1 | INTRODUCTION
Celiac disease (CD) is a gluten-induced multisystemic autoimmune disease
in genetically susceptible individuals.1 In recent
years, there has been increasing recognition that the pattern of
presentation of pediatric CD may be changing.1,2
Classic CD manifesting with diarrhea, malabsorption and failure to
thrive may be less common than the more subtle presentations such as
oligosymptomatic, latent, potential, and extraintestinal system findings
related with nervous, otologic, dermatological, dental and
musculoskeletal findings.3,4 If undiagnosed
extraintestinal findings remain untreated, leaving individuals exposed
to the risk of long-term complications.5-7
Recent studies eye involvement in systemic and autoinflammatory diseases
such as inflammatory bowel disease, diabetes mellitus, rheumatoid
arthritis and Behçet’s disease.8-11 Mostly reflected
as a change in thicknesses of choroid and ganglion cell complex (GCC).
Choroid is highly vascular tissue present between retina and sclera and
providing main blood flow to the optical structures effected by
circulatory factors, such as intraocular and perfusion pressure,
endogenous nitric oxide production and
inflammation.12,13
In the acute inflammatory phase, cytokines increase the choroidal
vascular permeability and choroidal thickness (CT) usually increases,
while atrophic changes in recurrent inflammatory conditions result in
decreased CT.8-11,14 CD is also an autoimmune
inflammatory disease that would affect eyes of patients. Ocular findings
due to CD occupy an important place among these extraintestinal findings
because of the direct effect of visual function and ocular comfort on
quality of life.5-7 Bölükbaşı et al. has revealed that
mean CT measurements at all seven areas of subfoveal, nasal, and
temporal points were found to be higher in the adult celiac
group.15 There is only one study by Doğan et al. that
have found insignificant decrease in thickness of choroid in pediatric
CD patients at only subfoveal area. The studies about eye involvement
and effect of gluten free diet on ocular findings in CD patients are
scarce.1
Optical coherence tomography (OCT) calculates delays in reflected light
in different layers of the eye, allowing the reflected light to be
converted into 3D images showing depth dimensions. The axial resolution
of OCT has currently reached the very low value of 3 microns, and this
convenient, non-contact technique can yield images similar to biopsy
material viewed under a microscope. OCT can therefore be described as a
non-invasive tissue biopsy. Enhanced depth imaging optical coherence
tomography (EDI-OCT), a software application that can be installed on
spectral domain optical coherence tomography (SD-OCT) devices, is a
non-invasive method that provides deeper cross-sectional information
about vascularization of choroid, thicknesses of; choroid and GCC which
is composed of retinal nerve fibre layer (RNFL), ganglion cell layer
(GCL) and ınner plexiform layer (IPL).17,18
Ganglion cell comple is the sum of the three innermost layers: the
retinal nerve fiber layer RNFL, which is composed of axons; the GCL,
which is composed of cell bodies; and the IPL, which contains the
retinal ganglion cells dendrites.12 Early and initial
signs of systemic and autoimmune diseases can also be evaluated by
measuring the thickness of GCC layers by the help of
EDI-OCT.8-11 In Behçet’s disease, systemic lupus
erythematosus (SLE), multiple sclerosis (MS) and obesity patients
thicknesses of GCC layers are decreased due to effects of
autoinflammatory diseases and metabolic
stress.11,14,19,20 There is only one study in adult
and one small size pediatric study reporting thinning of RNFL layer in
CD patients.21,22 In the present study, measurement of
thicknesses of choroid (at subfoveal, nasal and temporal points) and GCC
(RNFL at seven points GCL and IPL) in pediatric CD and control group in
order to evaluate eye findings and effect of gluten free diet on ocular
involvement which is an important extraintestinal finding of CD.