Retinal microvascular changes in patients with systemic lupus erythematosus: Importance of OCTA

Kidney biopsy is the most reliable diagnostic method for lupus-induced nephritis, but retinal imaging may serve as a noninvasive alternative. Image credit: ©Sved Oliver – stock.adobe.com

A new study reported the importance of optical coherence tomography angiography (OCTA) for detecting the early changes in the retinal vascular plexus in patients with systemic lupus erythematosus (SLE), especially those with lupus nephritis, even before the development of retinopathy,¹ according to first author Ahmed Ibrahim Basiony, MD. He is from the Department of Ophthalmology Faculty of Medicine, Menoufia University, Menoufia, Egypt.

Lupus nephritis is one of the most common and serious organ-threatening complications of SLE, an autoimmune disease that affects multiple organs, impacting up to 40% of patients.² Kidney biopsy is the most reliable diagnostic method for lupus-induced nephritis.³

SLE affects the eyes, with keratoconjunctivitis sicca the first most common SLE manifestation, followed by retinal vasculopathy, which can present with subtle changes or cause permanent visual loss.⁴ “Lupus retinopathy is characterised by microcirculatory disturbances such as arteriolar stenosis, cotton wool spots and retinal hemorrhages. Severe cases may be complicated by central retinal vein or artery occlusion.⁵ Notably, about 88% of patients with lupus retinopathy have active SLE, making the presence of retinopathy a potential marker of disease activity,⁶ Dr Basiony and colleagues said.

The similar physiopathological pathways of ocular and renal microvascular tissues in patients with systemic lupus have been confirmed using fundus examination, OCT and high-resolution color electroretinography. The investigators conducted this case-control study to assess the correlation between renal functional and histologic features with the retinal microvasculature alterations in patients with systemic lupus using OCTA, which has emerged as a valuable, noninvasive imaging tool for detecting preclinical microvascular changes in systemic diseases like SLE.^7,8 OCTA allows for detailed non-invasive imaging of the retinal microvasculature, measurement of retinal layer thickness, and assessment of blood flow.⁹

Study methodology

The study included 36 eyes of 18 patients with lupus nephritis, 36 eyes of 18 patients with SLE and 30 eyes of 15 healthy controls. All patients with SLE underwent a rheumatologic evaluation; all study participants then underwent an ocular evaluation, including history, examination and investigations using OCTA.

The investigators also collected specimens and performed renal biopsy examinations; patients then were categorised as having lupus or lupus nephritis.

Analysis findings

No significant differences were found between patients and controls in the central foveal thickness and parafoveal thickness values. However, the foveal avascular zone (FAZ) area was significantly increased in the patient groups compared with the controls.

The entire superficial capillary plexus (SCP) vascular densities in the parafoveal and foveal regions were significantly decreased in the patient groups compared with the controls, i.e., the SCP values were 42.65 ± 2.23% in the SLE with nephritis group, 44.88 ± 2.09% in the SLE without nephritis group and 49.10 ± 3.12% in the healthy control group.

The SCP parafoveal vascular densities were 40.77 ± 3.27% in SLE with nephritis, 47.19 ± 2.63% in SLE without nephritis and 50.98 ± 4.80% in healthy controls. The SCP foveal vascular densities were 18.96 ± 3.43% in SLE with nephritis, 21.61 ± 4.00% in SLE without nephritis and 24.16 ± 2.69% in healthy controls.

The entire deep capillary plexus (DCP), parafoveal and foveal vascular densities were significantly reduced in the SLE with nephritis but showed only marginal differences in the SLE without nephritis compared to healthy controls, i.e., the DCP values were 48.04 ± 3.93% in SLE with nephritis, 53.63 ± 2.19% in SLE without nephritis and 54.88 ± 3.57% in healthy controls.

The DCP parafoveal vascular densities were 54.56 ± 2.37% in SLE with nephritis, 56.93 ± 1.90% in SLE without nephritis, and 57.39 ± 5.99% in healthy controls. The DCP foveal vascular densities were 34.42 ± 3.12% in SLE with nephritis, 41.96 ± 3.19% in SLE without nephritis and 42.55 ± 7.74% in healthy controls.

The authors commented, “OCTA plays a considerable role in detecting early changes in the retinal vascular plexus, even before the appearance of manifest symptoms in patients with SLE. Notably, the alterations in both the superficial and deep retinal vascular density, as well as the enlargement of the FAZ area, were more pronounced in patients with SLN compared to those with SLE without kidney involvement. Therefore, patients with lupus nephritis appear to be more susceptible to ocular involvement and warrant closer monitoring. Meanwhile, these findings highlight the merit of OCTA in allowing early intervention and modification of treatment strategies, including precise initiation of immunosuppressive therapy, potentially preventing further retinal damage and preserving vision.”

References

1. Basiony AI, Elgouhary SM, Mohamed HE, et al. Assessment of retinal microvascular changes in patients with systemic lupus erythematosus using optical coherence tomography angiography. Int J Retin Vitr. 2025;11:55. https://doi.org/10.1186/s40942-025-00677-2
2. Fanouriakis A, Kostopoulou M, Chee MAK, et al. 2019 Update of the joint European league against rheumatism and European renal association–European Dialysis and transplant association (EULAR/ERA EDTA) recommendations for the management of lupus nephritis. Ann Rheum Dis. 2020;79:713–723.
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8. Triggianese P, Cesareo M, Guarino MD, et al. Evaluation of retinal microvascular per fusion in hereditary angioedema: a case-control study. Orphanet J Rare Dis. 2020;15:20.
9. Kashani AH, Chen CL, Gahm JK, et al. Optical coherence tomography angiography: A comprehensive review of current methods and clinical applications. Prog Retin Eye Res. 2017;60:66–100.