4 | DISCUSSION
This is the first pediatric research studying CT at three different areas of choroid in order to evaluate the immunopathologic processes within choroid in pediatric CD patients reflecting eye involvement in this autoimmune disease by the help of EDI-OCT. There are studies in literature with different results; Bölükbaşı et al. found an increase in adult CD patients at seven areas (one subfoveal, three nasal, three temporal)15, but Doğan et al. found an insignificant decrease at subfoveal area in pediatric CD patients at gluten free diet for 5 years.16
According to our study results in pediatric CD patients who made gluten free diet for one year after endoscopic diagnosis, CT were thinner at all subfoveal, nasal and temporal points compared to control group. Our findings were supporting the study results of Dogan. Although they made the CT measuements at only one point at subfoveal area, in our study, CT measurements were made at three different points of choroid. Baltmr A et al. reported that, in the acute inflammatory phase, CT usually increases, while atrophic changes in recurrent inflammatory conditions result in decreased CT in local ocular inflammation.24Tekin et al. found a significant decrease in CT in pediatric malnutrition cases.25 Our findings may be reflecting that the immunopathologic changes in choroid did not recover with gluten free diet since intestinal mucosa recovery is incomplete at one year or may be reflecting atrophic changes in CT without recovery with gluten free diet or may be due to effect of malnutrition and malabsorbtion of vitamin A and D. There is a need for follow up studies measuring CT at diagnosis time and after gluten free diet in follow-up period.
Early and initial signs of systemic and autoimmune diseases can also be evaluated by measuring the thickness of GCC complex composed of; RNFL, GCL and IPL of optic nerve by the help of EDI-OCT.8,9,10,11 Our measurement results of GCC layer thicknesses (Five points of RNFL, GCL and IPL) revealed similar results in CD and control groups. There are papers reporting decreased thicknesses of these layers in Behçet’s disease, SLE, MS and obesity patients due to effects of autoinflammatory diseases and metabolic stress.11,14,19,20 There is only one adult CD study by Hazar et al. reporting that superior and nasal RNFL was decreased.22 There is only one pediatric CD study by Hashas, reporting a decrease in global, temporal, superior temporal and superior nasal RNFL.23
GCC is a continuation of optic nerve. In our study we did not found a decrease in thicknesses of GCC layers which may reflect neural tissue involvement is a more complicated issue.12 Study by Hazar et al was in adults and study by Hashas in pediatric were with a small number study.21,23 Their theory accepts that the immune antibodies would be causing that decrease in RNFL, GCL and IPL, but these layers are not in direct contact with these antibodies. There are Behçet’s disase, SLE and MS studies reporting decreased thicknesses of GCC layers, which inflammatory effects of these diseases are directly influencing neural tissue.11,14,20 But antibodies causing Celiac disease
In conclusion, our study shows that Pediatric CD causing thinning of subfoveal, nasal and temporal areas of choroid, and this change is apparent even after one year gluten free diet as an extraintestinal finding. This finding may be a new form of nonclassical presentation of CD. Thickneses of GCC layers were similar in CD and control groups may be revealing the effect of diet or these layers are not involved in CD eye findings pathogenesis. Eye findings as an extraintestinal involvement should be more closely screened at diagnosis and longterm clinical results of thin choroid and GCC should be determined in pediatric CD.