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A case report of retinal complications of gout

A case report of retinal complications of gout A case report of retinal complications of gout
A case report of retinal complications of gout A case report of retinal complications of gout

A 62-year-old African American male had a long-standing history of chronic joint damage and tophi deposition in his hands. He complained of metamorphopsia in the left eye and slowly progressing blurred vision in both eyes.

 


These symptoms are associated with which of the following disease?

  • Gout
  • Conjunctivitis
  • Anterior uveitis


Gout is an inflammatory disorder in which there is the deposition of uric acid in tissues. It results in the inflammation of various joints, especially the joints of the hand, knees, foot, etc. However, various other organs are also reported to be involved including the eye. The number of previous case reports determined the association of various eye diseases such as conjunctivitis and anterior uveitis with inflammation. Multiple studies reported the deposition of gouty crystal in the cornea, sclera, and iris. Other associations between gout and blurred disc margins, elevated intraocular pressure, and possibly posterior uveitis had been reported in a previous case report. However, direct urate crystal deposits were not observed in the retina.

Herein the case of a patient with macular crystals and advanced systemic gout had been reported.

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Key take away

To manage the risk of macular degeneration, and vascular occlusions among gout patients the anterior and posterior examination of dilated eyeball should be carried out carefully.

Medical history

The patient had a long-standing history of uncontrolled gout.

Examination & lab investigations

The best-corrected visual acuity of the patient was 20/30 in both eyes. Anterior examination except posterior and bilateral nuclear subcapsular cataracts was normal. No corneal or conjunctival pathology was observed. The left macula of the patient demonstrated subretinal, highly refractile lesions and geographic atrophy. The lesions were predominately distributed at the termination of retinal arterioles in the macula. Epithelial mottling can be seen in the fundus exam of the right eye.

Management

The patient was given the Amsler grid for the improvement of his central visual field; he was followed up in the clinic. His visual acuity and retinal exam were found to be stable over the last 12 months. He reported a slight worsening of metamorphopsia in the left eye.

Discussion

Previous studies had not reported association of retinal lesions with gout, described as an effector of the anterior segment causing uveitis, conjunctivitis and corneal deposits. Hyperlipidemia and cholesterol emboli were considered the most likely causes of these findings. But these conditions had been well controlled by statin medication previously. Also, he has no cardiac disease or carotid artery.

Retinal involvement in hyperlipidemia presents at a much earlier age and is prominent in patients with familial hyperlipidemia syndromes. In this patient, the age-related macular degeneration (ARMD) was also considered. Moreover, the macular degeneration is rare in African American descent. Additionally, at the time of presentation, the level of uric acid was normal, i.e., 5.3 mg/dL. Uric acid levels can be normal at the time of an attack of gout as documented by previous studies, therefore serum uric acid levels cannot help predict chronicity of the macular lesions.

Learning

  • Patients with gout and visual symptoms should be thoroughly examined as retinopathy may be associated with chronic uncontrolled gout
  • Patients with visual complaints should undergo an examination of both the anterior and posterior segment and a dilated examination with the typical anterior segment slit-lamp 

References

    1. Ferry AP, Safir A, Melikian HE. Ocular abnormalities in patients with gout. Ann Ophthalmol. 1985;17:632–5. 4073719
    2. Berman EL. Clues in the eye: ocular signs of metabolic and nutritional disorders. Geriatrics. 1995;50(7):34. 7601360
    3. Fishman RS, Sunderman FW. Band keratopathy in gout. Arch Ophthalmol. 1996;75:367–9. 5903822
    4. Coassin M, Piovanetti O, Stark WJ, Green WR. Urate deposition in the iris and anterior chamber. Ophthalmology. 2006;113:462–5. 16513461
    5. Martinez-Cordero E, Barreira-Mercado E, Katona G. Eye tophi deposition in gout. J Rheumatol. 1986;13:471–3. 3723515
    6. Lo WR, Broocker G, Grossniklaus HE. Histopathologic examination of conjunctival tophi in gouty arthritis. Am J Ophthalmol. 2005;140: 1152–4. 16376674
    7. Yulek F, Çağıl N, Orhan N, et al. Gout attack with unusual ocular complications. Rheumatol Int. 2009;29:557–9. 18841369
    8. Kumar J, Weirzbicki AS. Images In Clinical Medicine. Lipemia Retinalis. N Engl J Med. 2005;353:823. 16120862
    9. Schlesinger N, Norquist JM, Watson DJ. Serum Urate During Acute Gout. J Rheumatol. 2009;36:1287–9. 19369457

Source:

BMC Ophthalmol. 2018 Jan 19;18(1):11.

Article:

Retinal complications of gout: a case report and review of the literature

Authors:

Ying Jiang et al.

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