{"paper_id":"04f0d0fa-0cb5-4809-a13c-7aec6ef331c1","body_text":"Restoring Vision in SLE: Successful Management of Lupus Retinopathy – A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Restoring Vision in SLE: Successful Management of Lupus Retinopathy – A Case Report Md Mehedi Hasan, Sanghita Banik Proma, Sakan Binte Imran, Tanjila Hossain, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5942169/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease which significantly affects multiple organs, including the ocular structures. Lupus retinopathy is one of those ocular manifestations, characterized by retinal ischemia and microvascular damage. Case Summary During a study on retinal changes of Systemic Lupus Erythematosus (SLE) patients, we coincidently noticed some cases with lupus retinopathy, whose retinal changes were reversible after getting treatment for Systemic Lupus Erythematosus (SLE). This case report belongs to those cases. This case report presents a 45-year-old female who had initial complaints of blurred vision in right of eye. The patient was concurrently diagnosed as Systemic lupus erythematosus (SLE), evidenced by polyarticular pain, fever and positive immunological and serological markers. The patient's visual symptoms significantly improved after receiving high dose glucocorticoids and immunosuppressive medications targeted towards her systemic symptoms of SLE. The follow-up exam showed that her vision had fully recovered and that his retinal lesions had resolved. Conclusion This case highlights the significance of lupus retinopathy as a potential early ocular manifestation of Systemic Lupus Erythematosus (SLE). Recognizing lupus retinopathy in its initial stages can not only prevent severe visual impairment but also facilitate the early diagnosis of SLE. Regular ophthalmologic screening is therefore essential in patients at risk, as it can play a pivotal role in the timely diagnosis and management of SLE. Systemic Lupus Erythematosus (SLE) Autoimmune disease Lupus retinopathy Ocular manifestations. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Systemic Lupus Erythematosus (SLE) is a connective tissue disorder of autoimmune origin which has a wide range of protean manifestations with variable course and prognosis 1 . It is a multi-system disorder that affects almost all organs, most commonly involving skin, joints and kidney 2 . Ocular involvement is reported in around one-third of the patients which can also present as an initial manifestation (2,3) . Lupus Retinopathy being the second most common ocular finding after keratoconjunctivitis sicca, is a sight-threatening condition which is characterized by deposition of immune complex in the retinal microvasculature leading to a chronological sequence of vascular occlusion, leakage, microinfarcts formation and retinal vasculitis 2 . Cotton wool exudates, hemorrhages, vascular tortuosity and attenuation, optic neuritis, optic atrophy, papilledema, macular edema, choroidopathy lastly chorioretinopathy are all possible manifestations of Lupus retinopathy, denoting that it has a wide range of clinical manifestations, from being asymptomatic to severe loss of vision 4 . We report a case of symptomatic lupus retinopathy with significant vision loss, whose ocular manifestation was reversed due to early recognition and a multidisciplinary treatment approach, both clinically and morphologically. Patient presentation A 38-year-old lady presented with a sudden onset of blurring of vision in her right eye having no pain, itching, redness, or lacrimation. On ocular examination, visual acuity was 6/60 in the right eye and 6/6 in the left eye. The Patient can’t recognize primary colours . There is no external ophthalmoplegia. Afterwards Fundoscopy examination revealed that the media was clear, red reflex, and fundal glow were present in both eyes. The right eye showed mild hyperemic disc with blurred nasal margin. There were widespread cotton wool exudates, notably on 5, 8, 10, and 11 O’clock positions of the right fundus (Figure 1). The left fundus showed no abnormality. Fundus fluorescein angiography (FFA) of Rt eye showing colour fundus and red-free photographs & successive phase of arteriolar- arteriovenous & venous phase which showed cotton wool spots present and temporal pallor disc (Figure 3). Optical Coherence Tomography (OCT) of the right eye reveals no abnormality (Figure 4). Upon querying, the patient revealed she had a feverish feeling, generalized body aches, and multiple joint pain with significant morning stiffness for the last 2 months. Initially involving the wrist, the joint pain gradually involved both large and small joints. She didn’t have any known comorbidity like DM, HTN or hypercoagulable conditions. On examination, body temperature was 100 degrees F, joint tenderness was present with a tenderness score of 2/4, and mild edema. There was no joint swelling or deformity. Routine investigations showed increased ESR, urine R/E shows 3+ proteinuria, and 24-hour Urinary Total Protein (UTP) is 2.4 gm (Table 1). Immunological investigation showed ANA was strongly positive, and Anti-dsDNA was positive. Significant consumption of C3 and C4 was also observed. So, the patient was ultimately diagnosed with a case of Systemic Lupus Erythematosus (SLE) according to the ACR diagnostic criteria with the following complications, lupus nephritis and lupus retinopathy. Her SLEDAI score was 23. Therefore, the patient was labeled as a case of very severe SLE. She was treated with a high dose of methylprednisolone followed by oral prednisolone and mycophenolate mofetil (MMF) targeting the systemic features of Systemic Lupus Erythematosus (SLE). Table 1: Investigations profile Parameters At the time of diagnosis On follow-up ANA Strongly positive Anti-dsDNA positive Within normal limit C3,C4 Reduced Within normal limit Urine R/E Protein +++ Protein (trace) 24 hours UTP 2.4gm 0.2gm SLEDAI 23 (Very severe) 4(mild) Fundoscopic finding (Right eye) Cotton wool exudates Optic disc hyperemic with blurred margin Temporal pallor persist (less than before) Fundoscopic Finding (Left eye) Normal Normal After treatment, the patient’s systemic features were gradually improving. After 1 year of follow-up, her joint pain was better, having no fever or edema. Her 24-hours UTP became 0.2 gm. This Time, her SLEDAI score was 4. On visual assessment, her vision was better with a visual acuity 6/18. Fundoscopic examination revealed reduced optic disc paleness on the temporal side and there were no cotton wool exudates (Figure 2). Thus, it became evident that her vision was partially improved with restored fundus morphology by providing treatment focusing on her systematic symptoms. Upon follow-up of the patient the fundoscopic finding of the eye showed retinopathy was reversed, yet the pale optic disc persisted to some extent but was better than before (Figure 5). Optical Coherence Tomography (OCT) of the right macula showed normal findings (Figure 6). Discussion Lupus retinopathy is an important ocular manifestation, which occurs with an incidence of 3-29% 5 . The fate of SLE is worse with retinopathy compared to SLE without retinopathy as it serves as a marker of poor prognosis 4 . Even sudden and painless loss of vision as an ocular complication due to vaso-occlusive retinopathy over a short span of time has been reported 6 . Emphasizing the urgency of early detection followed by prompt management can thereby lead to a better prognosis of both systemic and retinal lupus 7 . Our patient is one of the living pieces of evidence of such an incident. Although ACR diagnostic criteria don’t include Lupus retinopathy as a diagnostic tool, it can accurately indicate active systemic lupus activity which demands proper evaluation and appropriate management for better prognosis 8 . It accounts for further studies and concurrent research to support and establish their prior statement. As evidence backed up the fact that Lupus retinopathy is rather seen at an earlier stage of SLE and even makes the prognosis worse, it surely needs to be considered as an inclusion criteria going onwards. So, early diagnosis and adequate treatment of SLE can be ensured. Conclusion Systemic lupus erythematosus (SLE) is one of the numerous systemic disorders that have the fundus as its concealed mirror which reflects not only its progression but also its reversibility status. Therefore, fundoscopic findings serve as a prognostic factor, a measure of disease severity, and a diagnostic technique for SLE. Recommendation: Lupus retinopathy can be the earliest feature of Systemic Lupus Erythematosus (SLE). If detected early and taken the appropriate measures on time, it is treatable. Thus, the fundoscopic examination is strongly advised as a routine screening procedure at the time of diagnosis and during follow-up, as recommended by this case report. Declarations Ethical Clearance Complete information was given to the patient and written informed consent was obtained from the patient. Consent to Publication Written informed consent was obtained from the participant for publication of the case report. Data and materials availability Declaration The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing Interest The authors declare no competing interest. Funding Declaration The case report titled “Restoring Vision in SLE: Successful management of Lupus Retinopathy – A case Report” was conducted at Sir Salimullah Medical College Mitford Hospital. No funding was provided for this purpose. Authors Contribution Dr. Md Mehedi Hasan, Dr. Sanghita Banik Proma and Dr. Sakan Binte Imran : writing the original draft and revising. Dr. Tanjila Hossain : validation and reviewing the draft. Dr. Amiruzzaman : supervision, reviewing and revising the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable Authors Details 1.Dr. Md Mehedi Hasan Postgraduate trainee, Department of Medicine. Sir Salimullah Medical College Mitford Hospital,Dhaka, Bangladesh [email protected] 2. Dr. Sanghita Banik Proma Master’s Student, University College London, London, England. [email protected] 3. Dr. Sakan Binte Imran Medical Graduate, Sir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh. [email protected] 4. Dr. Tanjila Hossain Associate Professor, Department of Ophthalmology. Sir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh [email protected] 5. Dr. Amiruzzaman. Associate Professor, Department of Medicine. Sir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh [email protected] References Murugan, S. B., & Somanath, A. (2023). Commentary: Systemic lupus erythematosus retinopathy: Eye or multisystem involvement? Indian Journal of Ophthalmology, 71(5), 1994–1995. https://doi.org/10.4103/ijo.ijo_3386_22 David, S. et al. (2022) Bilateral lupus chorioretinopathy in a patient with active systemic lupus erythematosus , Cureus . Available at: https://www.cureus.com/articles/112300-bilateral-lupus-chorioretinopathy-in-a-patient-with-active-systemic-lupus-erythematosus (Accessed: 26 January 2025). Palejwala, N. V., Walia, H. S., & Yeh, S. (2012). Ocular Manifestations of Systemic lupus erythematosus: A review of the literature. Autoimmune Diseases, 2012, 1–9. https://doi.org/10.1155/2012/290898 Systemic lupus erythematosus (SLE) (2024) EyeWiki . Available at: https://eyewiki.org/Systemic_Lupus_Erythematosus_(SLE) (Accessed: 26 January 2025). Vaillant, A.A.J. (2023) Systemic lupus erythematosus , StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK535405/ (Accessed: 26 January 2025). Malik Hasnat ul Hassan Khan et al. (2024) Insight into systemic lupus erythematosus: Unveiling central retinal artery occlusion as an initial indicator , Cureus . Available at: https://doi.org/10.7759/cureus.67276 (Accessed: 26 January 2025). Kharel, R., Shah, D.N. and Singh, D. (2016) ‘Role of lupus retinopathy in systemic lupus erythematosus’, Journal of Ophthalmic Inflammation and Infection , 6(1). doi:10.1186/s12348-016-0081-4. Rishi, P. et al. (2014) ‘Systemic lupus erythematosus retinopathy in a 32-year-old female: Report of a case’, Indian Journal of Ophthalmology , 62(9), p. 951. doi:10.4103/0301-4738.143940. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5942169\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Case Report\",\"associatedPublications\":[],\"authors\":[{\"id\":411215505,\"identity\":\"58a3c8a0-115d-4bad-99d3-2cbe31ccb009\",\"order_by\":0,\"name\":\"Md Mehedi Hasan\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Sir Salimullah Medical College Mitford Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Md\",\"middleName\":\"Mehedi\",\"lastName\":\"Hasan\",\"suffix\":\"\"},{\"id\":411215506,\"identity\":\"9da46026-6d46-420d-9a9f-54766ffae281\",\"order_by\":1,\"name\":\"Sanghita Banik Proma\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University College London\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Sanghita\",\"middleName\":\"Banik\",\"lastName\":\"Proma\",\"suffix\":\"\"},{\"id\":411215507,\"identity\":\"b8f80ac3-3031-43ab-bd46-f7d7d81d917a\",\"order_by\":2,\"name\":\"Sakan Binte Imran\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"Sir Salimullah Medical College Mitford Hospital\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Sakan\",\"middleName\":\"Binte\",\"lastName\":\"Imran\",\"suffix\":\"\"},{\"id\":411215508,\"identity\":\"6301ec0e-c3cb-4312-90eb-49017b25c668\",\"order_by\":3,\"name\":\"Tanjila Hossain\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Sir Salimullah Medical College Mitford Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Tanjila\",\"middleName\":\"\",\"lastName\":\"Hossain\",\"suffix\":\"\"},{\"id\":411215509,\"identity\":\"4ab7269a-90a5-45a2-a910-b44a2db8594b\",\"order_by\":4,\"name\":\"Amiruzzaman .\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Sir Salimullah Medical College Mitford Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Amiruzzaman\",\"middleName\":\"\",\"lastName\":\".\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-02-01 14:08:17\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-5942169/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-5942169/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":75598904,\"identity\":\"1d24a361-9df9-42a0-a9d2-c165de1c5040\",\"added_by\":\"auto\",\"created_at\":\"2025-02-06 08:35:49\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":508832,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFundal Photograph Showing right-sided pale optic disc and Cotton wool exudates. Left-sided Fundus was normal.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5942169/v1/baa78a5f4b6167796681d791.jpg\"},{\"id\":75598905,\"identity\":\"a2ebab44-11cd-44b2-9507-9edf42c518b3\",\"added_by\":\"auto\",\"created_at\":\"2025-02-06 08:35:49\",\"extension\":\"jpg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":303725,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFundal photograph showed reduced optic paleness on temporal side of the right eye\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image2.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5942169/v1/910e800487f09bf0ca5d3cbe.jpg\"},{\"id\":75598907,\"identity\":\"b551f3da-34a2-4ac3-92c8-5ff3160d8b48\",\"added_by\":\"auto\",\"created_at\":\"2025-02-06 08:35:49\",\"extension\":\"jpg\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":539094,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFundus fluorescein angiography (FFA) of the right eye showing colour fundus, red-free photographs \\u0026amp; successive phase of arteriolar- arteriovenous \\u0026amp; venous phase revealed Cotton wool spots and pallor optic disc.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image3.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5942169/v1/359a6eb51049031b07bd2f86.jpg\"},{\"id\":75600427,\"identity\":\"ed00f012-7918-4b64-908f-c858500a2c0a\",\"added_by\":\"auto\",\"created_at\":\"2025-02-06 08:43:49\",\"extension\":\"jpg\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":339839,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eOptical Coherence Tomography (OCT) Macula of right eye revealed no abnormality of the macula.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image4.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5942169/v1/06e73ed7de32687e80dab1ae.jpg\"},{\"id\":75600426,\"identity\":\"cc816983-925b-405c-8bfc-a6b7b082b111\",\"added_by\":\"auto\",\"created_at\":\"2025-02-06 08:43:49\",\"extension\":\"jpg\",\"order_by\":5,\"title\":\"Figure 5\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":307239,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFundus fluorescein angiography (FFA) of the right eye showing Pale optic disc.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image5.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5942169/v1/c2d16425e8b35284500e947f.jpg\"},{\"id\":75600912,\"identity\":\"5681d1ad-3c12-4fb1-aadc-715ea1835edb\",\"added_by\":\"auto\",\"created_at\":\"2025-02-06 08:51:49\",\"extension\":\"jpg\",\"order_by\":6,\"title\":\"Figure 6\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":267446,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eOptical Coherence Tomography(OCT) Macula showing normal findings.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image6.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5942169/v1/80d4414f410088ac0065be81.jpg\"},{\"id\":75600915,\"identity\":\"b6f4ba01-aa17-4a5b-b4af-6faaeb2af01d\",\"added_by\":\"auto\",\"created_at\":\"2025-02-06 08:51:54\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":2794376,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5942169/v1/a51bac8c-f944-48c5-a484-df2357438588.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Restoring Vision in SLE: Successful Management of Lupus Retinopathy – A Case Report \",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eSystemic Lupus Erythematosus (SLE) is a connective tissue disorder of autoimmune origin which has a wide range of protean manifestations with variable course and prognosis\\u003csup\\u003e1\\u003c/sup\\u003e. It is a multi-system disorder that affects almost all organs, most commonly involving skin, joints and kidney\\u003csup\\u003e2\\u003c/sup\\u003e. Ocular involvement is reported in around one-third of the patients which can also present as an initial manifestation\\u003csup\\u003e(2,3)\\u003c/sup\\u003e. Lupus Retinopathy being the second most common ocular finding after keratoconjunctivitis sicca, is a sight-threatening condition which is characterized by deposition of immune complex in the retinal microvasculature leading to a chronological sequence of vascular occlusion, leakage, microinfarcts formation and retinal vasculitis\\u003csup\\u003e2\\u003c/sup\\u003e. Cotton wool exudates, hemorrhages, vascular tortuosity and attenuation, optic neuritis, optic atrophy, papilledema, macular edema, choroidopathy lastly chorioretinopathy are all possible manifestations of Lupus retinopathy, denoting that it has a wide range of clinical manifestations, from being asymptomatic to severe loss of vision\\u003csup\\u003e4\\u003c/sup\\u003e. We report a case of symptomatic lupus retinopathy with significant vision loss, whose ocular manifestation was reversed due to early recognition and a multidisciplinary treatment approach, both clinically and morphologically.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\"},{\"header\":\"Patient presentation\",\"content\":\"\\u003cp\\u003eA 38-year-old lady presented with a sudden onset of blurring of vision in her right eye having no pain, itching, redness, or lacrimation. On ocular examination, visual acuity was 6/60 in the right eye and 6/6 in the left eye. The Patient can\\u0026rsquo;t recognize primary colours . There is no external ophthalmoplegia. Afterwards Fundoscopy examination revealed that the media was clear, red reflex, and fundal glow were present in both eyes. The right eye showed mild hyperemic disc with blurred nasal margin. There were widespread cotton wool exudates, notably on 5, 8, 10, and 11 O\\u0026rsquo;clock positions of the right fundus (Figure 1). The left fundus showed no abnormality. Fundus fluorescein angiography (FFA) of Rt eye showing colour fundus and red-free photographs \\u0026amp; successive phase of arteriolar- arteriovenous \\u0026amp; venous phase which showed cotton wool spots present and temporal pallor disc (Figure 3). Optical Coherence Tomography (OCT) of the right eye reveals no abnormality (Figure 4). Upon querying, the patient revealed she had a feverish feeling, generalized body aches, and multiple joint pain with significant morning stiffness for the last 2 months. Initially involving the wrist, the joint pain gradually involved both large and small joints. She didn\\u0026rsquo;t have any known comorbidity like DM, HTN or hypercoagulable conditions. On examination, body temperature was 100 degrees F, joint tenderness was present with a tenderness score of 2/4, and mild edema. There was no joint swelling or deformity. Routine investigations showed increased ESR, urine R/E shows 3+ proteinuria, and 24-hour Urinary Total Protein (UTP) is 2.4 gm (Table 1). Immunological investigation showed ANA was strongly positive, and Anti-dsDNA was positive. Significant consumption of C3 and C4 was also observed. So, the patient was ultimately diagnosed with a case of Systemic Lupus Erythematosus (SLE) according to the ACR diagnostic criteria with the following complications, lupus nephritis and lupus retinopathy. Her SLEDAI score was 23. Therefore, the patient was labeled as a case of very severe SLE. She was treated with a high dose of methylprednisolone followed by oral prednisolone and mycophenolate mofetil (MMF) targeting the systemic features of Systemic Lupus Erythematosus (SLE).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1: Investigations profile\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"624\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eParameters\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAt the time of diagnosis\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eOn follow-up\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eANA\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eStrongly positive\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAnti-dsDNA\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003epositive\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eWithin normal limit\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eC3,C4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eReduced\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eWithin normal limit\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eUrine R/E\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eProtein +++\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eProtein (trace)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e24 hours UTP\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e2.4gm\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0.2gm\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSLEDAI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e23 (Very severe)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e4(mild)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eFundoscopic finding (Right eye)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eCotton wool exudates\\u003c/p\\u003e\\n \\u003cp\\u003eOptic disc hyperemic with blurred margin\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eTemporal pallor persist (less than before)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eFundoscopic Finding (Left eye)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eNormal\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eNormal\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eAfter treatment, the patient\\u0026rsquo;s systemic features were gradually improving. After 1 year of follow-up, her joint pain was better, having no fever or edema. Her 24-hours UTP became 0.2 gm. This Time, her SLEDAI score was 4. On visual assessment, her vision was better with a visual acuity \\u0026nbsp;6/18. Fundoscopic examination revealed reduced optic disc paleness on the temporal side and there were no cotton wool exudates (Figure 2). Thus, it became evident that her vision was partially improved with restored fundus morphology by providing treatment focusing on her systematic symptoms. Upon follow-up of the patient the fundoscopic finding of the eye showed retinopathy was reversed, yet the pale optic disc persisted to some extent but was better than before (Figure 5). Optical Coherence Tomography (OCT) of the right macula showed normal findings (Figure 6).\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eLupus retinopathy is an important ocular manifestation, which occurs with an incidence of 3-29%\\u003csup\\u003e5\\u003c/sup\\u003e. The fate of SLE is worse with retinopathy compared to SLE without retinopathy as it serves as a marker of poor prognosis\\u003csup\\u003e4\\u003c/sup\\u003e. Even sudden and painless loss of vision as an ocular complication due to vaso-occlusive retinopathy over a short span of time has been reported\\u003csup\\u003e6\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eEmphasizing the urgency of early detection followed by prompt management can thereby lead to a better prognosis of both systemic and retinal lupus\\u003csup\\u003e7\\u003c/sup\\u003e. Our patient is one of the living pieces of evidence of such an incident.\\u003c/p\\u003e\\n\\u003cp\\u003eAlthough ACR diagnostic criteria don\\u0026rsquo;t include Lupus retinopathy as a diagnostic tool, it can accurately indicate active systemic lupus activity which demands proper evaluation and appropriate management for better prognosis\\u003csup\\u003e8\\u003c/sup\\u003e. It accounts for further studies and concurrent research to support and establish their prior statement. As evidence backed up the fact that Lupus retinopathy is rather seen at an earlier stage of SLE and even makes the prognosis worse, it surely needs to be considered as an inclusion criteria going onwards. So, early diagnosis and adequate treatment of SLE can be ensured.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eSystemic lupus erythematosus (SLE) is one of the numerous systemic disorders that have the fundus as its concealed mirror which reflects not \\u0026nbsp;only its progression but also its reversibility status. Therefore, fundoscopic findings serve as a prognostic factor, a measure of disease severity, and a diagnostic technique for SLE.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eRecommendation:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eLupus retinopathy can be the earliest feature of Systemic Lupus Erythematosus (SLE). If detected early and taken the appropriate measures on time, it is treatable. Thus, the fundoscopic examination is strongly advised as a routine screening procedure at the time of diagnosis and during follow-up, as recommended by this case report.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthical Clearance \\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eComplete information was given to the patient and written informed consent was obtained from the patient.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent to Publication \\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;Written informed consent was obtained from the participant for publication of the case report.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e Data and materials availability Declaration\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interest \\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no competing interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eFunding Declaration \\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe case report titled \\u0026ldquo;Restoring Vision in SLE: Successful management of Lupus Retinopathy \\u0026ndash; A case Report\\u0026rdquo; was conducted at Sir Salimullah Medical College Mitford Hospital. No funding was provided for this purpose.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors Contribution \\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDr. Md Mehedi Hasan, Dr. Sanghita Banik Proma and Dr. Sakan Binte Imran : writing the original draft and revising.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;Dr. Tanjila Hossain : validation and reviewing the draft.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eDr. Amiruzzaman : supervision, reviewing and revising the manuscript. All authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors Details\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.Dr. Md Mehedi Hasan\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ePostgraduate trainee, Department of Medicine.\\u003c/p\\u003e\\n\\u003cp\\u003eSir Salimullah Medical College Mitford Hospital,Dhaka, Bangladesh\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003emehedissmcms@gmail.com\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2. Dr. Sanghita Banik Proma\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eMaster\\u0026rsquo;s Student,\\u003c/p\\u003e\\n\\u003cp\\u003eUniversity College London, London, England.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003epsanghita81@gmail.com\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3. Dr. Sakan Binte Imran\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eMedical Graduate,\\u003c/p\\u003e\\n\\u003cp\\u003eSir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003esakanbinteimran.ssmc@gmail.com\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e4. Dr. Tanjila Hossain\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAssociate Professor, Department of Ophthalmology.\\u003c/p\\u003e\\n\\u003cp\\u003eSir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003etanjilahossain1976@gmail.com\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e5. Dr. Amiruzzaman.\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAssociate Professor, Department of Medicine.\\u003c/p\\u003e\\n\\u003cp\\u003eSir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003esuman24th.az@gmail.com\\u003c/strong\\u003e\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eMurugan, S. B., \\u0026amp; Somanath, A. (2023). Commentary: Systemic lupus erythematosus retinopathy: Eye or multisystem involvement? Indian Journal of Ophthalmology, 71(5), 1994\\u0026ndash;1995. https://doi.org/10.4103/ijo.ijo_3386_22\\u003c/li\\u003e\\n\\u003cli\\u003eDavid, S. \\u003cem\\u003eet al.\\u003c/em\\u003e (2022) \\u003cem\\u003eBilateral lupus chorioretinopathy in a patient with active systemic lupus erythematosus\\u003c/em\\u003e, \\u003cem\\u003eCureus\\u003c/em\\u003e. Available at: https://www.cureus.com/articles/112300-bilateral-lupus-chorioretinopathy-in-a-patient-with-active-systemic-lupus-erythematosus (Accessed: 26 January 2025).\\u003c/li\\u003e\\n\\u003cli\\u003ePalejwala, N. V., Walia, H. S., \\u0026amp; Yeh, S. (2012). Ocular Manifestations of Systemic lupus erythematosus: A review of the literature. Autoimmune Diseases, 2012, 1\\u0026ndash;9. https://doi.org/10.1155/2012/290898\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cem\\u003eSystemic lupus erythematosus (SLE)\\u003c/em\\u003e (2024) \\u003cem\\u003eEyeWiki\\u003c/em\\u003e. Available at: https://eyewiki.org/Systemic_Lupus_Erythematosus_(SLE) (Accessed: 26 January 2025).\\u003c/li\\u003e\\n\\u003cli\\u003eVaillant, A.A.J. (2023) \\u003cem\\u003eSystemic lupus erythematosus\\u003c/em\\u003e, \\u003cem\\u003eStatPearls [Internet].\\u003c/em\\u003e Available at: https://www.ncbi.nlm.nih.gov/books/NBK535405/ (Accessed: 26 January 2025).\\u003c/li\\u003e\\n\\u003cli\\u003eMalik Hasnat ul Hassan Khan \\u003cem\\u003eet al.\\u003c/em\\u003e (2024) \\u003cem\\u003eInsight into systemic lupus erythematosus: Unveiling central retinal artery occlusion as an initial indicator\\u003c/em\\u003e, \\u003cem\\u003eCureus\\u003c/em\\u003e. Available at: https://doi.org/10.7759/cureus.67276 (Accessed: 26 January 2025).\\u003c/li\\u003e\\n\\u003cli\\u003eKharel, R., Shah, D.N. and Singh, D. (2016) \\u0026lsquo;Role of lupus retinopathy in systemic lupus erythematosus\\u0026rsquo;, \\u003cem\\u003eJournal of Ophthalmic Inflammation and Infection\\u003c/em\\u003e, 6(1). doi:10.1186/s12348-016-0081-4.\\u003c/li\\u003e\\n\\u003cli\\u003eRishi, P. \\u003cem\\u003eet al.\\u003c/em\\u003e (2014) \\u0026lsquo;Systemic lupus erythematosus retinopathy in a 32-year-old female: Report of a case\\u0026rsquo;, \\u003cem\\u003eIndian Journal of Ophthalmology\\u003c/em\\u003e, 62(9), p. 951. doi:10.4103/0301-4738.143940.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Systemic Lupus Erythematosus (SLE), Autoimmune disease, Lupus retinopathy, Ocular manifestations.\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5942169/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5942169/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSystemic Lupus Erythematosus (SLE) is a chronic autoimmune disease which significantly affects multiple organs, including the ocular structures. Lupus retinopathy is one of those ocular manifestations, characterized by retinal ischemia and microvascular damage.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCase Summary\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDuring a study on retinal changes of Systemic Lupus Erythematosus (SLE) patients, we coincidently noticed some cases with lupus retinopathy, whose retinal changes were reversible after getting treatment for Systemic Lupus Erythematosus (SLE). This case report belongs to those cases. This case report presents a 45-year-old female who had initial complaints of blurred vision in right of eye. The patient was concurrently diagnosed as Systemic lupus erythematosus (SLE), evidenced by polyarticular pain, fever and positive immunological and serological markers. The patient's visual symptoms significantly improved after receiving high dose glucocorticoids and immunosuppressive medications targeted towards her systemic symptoms of SLE. The follow-up exam showed that her vision had fully recovered and that his retinal lesions had resolved.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis case highlights the significance of lupus retinopathy as a potential early ocular manifestation of Systemic Lupus Erythematosus (SLE). Recognizing lupus retinopathy in its initial stages can not only prevent severe visual impairment but also facilitate the early diagnosis of SLE. Regular ophthalmologic screening is therefore essential in patients at risk, as it can play a pivotal role in the timely diagnosis and management of SLE.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Restoring Vision in SLE: Successful Management of Lupus Retinopathy – A Case Report \",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-02-06 08:35:44\",\"doi\":\"10.21203/rs.3.rs-5942169/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"dcc0901e-6354-4c86-91b3-726ba16eef1c\",\"owner\":[],\"postedDate\":\"February 6th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-02-06T08:35:44+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-02-06 08:35:44\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5942169\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5942169\",\"identity\":\"rs-5942169\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}