1 Ann Rheum Dis Month 2019 Vol 0 No 0 Is retinal microvascular damage an early manifestation of systemic sclerosis? We read with great interest the paper by Rothe et al, recently published on Annals of the Rheumatic Diseases, 1 who provided evidence that patients affected with systemic sclerosis (SSc) had impaired retinal microvascular perfusion, despite the lack of ocular symptoms. Angiograms of the full retina were obtained by optical coherent tomography (OCTA) in 12 patients with SSc with established disease and 12 matched healthy subjects in a case-control cross-sectional study. The retinal microvascular damage was not confirmed by the conventional fluorescence angiography (FA), but we do believe that FA would have detected similar findings, as previously reported. 2 3 We were not surprised by these results as a tissue vascular damage is expected whereby macro-angiopathy and micro-angiopathy are the hallmark of the disease. Indeed, in Rothe’s study, 10 out of 12 patients have suffered with digital ulcers, 1 although a correlation between retinal vasculitis and nailfold capillaroscopy patterns had not been reported. 3 However, the issue to be raised is whether the OCTA findings can be predictive of an overt ocular disease and therefore these patients should be worthy to undergo a specific treatment. Some years ago, we reported a series of three patients with SSc whose disease onset was characterised with visual disor- ders and retinal vascular abnormalities at FA. 4 All three patients had Raynaud phenomenon (RP) and tested positive for antinu- clear antibodies, but only one had also sclerodactyly by the time of ocular disease and none fulfilled the 1980 ACR classification criteria for SSc. Additional SSc-related symptoms occurred after 1–5 years. Of note, after release of ACR/EULAR 2013 classifica- tion criteria, all three patients would have defined as early SSc: this evidence can pave the way to several points of speculation. Should patients with acute vision abnormalities and RP be investigated for SSc? Might OCTA be of aid for identifying patients with early SSc at risk to develop ocular disease? We believe that these issues should be addressed by further studies on longitudinal cohort of patients with SSc with early disease. Florenzo Iannone, Cinzia Rotondo School of Medicine, University of Bari, Bari, Italy Correspondence to Professor Florenzo Iannone, School of Medicine, University of Bari, Bari 70124, Italy; forenzo.iannone@uniba.it Competing interests None declared. Patient consent for publication Not required. Provenance and peer review Not commissioned; internally peer reviewed. © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ. To cite Iannone F, Rotondo C. Ann Rheum Dis Epub ahead of print: [please include Day Month Year]. doi:10.1136/annrheumdis-2019-215127 Received 24 January 2019 Accepted 26 January 2019 Ann Rheum Dis 2019;0:1. doi:10.1136/annrheumdis-2019-215127 REFERENCES 1 Rothe M, Rommel F, Klapa S, et al. Evaluation of retinal microvascular perfusion in systemic sclerosis: a case–control study. Ann Rheum Dis 2019. doi:10.1136/ annrheumdis-2018-214541. [Epub ahead of print: 3 Jan 2018]. 2 Waszczykowska A, Goś R, Waszczykowska E, et al. Prevalence of ocular manifestations in systemic sclerosis patients. Arch Med Sci 2013;9:1107–13. 3 Ushiyama O, Ushiyama K, Yamada T, et al. Retinal fndings in systemic sclerosis: a comparison with nailfold capillaroscopic patterns. Ann Rheum Dis 2003;62:204–7. 4 Rotondo C, Lopalco G, Lapadula G, et al. Retinal vessels thrombosis as onset manifestation of systemic sclerosis: 3 clinical cases. J Rheumatol 2014;41:2495–6. Correspondence on 9 February 2019 by guest. Protected by copyright. http://ard.bmj.com/ Ann Rheum Dis: first published as 10.1136/annrheumdis-2019-215127 on 9 February 2019. Downloaded from