Retinal Vasculitis With Branch Retinal Vein Occlusion Associated With Anti-phospholipid Syndrome: A Case Report

1. Mario Hutapea
2. Soedarman Sjamsoe
3. Gitalisa Andayani
4. Made Susiyanti
5. Lukman Edwar
6. Rina Ladist

Faculty of Medicine University of Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

Purpose:
To report a rare case of retinal vasculitis with branch retinal vein occlusion in an anti-phospholipid syndrome patient that was successfully managed with anticoagulant and immunosuppressive agent.

Methods:
Case report of a 24-year-old man presented with an acute painless loss of vision in the upper nasal of his right eye since 3 days before admission. He experienced floaters. The best-corrected visual acuity was 20/20 ODS. Fundus examination of the right eye showed dilated and tortuous veins with phlebitis, exudates, and intraretinal hemorrhages in the lower temporal region. Fluorescence angiography of the right eye confirmed delayed filling in the lower temporal vein, with hyperfluorescence leakage. Investigations revealed positive anti-β2 glycoprotein-1IgM, positive anti-cardiolipin antibody IgM and IgG.

The patient was diagnosed as having retinal vasculitis with branch retinal vein occlusion OD. The medical chart of the patient was reviewed.

Results:
The patient was referred to the internist and managed with subcutaneous injection of fondaparinux 2.5 mg once daily for 2 days, methylprednisolone oral 48 mg once daily, and azathioprine oral 50 mg twice daily. On the follow-up, the condition was improving. The floaters diminished. Fundus examination showed decreased vein turtuosity, phlebitis, and exudates. The oral steroid was tapered and kept on maintainance dose to prevent flaring-up of the disease.

Conclusions:
Anti-phospholipid syndrome should be considered as one of the risk factors for developing retinal vasculitis with branch retinal vein occlusion in a young adult patient. The management should be addressed to the underlying disease.