-6 months due to the occurrence of complications of
neovascular proliferation.
2.2 Treatment results in the Simple retinal occlusion group:
- The rate of embolism and anemic retinopathy, neovascular proliferation
before treatment, these lesions gradually decreased and ended 12 months after


24
treatment.
- Laser prophylaxis complications in 57.7% of cases, 11.5% combined with
retina laser and Avastin injection intraocular. Vision improved over time, and
the difference was statistically significant compared to before treatment.
2.3. Comparing the treatment results in 2 groups:
- The rate of occurrence of severe proliferation complications requiring
intraocular injection or surgery in the two groups is similar but the time of
occurrence and development of these complications in the group is different.
- Success rate of the two similar groups. However, the percentage of eyes
with postoperative visual acuity> 20/200 in 2 groups has a statistically

significant difference with p <0.05. In retinal vein occlusion, this percentage is
76.9%, with vision> 20/200 after treatment is much higher than Retinal
Vasculitis of 46.2%.
2.4. General results:
- Good vision results after treatment accounted for 69.3%, improved posttreatment visual acuity at the end of the follow-up significantly statistically
compared to before treatment.
- The overall success rate in the study was 30.8%, partial success of 65.4%,
failure in 2 cases accounted for 3.8%.
- Percentage of vision acuity> 20/200 after treatment (slight visual lesions)
is 61.5%.