Interpreting vasculitis – clinical assessment

A thorough and comprehensive examination is important for the management of patients with retinal vasculitis. A thorough history, systematic review and physical examination, and laboratory tests can help rule out underlying systemic disease; the latter can be inflammatory or autoimmune in nature. These are particularly important in patients who require systemic immunosuppression to control ocular symptoms. Corresponding tests include a complete blood count and classification, kidney and liver tests, and routine blood sedimentation and urine tests. Studies for coagulation include evaluation of lupus anticoagulants or anticardiolipin antibodies, which can be helpful in evaluating patients with unexplained occlusive or ischemic renal vasculitis. Purified protein derivative skin tests may also be done to rule out tuberculosis as a possible cause. A chest x-ray in a patient with positive PPD can help rule out tuberculosis or find hilar lymph node enlargement; the latter is usually seen in patients with nodal disease. If the history or clinical presentation suggests the possibility of inflammatory disease, relevant investigations should be performed. It is particularly important for treatable diseases, such as syphilis, Lyme disease, or HSV infection. Testing for HLA can also be helpful in the diagnosis of certain patients. Immunologic markers such as antinuclear antibodies, antineutrophil cytoplasmic antibodies, and complement content measurements are helpful in diagnosing systemic autoimmune diseases. Fluorescence-stained angiography is important for the diagnosis and follow-up of these patients. Inflammatory lesions of the retinal vasculature can be diagnosed and confirmed by the vascular leakage and wall staining observed by fluoroscopic staining angiography. Other manifestations of active disease revealed on angiography include optic nerve staining or leakage, capillary occlusion or vascular occlusion, cystoid macular edema, and neovascularization. Angiography is important when microscopic examination of the retina fails to reveal any clear manifestations of active disease (e.g., exophthalmos formation, perivascular and intraretinal infiltrates). No literature has yet reported the relevance of electrophysiological examination for the evaluation of patients with retinal vasculitis. Electrooculography (EOG) may be useful to determine the extent of primary or secondary retinal pigment epithelial lesions. Electroretinography (ERG) can help determine the extent of retinal damage and assess the stage of disease. A decrease in a- and b-wave amplitudes is often observed, but the b-wave:a-wave amplitude (wave amplitude) ratio remains constant. These ERG changes are not specific.