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Trandafir CM, Balica NC, Horhat DI, Mot IC, Sarau CA, Poenaru M. Granulomatosis with Polyangiitis (GPA)-A Multidisciplinary Approach of a Case Report. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1837. [PMID: 36557039 PMCID: PMC9785195 DOI: 10.3390/medicina58121837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
Granulomatosis with polyangiitis is an atypical, multisystem disease with unknown etiology that generally affects both genders equally, with a predominance in the Caucasian racial group for individuals in their fourth decade. The disease affects the small vessels of the respiratory system, lungs, and kidneys. ENT manifestations are common, but ocular involvement is also frequent and can occur as an initial harbinger of the disease. The signs and symptoms of the disease are non-pathognomonic and sometimes localized, but it carries a poor prognosis if left untreated. Early diagnosis of granulomatosis with polyangiitis can be difficult and is established by a clinical examination along with laboratory tests for anti-neutrophil cytoplasmic antibodies (ANCA) and anatomopathological exam results that showcase necrosis, granulomatous inflammation, and vasculitis. Although the ocular involvement is not life threatening, it can cause blindness and may also be a sign of the active form of this systemic fatal disease. Treatment strategies involving immunosuppression and adjuvant therapies improve the prognosis. In this article we present a rare case of a patient diagnosed with granulomatosis with polyangiitis in our ENT department in 2003, with a follow-up for19 years in our clinic.
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Affiliation(s)
- Cornelia M. Trandafir
- Department of ENT, Victor Babeş University of Medicine and Pharmacy, 300041 Timisoara, Romania
- ENT Department, SCMUT Hospital Timisoara, Bd. Revolutiei No. 6, 300054 Timisoara, Romania
| | - Nicolae Constantin Balica
- Department of ENT, Victor Babeş University of Medicine and Pharmacy, 300041 Timisoara, Romania
- ENT Department, SCMUT Hospital Timisoara, Bd. Revolutiei No. 6, 300054 Timisoara, Romania
| | - Delia I. Horhat
- Department of ENT, Victor Babeş University of Medicine and Pharmacy, 300041 Timisoara, Romania
- ENT Department, SCMUT Hospital Timisoara, Bd. Revolutiei No. 6, 300054 Timisoara, Romania
| | - Ion C. Mot
- Department of ENT, Victor Babeş University of Medicine and Pharmacy, 300041 Timisoara, Romania
- ENT Department, SCMUT Hospital Timisoara, Bd. Revolutiei No. 6, 300054 Timisoara, Romania
| | - Cristian A. Sarau
- Department of Medical Semiology I, Victor Babeş University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Marioara Poenaru
- ENT Department, SCMUT Hospital Timisoara, Bd. Revolutiei No. 6, 300054 Timisoara, Romania
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Dong LK, Park JK, Gulati R, Campbell B, Lee HBH. Silicone Sphere Implant Extrusion From Orbital Granulomatosis With Polyangiitis: A Rare Complication in the Anophthalmic Socket. Ophthalmic Plast Reconstr Surg 2022; 38:e170-e173. [PMID: 35699211 DOI: 10.1097/iop.0000000000002224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Orbital implant extrusion is a known complication following evisceration and enucleation. In this case report, we present a 45-year-old woman who presented with a left silicone implant exposure and infection 2 years following evisceration with saddle nose on examination. CT of the maxillofacial bones without contrast showed bilateral soft tissue infiltration around the superior recti muscles, as well as a nasal septum perforation from extensive sinus disease. Left orbitotomy revealed a small fibrotic mass near the orbital roof. Biopsy and serology results were consistent with granulomatosis with polyangiitis.
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Affiliation(s)
- Libing Kathy Dong
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, U.S.A
| | - Ji Kwan Park
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, U.S.A
- Oculofacial Plastic and Orbital Surgery, Indianapolis, IN, U.S.A
- Ascension St. Vincent Hospital, Indianapolis, IN, U.S.A
| | - Rohit Gulati
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, U.S.A
| | - Benjamin Campbell
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, U.S.A
- Oculofacial Plastic and Orbital Surgery, Indianapolis, IN, U.S.A
- Ascension St. Vincent Hospital, Indianapolis, IN, U.S.A
| | - Hui Bae Harold Lee
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, U.S.A
- Oculofacial Plastic and Orbital Surgery, Indianapolis, IN, U.S.A
- Ascension St. Vincent Hospital, Indianapolis, IN, U.S.A
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Mehta S, Chitnis N, Medhekar A. Utility of Optical Coherence Tomography Angiography (OCTA) in Granulomatosis With Polyangiitis. Cureus 2022; 14:e22612. [PMID: 35371706 PMCID: PMC8958215 DOI: 10.7759/cureus.22612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2022] [Indexed: 11/25/2022] Open
Abstract
A 61-year-old male presented with visual loss in the left eye. A CT scan of the chest revealed multiple lung cavities in both lungs. He had a positive C-ANCA suggestive of granulomatosis with polyangiitis. There were multiple areas of superficial retinal opacification in the right eye and anterior ischemic optic neuropathy in the left eye. An optical coherence tomography (OCT)/optical coherence tomography angiography (OCTA) revealed areas of superficial capillary dropout and areas of flow void in the choriocapillaris. The patient underwent immunosuppressive therapy and at follow-up, there was a reduction in the flow voids. Use of the OCT/OCTA allowed us to detect clinically visible and occult retinal/choroidal ischemia/inflammation and monitor response.
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Primary Nasocutaneous Fistulae in Granulomatosis With Polyangiitis: A Case Series and Literature Review. Ophthalmic Plast Reconstr Surg 2021; 37:55-60. [PMID: 32282641 DOI: 10.1097/iop.0000000000001678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To report the presentation, investigation, management, and outcomes of primary nasocutaneous fistulae in granulomatosis with polyangiitis and review the literature of this complication. METHODS Retrospective series of 5 patients with granulomatosis with polyangiitis and nasocutaneous fistulae and the medical and surgical management strategies employed. RESULTS Two cases presented with fistulae as the primary symptom of their systemic disease. Systemic management of granulomatosis with polyangiitis is a primary concern and two cases had inadequate control at presentation such that surgical intervention was deferred. Of the other 3 cases, 2 were closed using a median forehead flap and the other with an orbicularis advancement flap. An endonasal approach was attempted in 1 case but was unsuccessful due to the friable nature of the nasal mucosal tissue. CONCLUSIONS Nasocutaneous fistulae should alert the clinician to underlying granulomatosis with polyangiitis, which may be a presentation of this condition. Systemic management of disease is often a barrier to surgical management. Myocutaneous flaps may be the most reliable management option to achieve closure.
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Sahyouni R, Moshtaghi O, Abouzari M, Le P, Birkenbeuel J, Cheung D, Lin HW, Djalilian HR. A Case Series of Granulomatosis With Polyangiitis Primarily Diagnosed by Otological Manifestations. Ann Otol Rhinol Laryngol 2018; 128:263-266. [DOI: 10.1177/0003489418815517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To describe a case series of previously undiagnosed granulomatosis with polyangiitis (GPA) patients who presented primarily with otological manifestations. Method: We report a series of patients visited at a neurotology clinic who were eventually diagnosed with GPA based on their otologic complaints and had no prior knowledge of having this condition. Results: In this series, 10 (91%) patients presented with hearing loss (HL), more than half of which were bilateral (60%). Upon audiometric examination, all but 1 patient had mixed, conductive, or sensorineural HL. All patients presented with eustachian tube dysfunction (ETD), otitis media with effusion (OME), or both. Nasal endoscopy showed intranasal pathology in 3 (27%) patients. Otologic symptoms were improved in all patients after treatment with an average of 4 in-office follow-up appointments. Conclusion: GPA should be included in the differential diagnosis of adults with unexplained mixed hearing loss, new onset serous effusion, or acute otitis media in the absence of a previous history of ETD. Laboratory tests (ie, anti-neutrophil cytoplasmic autoantibody, erythrocyte sedimentation rate, and C-reactive protein) along with a urinalysis can aid in screening these patients. In cases in which the index of suspicion is high, repeated testing could reduce the risk of false negative findings.
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Affiliation(s)
- Ronald Sahyouni
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, CA, USA
- Department of Biomedical Engineering, University of California, Irvine, CA, USA
| | - Omid Moshtaghi
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, CA, USA
| | - Mehdi Abouzari
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, CA, USA
| | - Phuonganh Le
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, CA, USA
| | - Jack Birkenbeuel
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, CA, USA
| | - Dillon Cheung
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, CA, USA
| | - Harrison W. Lin
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, CA, USA
| | - Hamid R. Djalilian
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, CA, USA
- Department of Biomedical Engineering, University of California, Irvine, CA, USA
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Gallogly JA, Faraji F, Jumaily MH, Schneider JS, Brunworth JD. Diagnostic dilemmas of mechanical restriction of the medial rectus: A case report. ALLERGY & RHINOLOGY 2018; 9:2152656718764231. [PMID: 29977655 PMCID: PMC6028159 DOI: 10.1177/2152656718764231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Due to the proximity of the maxillary sinus and ethmoid sinuses to the orbit, inflammatory processes that originate in the sinonasal region have the potential to extend into the orbit. Objective We presented a case of ptosis and restrictive strabismus of the medial rectus muscle. Methods A case report with a literature review of possible diagnoses. Results Biopsy, imaging, and laboratory evaluation by otolaryngology, ophthalmology, and rheumatology services were unable to identify the cause of the fibrosis after 22 months of follow-up. A response to oral steroids indicated an inflammatory process. Conclusion Unilateral mechanical restriction of the medial rectus muscle is a rare complication of nasal disease. Inflammatory processes and iatrogenic injury are known to cause fibrosis of surrounding tissue. We presented a unique case of medial rectus fibrosis that did not meet the diagnostic criteria of recognized etiologies.
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Affiliation(s)
- James A Gallogly
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri.,No funding sources supported research.,The authors have no conflicts of interest to declare pertaining to this article
| | - Farhoud Faraji
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri.,No funding sources supported research.,The authors have no conflicts of interest to declare pertaining to this article
| | - Mejd H Jumaily
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri.,No funding sources supported research.,The authors have no conflicts of interest to declare pertaining to this article
| | - John S Schneider
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri.,No funding sources supported research.,The authors have no conflicts of interest to declare pertaining to this article
| | - Joseph D Brunworth
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri.,No funding sources supported research.,The authors have no conflicts of interest to declare pertaining to this article
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Abstract
PURPOSE To report a case of hemiretinal vein occlusion in a patient with Wegener's granulomatosis. RESULTS Retinal vein occlusion may occur in patients with Wegener's granulomatosis even in the absence of active inflammation affecting the retinal venules. CONCLUSIONS Wegener's granulomatosis should be considered in the diagnostic workup of young patients with major retinal vascular occlusion and concurrent history of pulmonary and/or renal disease.
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Shim KY, Sohn SI, Kim YC. Central Retinal Arterial Occlusion in Granulomatosis with Polyangiitis. KOREAN JOURNAL OF OPHTHALMOLOGY 2018; 32:519-520. [PMID: 30549477 PMCID: PMC6288024 DOI: 10.3341/kjo.2018.0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Kyu Young Shim
- Department of Ophthalmology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Yu Cheol Kim
- Department of Ophthalmology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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MACULA RETINAL VASCULITIS AND CHOROIDITIS ASSOCIATED WITH GRANULOMATOSIS WITH POLYANGIITIS. Retin Cases Brief Rep 2017; 11:119-122. [PMID: 27305849 DOI: 10.1097/icb.0000000000000307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To report a case series of two cases of granulomatosis with polyangiitis, previously known as Wegener granulomatosis, which developed macular necrosis, not previously associated with granulomatosis with polyangiitis, healed with fibrosis, despite aggressive immune-modulating therapy and good control of systemic disease. METHODS Case series of two cases with observation of treatment progress. RESULTS The results reported the progress of response to treatment in the two cases, which resulted in the final outcome of fibrosis in the macula region, despite being on aggressive immune-modulating therapy and good systemic control. CONCLUSION Granulomatosis with polyangiitis can be associated with macular necrosis leading to fibrosis, unresponsive to immune-modulating therapy.
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Abstract
PURPOSE To report a case of frosted branch angiitis in a patient with granulomatosis with polyangiitis. METHODS Clinical case report. Imaging was obtained with pseudo-color scanning laser ophthalmoscope photographs, fluorescein angiography, spectral domain optical coherence tomography, and B-scan ultrasound. RESULTS A 24-year-old woman with a clinical history of granulomatosis with polyangiitis who presented with acute vision loss was found to have frosted branch angiitis with concurrent posterior scleritis and orbital inflammation. These findings improved rapidly after initiation of high-dose intravenous solumedrol. CONCLUSION This is a unique case of frosted branch angiitis associated with granulomatosis with polyangiitis. The authors are not aware of a previous report of this association. Although rare, retinal vasculitis should be recognized as a potential complication of granulomatosis with polyangiitis and can respond rapidly to prompt initiation of therapy.
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Ocular Inflammation in the Setting of Concomitant Systemic Autoimmune Conditions in an Older Male Population. Cornea 2016; 34:762-7. [PMID: 26053887 DOI: 10.1097/ico.0000000000000437] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This retrospective cross-sectional study was designed to investigate the frequency and types of inflammatory ocular manifestations of specific systemic autoimmune diseases in a South Florida Veterans Affairs Hospital population. METHODS Demographic and medical diagnosis information was extracted from the Veterans Administration database for 1225 patients. These patients were seen in Miami and Broward Veterans Affairs hospitals between April 18, 2008, and April 17, 2013, and were diagnosed with at least 1 of the following: systemic lupus erythematosus, sarcoid, rheumatoid arthritis, polymyalgia rheumatica, Takayasu arteritis, giant cell arteritis, Kawasaki disease, polyarteritis nodosa, Buerger disease, Henoch-Schonlein purpura, Behcet syndrome, granulomatosis with polyangiitis, other polyarteritis nodosa-associated vasculitides, or arteritis not otherwise specified. RESULTS Of 1225 patients, 618 were seen in the VA eye clinic and 25 were diagnosed with concomitant inflammatory ocular conditions. Uveitis was the most common, and included 8 cases of anterior, 1 anterior-intermediate, 1 intermediate, 2 panuveitis, and 3 unspecified. Other manifestations included 7 cases of keratitis and 2 each of scleritis, episcleritis, and acute ischemic optic neuropathy. The overall frequency of inflammatory ocular disease was 2%. The diseases associated with the highest frequency of ocular involvement were granulomatosis with polyangiitis (1/8), sarcoid (9/198), giant cell arteritis (2/68), and rheumatoid arthritis (11/576). Of these 25 patients, 9 were diagnosed with eye disease before systemic disease. CONCLUSIONS In this population, ocular manifestations were rarely the presenting feature of systemic disease, but autoimmune disorders are an important underlying cause of inflammatory eye disease that should be considered on first evaluation, even in this "nontraditional," predominantly male, autoimmune disease population.
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Ursea R, De Castro D, Bowen TJ, Chan CC. The role of conjunctival biopsy in the diagnosis of granulomatosis with polyangiitis. J Ophthalmic Inflamm Infect 2015; 5:1. [PMID: 25632308 PMCID: PMC4303600 DOI: 10.1186/s12348-014-0033-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 12/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study is to describe a patient who was diagnosed with granulomatosis with polyangiitis based on conjunctival biopsy. This study is a case report and review of the literature. FINDINGS A 48-year-old Caucasian woman presented with a 2-week history of a left eye peripheral corneal ulcer with adjacent conjunctivitis and a 4-month history of a non-resolving productive cough. Given her elevated serum perinuclear antineutrophil cytoplasmic antibody (P-ANCA) and erythrocyte sedimentation rate (ESR) levels as well as a chest computed topography (CT) that showed bilateral patchy infiltrates, suspicion of limited granulomatosis with polyangiitis with lung and ocular involvement was high. Because bronchoalveolar lavage was nondiagnostic for granulomatous disease, conjunctival biopsy was initially attempted in order to avoid a more invasive lung biopsy. The conjunctival biopsy revealed mixed subacute inflammatory mediators and vasculitis consistent with granulomatosis with polyangiitis. CONCLUSIONS Conjunctival biopsy may be a valuable, minimally invasive method for diagnosing systemic granulomatosis with polyangiitis.
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Affiliation(s)
- Roxana Ursea
- Department of Ophthalmology and Vision Science, College of Medicine, University of Arizona, Tucson, AZ 85711 USA
| | - Dawn De Castro
- Oculoplastics Service, Massachusetts Eye and Ear Infirmary, Boston, MA 02114 USA
| | - Trent J Bowen
- College of Medicine, University of Arizona, Tucson, AZ 85711 USA
| | - Chi-Chao Chan
- Immunopathology Section, National Eye Institute, Bethesda, MD 20892 USA
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Hachicha F, Brour J, Zahaf A, Ben Abdallah M, Ouederni M, Cheour M, Kraiem A. [Progression of a rare and serious ocular manifestation of Wegener's granulomatosis: occlusive retinal vasculitis]. J Fr Ophtalmol 2014; 37:e153-5. [PMID: 25455551 DOI: 10.1016/j.jfo.2014.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 03/10/2014] [Accepted: 03/20/2014] [Indexed: 10/24/2022]
Affiliation(s)
- F Hachicha
- Service d'ophtalmologie, hôpital Habib Thameur, rue de Bab el falah, 2004 Tunis, Tunisie; Faculté de médecine de Tunis, université Tunis El Manar, Tunis, Tunisie.
| | - J Brour
- Service d'ophtalmologie, hôpital Habib Thameur, rue de Bab el falah, 2004 Tunis, Tunisie; Faculté de médecine de Tunis, université Tunis El Manar, Tunis, Tunisie
| | - A Zahaf
- Service d'ophtalmologie, hôpital Habib Thameur, rue de Bab el falah, 2004 Tunis, Tunisie; Faculté de médecine de Tunis, université Tunis El Manar, Tunis, Tunisie
| | - M Ben Abdallah
- Service d'ophtalmologie, hôpital Habib Thameur, rue de Bab el falah, 2004 Tunis, Tunisie; Faculté de médecine de Tunis, université Tunis El Manar, Tunis, Tunisie
| | - M Ouederni
- Service d'ophtalmologie, hôpital Habib Thameur, rue de Bab el falah, 2004 Tunis, Tunisie
| | - M Cheour
- Service d'ophtalmologie, hôpital Habib Thameur, rue de Bab el falah, 2004 Tunis, Tunisie; Faculté de médecine de Tunis, université Tunis El Manar, Tunis, Tunisie
| | - A Kraiem
- Service d'ophtalmologie, hôpital Habib Thameur, rue de Bab el falah, 2004 Tunis, Tunisie; Faculté de médecine de Tunis, université Tunis El Manar, Tunis, Tunisie
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Christakopoulos C, Heegaard S, Saunte JP. Surgically induced necrotizing scleritis in Wegener's granulomatosis. Acta Ophthalmol 2014; 92:e588-9. [PMID: 24845776 DOI: 10.1111/aos.12421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
| | - Steffen Heegaard
- Department of Neuroscience and Pharmacology; Eye Pathology Institute; University of Copenhagen; Copenhagen Denmark
- Department of Ophthalmology; Glostrup Hospital; University of Copenhagen; Glostrup Denmark
| | - Jon Peiter Saunte
- Department of Ophthalmology; Glostrup Hospital; University of Copenhagen; Glostrup Denmark
- Department of Ophthalmology; Hillerød Hospital; Hillerød Denmark
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Bilateral lacrimal drainage obstruction and its association with secondary causes. Ophthalmic Plast Reconstr Surg 2014; 30:152-6. [PMID: 24614546 DOI: 10.1097/iop.0000000000000034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Etiologies of lacrimal obstruction requiring a dacryocystorhinostomy (DCR) have been reviewed previously but most commonly are thought to result from "primary acquired" nasolacrimal duct obstruction, a process of chronic inflammation in a narrowed duct. The authors have observed that secondary causes are frequently associated with bilateral lacrimal outflow disease. The purpose of this study is to investigate this relationship to help the clinician prioritize which patients to evaluate for secondary causes. METHODS This is a retrospective case-controlled review of patients who underwent bilateral DCR from 1986 to 2012 at this institution. They are compared with an age and gender-matched control group who underwent unilateral DCR. Statistical analysis was undertaken using the Pearson chi-square test for p value, except for age, which used the Wilcoxon rank sum test. Logistic regression was used for comparing prevalence of secondary issues in bilateral disease versus unilateral disease, with age as covariate. RESULTS Two hundred thirty-five patients underwent bilateral (91) or unilateral DCR (144). Twice as many patients undergoing bilateral DCR had an underlying secondary cause compared with the patients undergoing unilateral DCR. (38%, 19%, p= 0.001, odds ratio 2.59). In patients <50, the odds ratio of a secondary cause in bilateral disease would be 5.34 compared with patients older than 80. (p = 0.0002) Patients in the bilateral DCR group underwent revisions at more than twice the rate as patients in the unilateral DCR group (26%, 12%, p = 0.007). CONCLUSIONS Ophthalmologists should have a high index of suspicion for secondary conditions underlying bilateral lacrimal outflow obstruction, especially in patients <50. These patients should undergo laboratory workup and intraoperative biopsy. They should also be counseled regarding a higher failure rate.
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Taylor SRJ, Salama AD, Pusey CD, Lightman S. Ocular manifestations of Wegener’s granulomatosis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2.1.91] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Siddiqui S, Kinshuck AJ, Srinivasan VR. Orbital apex syndrome secondary to granulomatosis with polyangiitis. BMJ Case Rep 2013; 2013:bcr-2013-009519. [PMID: 24311409 DOI: 10.1136/bcr-2013-009519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Orbital apex syndrome (OAS) is an optic nerve dysfunction with palsy of the third, fourth and sixth cranial nerves and ophthalmic division of the fifth cranial nerve. Causes can be infective, inflammatory, traumatic, neoplastic or vasculitic. We describe the first case in British literature and second worldwide of OAS presenting as granulomatosis with polyangiitis (GPA). A 38-year-old patient presented with left periorbital swelling and pain. An examination revealed left eye proptosis, tenderness in the ophthalmic distribution of the trigeminal nerve, unilateral ophthalmoplegia and reduced visual acuity. Initial treatment included intravenous antibiotics, steroids and nasal decongestants.Imaging demonstrated sinusitis and a suspected abscess from the infratemporal fossa to the orbital apex. However, sinus surgery showed granulation tissue without pus. The biopsy result was highly suggestive of GPA. A subsequent vasculitic screen was cytoplasmic-antineutrophil cytoplasmic antibody positive.This case highlights an unusual presentation of OAS secondary to GPA, as initial features suggested an infective cause.
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Alrashidi S, Yousef YA, Krema H. Visual loss from scleritis in C-ANCA-positive microscopic polyangiitis. BMJ Case Rep 2013; 2013:bcr-2013-009583. [PMID: 23761504 DOI: 10.1136/bcr-2013-009583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Scleritis is an inflammation of the outer eye coating that manifests with redness and ocular pain, and tends to be more severe when associated with a systemic collagen disease. Antineutrophil cytoplasmic antibody (ANCA)-positive microscopic polyangiitis is an autoimmune, multisystem, chronic disease characterised by damage to the endothelial lining of small vessels, and can be associated with severe scleritis that necessitates early aggressive therapy to prevent severe ocular complications.
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Affiliation(s)
- Salah Alrashidi
- Princess Margaret Cancer Centre, Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
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Reddy SC, Tajunisah I, Rohana T. Bilateral scleromalacia perforans and peripheral corneal thinning in Wegener's granulomatosis. Int J Ophthalmol 2011; 4:439-42. [PMID: 22553696 DOI: 10.3980/j.issn.2222-3959.2011.04.22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 06/02/2011] [Indexed: 11/02/2022] Open
Abstract
A rare case of bilateral scleromalacia perforans, bilateral peripheral corneal thinning (contact lens cornea) and unilateral orbital inflammatory disease in a 50 year old female patient with an indolent form Wegener's granulomatosis(WG) involving lungs and sinuses is reported. The patient survived for 12 years after the initial diagnosis of systemic disease. There was perforation of left globe following trauma and no perforation of the right globe till the last follow up of the patient.
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Affiliation(s)
- S C Reddy
- Department of Ophthalmology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Platnick J, Crum AV, Soohoo S, Cedeño PA, Johnson MH. The globe: infection, inflammation, and systemic disease. Semin Ultrasound CT MR 2011; 32:38-50. [PMID: 21277490 DOI: 10.1053/j.sult.2010.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Infection, inflammation, and systemic diseases affecting the globe encompass a broad range of pathologies which may ultimately lead to progressive vision loss. Clinical symptomatology varies from the inexorably silent progressive visual loss to an acute presentation of ocular pain and/or red eye. Most are diagnosed by clinical ophthalmologic examination with selective use of ultrasound, computed tomography, and magnetic resonance imaging for confirmation of the diagnosis, assessment of disease extent, and signs of associated systemic disease. Knowledge of the differential diagnoses of vision loss, ocular pain, and redness makes imaging analysis of this diverse group of processes more precise.
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Affiliation(s)
- Joseph Platnick
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
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21
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The eye in rheumatic disease. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
PURPOSE To demonstrate the effectiveness of Rituximab in the management of peripheral ulcerative keratitis (PUK) associated with Wegener granulomatosis (WG). METHODS A 50-year-old female with WG, confirmed by skin biopsy and positive anti-neutrophil cytoplasmic antibodies 3 years prior, was presented with a corneoscleral granulomatous mass that affected the superior limbus and with vasculitic PUK in the right eye. The mass was treated daily with oral prednisone (1 mg.kg-1.d-1) in conjunction with weekly maintenance treatment of 10 mg of methotrexate. After 2 months of treatment, the volume of the nodular granulomatous lesion decreased. However, the PUK and corneal thinning persisted, which presented a risk for corneal perforation. Subsequently, two 1000-mg infusions of rituximab were administered at weekly intervals. RESULTS One week after the first administration of rituximab, we observed persistence of corneal thinning, flattening of the nodular lesion, and disappearance of the necrotic foci. After the second rituximab treatment, the patient exhibited no signs of corneal perforation and we further observed total epithelialization of the PUK. No systemic side effects were seen. After 2 months, no nodular lesion was observed, although conjunctival epithelialization from the previous PUK remained. Weekly methotrexate and 10 mg of prednisone per day were maintained. CONCLUSIONS Rituximab seems to offer therapeutic promise in the treatment of refractory PUK associated with WG. Rituximab may be the elective treatment for severe anterior ocular inflammation associated with risk for corneal perforation, as a result of WG.
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Wegener's granulomatosis: clinical manifestations, differential diagnosis, and management of ocular and systemic disease. Surv Ophthalmol 2010; 55:429-44. [PMID: 20638092 DOI: 10.1016/j.survophthal.2009.12.003] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 12/05/2009] [Accepted: 12/16/2009] [Indexed: 11/22/2022]
Abstract
Wegener's granulomatosis (WG) is a systemic inflammatory disease whose histopathologic features often include necrosis, granuloma formation, and vasculitis of small-to-medium-sized vessels. WG involves many interrelated pathogenic pathways that are genetic, cell-mediated, neutrophil-mediated, humoral, and environmental. WG most commonly involves the upper respiratory tract, lungs, and kidneys, but has been reported to affect almost any organ. Ophthalmologic involvement is an important cause of morbidity in WG patients, occurring in approximately one-half of patients. The presence of unexplained orbital inflammatory disease, scleritis, peripheral ulcerative keratitis, cicatricial conjunctivitis, nasolacrimal duct stenosis, retinal vascular occlusion, or infrequently uveitis should raise the question of possible WG. A thorough clinical examination, laboratory testing, radiologic imaging, and histologic examination are essential to diagnosing WG and excluding potential mimics. Previously a uniformly fatal disease, treatment with cytotoxic and immunosuppressive agents has greatly improved survival. Treatment-related morbidity is a serious limitation of conventional therapies, leading to numerous ongoing studies of alternative agents.
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Ophthalmic presentation of Wegener's granulomatosis on a background of polymyalgia rheumatica. Clin Exp Ophthalmol 2010; 38:65-7. [PMID: 20447103 DOI: 10.1111/j.1442-9071.2009.02217.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present a case of Wegener's granulomatosis (WG) in a 79-year-old man with limbitis and granulomatous conjunctivitis, on a background of polymyalgia rheumatica (PMR). The undifferentiated nature of ocular presentations of WG can be diagnostically challenging, especially in cases, such as this, where findings are initially inconclusive and evolve with time. This case highlights the significance of a history of PMR in patients with ocular inflammation. The systemic inflammatory systems of WG, including arthralgias, may mimic other conditions such as PMR. Patients with undifferentiated ocular inflammatory syndromes should be questioned regarding arthralgias, myalgias and stiffness. Such symptoms, or a background of PMR, should raise suspicion of WG.
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25
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Watkins AS, Kempen JH, Choi D, Liesegang TL, Pujari SS, Newcomb C, Nussenblatt RB, Rosenbaum JT, Thorne JE, Foster CS, Jabs DA, Levy-Clarke GA, Suhler EB, Smith JR. Ocular disease in patients with ANCA-positive vasculitis. J Ocul Biol Dis Infor 2009; 3:12-19. [PMID: 20835396 PMCID: PMC2933008 DOI: 10.1007/s12177-009-9044-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Accepted: 11/09/2009] [Indexed: 10/26/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-positive vasculitis-the term recently applied to Wegener's granulomatosis-is a rare multi-system inflammation characterized by necrotizing granulomas and vasculitis. We investigated the ocular manifestations of this disease in a group of patients drawn from five inflammatory eye disease clinics across the United States. Of 8,562 persons with ocular inflammation, 59 individuals were diagnosed with ANCA-positive vasculitis; 35 males and 21 females, aged 16 to 96 years, were included in this study. Ocular diagnoses were scleritis (75.0%), uveitis (17.9%), and other ocular inflammatory conditions (33.9%) including peripheral ulcerative keratitis and orbital pseudotumor. Mean duration of ocular disease was 4.6 years. Oral corticosteroids and other systemic immunosuppressive agents were used by 85.7% and 78.5% of patients, respectively. Over time, patients with ANCA-positive vasculitis experienced 2.75-fold higher mortality than other patients with inflammatory eye disease.
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Manifestations ophtalmologiques de la granulomatose de Wegener. Revue de la littérature à propos d’une observation. Nephrol Ther 2009; 5:603-13. [DOI: 10.1016/j.nephro.2009.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 05/11/2009] [Accepted: 05/12/2009] [Indexed: 11/23/2022]
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27
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A confusing patient’s history: small or large vessel vasculitis? Rheumatol Int 2009; 30:1681-3. [DOI: 10.1007/s00296-009-1144-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 09/13/2009] [Indexed: 10/20/2022]
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Levy-Clarke G, Ding X, Gangaputra S, Yeh S, Goodglick T, Byrnes G, Nussenblatt R, Chan CC. Recalcitrant granulomatous sclerouveitis in a patient with granulomatous ANCA-associated vasculitis. Ocul Immunol Inflamm 2009; 17:83-7. [PMID: 19412867 DOI: 10.1080/09273940802596500] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To report an unusual case of granulomatous sclerochoroiditis. DESIGN Interventional case report. METHODS A patient with ANCA-associated granulomatous vasculitis presented with nodular necrotizing scleritis, which was recalcitrant to multiple systemic immunosuppressive therapies and progressed to a blind painful eye, which was enucleated. RESULTS Histopathology revealed extensive occlusive vasculitis, diffuse T- and B- cellular infiltration, and lymphoid granulomatous formation. Enhanced MHC class II antigens, adhesion molecules, and Fas (CD95) and FasL (CD95L) were detected in the lesion. CONCLUSION Granulomatous sclerochoroiditis with aggressive immune reaction can be a complication of ANCA-associated granulomatous vasculitis.
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Affiliation(s)
- Grace Levy-Clarke
- St. Luke's Cataract and Laser Center, St. Petersburg, Florida 33702, USA.
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29
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[Central Retinal Vein Occlusion accompanied by positive testing of serum antineutrophil cytoplasmic antibodies (c-ANCA)]. Ophthalmologe 2009; 105:1150-3. [PMID: 18551296 DOI: 10.1007/s00347-008-1770-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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30
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Vischio JA, McCrary CT. Orbital Wegener’s granulomatosis: a case report and review of the literature. Clin Rheumatol 2008; 27:1333-6. [DOI: 10.1007/s10067-008-0949-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 05/12/2008] [Accepted: 06/04/2008] [Indexed: 11/28/2022]
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31
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Arikan G, Saatci AO, Biberoglu K, Kupelioglu A. Intravitreal triamcinolone acetonide injection in CRVO associated with Wegener's granulomatosis. Ophthalmic Surg Lasers Imaging Retina 2007; 38:229-32. [PMID: 17552390 DOI: 10.3928/15428877-20070501-08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 33-year-old man developed unilateral non-ischemic central retinal vein occlusion associated with systemic Wegener's granulomatosis. Four milligrams of triamcinolone acetonide was injected intravitreally twice 6 months apart in conjunction with ongoing systemic immunosuppressive therapy. No change was made in the systemic immunosuppressive regimen. Wegener's granulomatosis should be considered in the differential diagnosis of central retinal vein occlusion in the young age group and intravitreal triamcinolone acetonide is a good adjunct to systemic immunosuppressive therapy that eliminates the need for modifying the systemic treatment regimen.
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Affiliation(s)
- Gul Arikan
- Department of Ophthalmology, Dokuz Eylul University School ofMedicine, Izmir, Turkey
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32
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McClintock SD, Barron AG, Olle EW, Deogracias MP, Warner RL, Opp MR, Johnson KJ. Role of interleukin-6 in a glucan-induced model of granulomatous vasculitis. Exp Mol Pathol 2007; 82:203-9. [PMID: 17222822 DOI: 10.1016/j.yexmp.2006.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Accepted: 07/07/2006] [Indexed: 10/23/2022]
Abstract
The role of interleukin-6 (IL-6) in granulomatous vasculitis is not well understood. To investigate its involvement in this type of vasculitis a model of glucan-induced pulmonary vasculitis employed interleukin-6 deficient (IL-6-/-) mice. Briefly, IL-6-/- mice and C57B/J6 wild type (IL-6+/+) mice were injected intravenously with a suspension of glucan isolated from the cell wall of bakers yeast which results in a granulomatous vasculitis primarily in the pulmonary vasculature. Histological examination demonstrated no significant difference in the number of infiltrating leukocytes between the IL-6+/+ and IL-6-/- glucan-injured mice. Similar numbers of granulomas were noted in both the IL-6+/+ and IL-6-/- injured animals, while no granulomas were seen in saline injected control mice. Cells recovered from the bronchoalveolar lavage (BAL) fluid were differentially stained and counted. While there was a significant increase in infiltrating leukocytes recovered from the BAL following glucan-induced injury, there was no significant difference between the IL-6+/+ and IL-6-/- mice. In addition, no difference was demonstrated in total protein content in the BAL fluid between IL-6+/+ and IL-6-/- mice. However, myeloperoxidase (MPO) activity in the lungs of the IL-6-/- mice was less than in their IL-6+/+ counterparts suggesting that these animals have a partial defect in their ability to recruit neutrophils in this model. Studies done to look for levels of other cytokines/chemokines in these animals to compensate for the loss of IL-6 revealed that only IL-10 in the sera (p<0.016) and BAL fluid (p<0.05) of IL-6-/- mice was significantly higher then their IL-6+/+-injured counterparts. These studies suggest that IL-6, while possibly involved in early neutrophil accumulation in this model does not appear critical to the development of the TH-2 mediated granulomatous vasculitis.
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Affiliation(s)
- Shannon D McClintock
- Department of Pathology, University of Michigan Medical School, 7520 MSRB I, 1301 Catherine Rd., Ann Arbor, MI 48109, USA
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34
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Wang M, Khurana RN, Sadda SR. Central retinal vein occlusion in Wegener's granulomatosis without retinal vasculitis. Br J Ophthalmol 2006; 90:1435-6. [PMID: 17057178 PMCID: PMC1857486 DOI: 10.1136/bjo.2006.095703] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Aristodemou P, Stanford M. Therapy insight: The recognition and treatment of retinal manifestations of systemic vasculitis. ACTA ACUST UNITED AC 2006; 2:443-51. [PMID: 16932736 DOI: 10.1038/ncprheum0268] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Accepted: 06/29/2006] [Indexed: 11/09/2022]
Abstract
A variety of retinal signs can occur in patients who have systemic vasculitides, or who experience complications of these diseases or their treatment. Although treatment of these retinal manifestations is usually the treatment of the systemic disease, specific treatment is occasionally indicated to preserve vision. The more prevalent of the systemic vasculitides are giant cell arteritis, polyarteritis nodosa, Wegener's granulomatosis, Churg-Strauss syndrome, relapsing polychondritis and systemic lupus erythematosus. Less frequently occurring vasculitides include Takayasu's arteritis, Goodpasture's disease, microscopic polyangiitis and Henoch-Schönlein purpura, as well as vasculitis secondary to scleroderma and rheumatoid arthritis. This article describes the pathogenesis, clinical features and treatment of retinal manifestations of systemic vasculitides.
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36
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Pakrou N, Selva D, Leibovitch I. Wegener’s Granulomatosis: Ophthalmic Manifestations and Management. Semin Arthritis Rheum 2006; 35:284-92. [PMID: 16616151 DOI: 10.1016/j.semarthrit.2005.12.003] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To provide an up-to-date and comprehensive review of Wegener's granulomatosis (WG) as a disease entity, focusing on the ophthalmic manifestations and management options. METHODS A search of Medline was undertaken between 1966 and 2005 regarding WG, systemic vasculitis, and the ocular manifestations of WG. Major ophthalmic and medical textbooks also were reviewed for content, as well as original references. RESULTS Involvement of ocular and orbital structures in patients with WG is common and may be a presenting feature. The ocular manifestations range from mild conjunctivitis and episcleritis to more severe inflammation with keratitis, scleritis, uveitis, and retinal vasculitis. Involvement of the nasolacrimal system and orbital tissues also can occur. Except for some cases of anterior segment inflammation, the ocular involvement will not respond to topical agents, but rather to systemic antiinflammatory and immunosuppressive regimens. Surgical intervention may be of value for obtaining tissue diagnosis, in achieving orbital decompression in cases of significant orbital disease with optic nerve compromise, or in cases of nasolacrimal duct obstruction. CONCLUSION WG is an important clinical entity that needs to be recognized early and treated appropriately. Ophthalmic manifestations are frequently encountered and can result in significant morbidity and even blindness. The management is challenging and often requires a multidisciplinary approach.
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Affiliation(s)
- Nima Pakrou
- Department of Ophthalmology and Visual Sciences, Royal Adelaide Hospital, Adelaide, Australia
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37
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de Silva DJ, Cole C, Luthert P, Olver JM. Masked orbital abscess in Wegener's granulomatosis. Eye (Lond) 2006; 21:246-8. [PMID: 16410813 DOI: 10.1038/sj.eye.6702211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Two patients with chronic Wegener's granulomatosis presented with worsening proptosis and visual acuity. Both patients had been maintained on long-term corticosteroids, which led to masking of the signs of orbital sepsis with potentially life-threatening implications.
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Affiliation(s)
- D J de Silva
- Oculoplastic and Orbital Service, Western Eye Hospital, London, UK
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38
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Toh T, Cooper RL, Parker A, Vote BJ. Wegener's granulomatosis presenting with painless bulbar-conjunctival ulcer and central retinal artery occlusion. Clin Exp Ophthalmol 2006; 34:51-3. [PMID: 16451259 DOI: 10.1111/j.1442-9071.2006.01144.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Herein an unusual case of Wegener's granulomatosis with a painless, bulbar-conjunctival ulcer in the right eye is reported. Rapid disease progression occurred with central retinal artery occlusion in the fellow eye. Biopsy of the diseased conjunctiva confirmed the clinical diagnosis. The clinical and histopathological findings are discussed.
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Affiliation(s)
- Tze'Yo Toh
- The Eye Hospital, 262 Charles Street, Launceston, Tasmania 7250, Australia
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39
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Jordan DR, Zafar A, Brownstein S, Faraji H. Cicatricial Conjunctival Inflammation With Trichiasis as the Presenting Feature of Wegener Granulomatosis. Ophthalmic Plast Reconstr Surg 2006; 22:69-71. [PMID: 16418677 DOI: 10.1097/01.iop.0000196321.02011.c5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Wegener granulomatosis has a variety of uncommon initial presentations. Although conjunctival involvement in this condition is rare, the diagnosis of Wegener granulomatosis should be suspected when the conjunctival inflammation is recurrent and not typical of other conjunctival inflammatory conditions.
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Affiliation(s)
- David R Jordan
- University of Ottawa Eye Institute, The Ottawa Hospital, Ontario, Canada.
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40
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Thorne JE, Jabs DA. Rheumatic Diseases. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50081-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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41
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Talar-Williams C, Sneller MC, Langford CA, Smith JA, Cox TA, Robinson MR. Orbital socket contracture: a complication of inflammatory orbital disease in patients with Wegener's granulomatosis. Br J Ophthalmol 2005; 89:493-7. [PMID: 15774931 PMCID: PMC1772590 DOI: 10.1136/bjo.2004.050039] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To describe the clinical characteristics of orbital socket contracture in patients with Wegener's granulomatosis (WG). METHODS A retrospective cohort study The medical records of 256 patients with WG examined at the National Institutes of Health from 1967 to 2004 were reviewed to identify patients with orbital socket contracture. Details of the orbital disease including Hertel exophthalmometry readings, radiological findings, and results of eye examinations were recorded. Orbital socket contracture was defined as orbital inflammation with proptosis followed by the development of enophthalmos and radiographic evidence of residual fibrotic changes in the orbit. To examine for risk factors in the development of a contracted orbit, patients with orbital socket contracture were compared to patients without contracture with respect to multiple variables including history of orbital surgery, orbital disease severity, and major organ system involvement. The main outcome measures were the clinical characteristics of orbital socket contracture associated with inflammatory orbital disease in patients with WG. RESULTS Inflammatory orbital disease occurred in 34 of 256 (13%) patients and detailed clinical data on 18 patients were available and examined. Orbital socket contracture occurred during the clinical course in six patients; the features included restrictive ophthalmopathy (five), chronic orbital pain (three), and ischaemic optic nerve disease (two) resulting in blindness (no light perception) in one patient. The orbital socket contracture occurred within 3 months of treatment with immunosuppressive medications for inflammatory orbital disease in five patients and was not responsive to immunosuppressive medications. The median degree of enophthalmos in the contracted orbit compared with the fellow eye was 2.8 mm (range 1.5-3.5 mm) by Hertel exophthalmometry. There were no risk factors that predicted development of orbital socket contracture. CONCLUSIONS In six patients with WG and active inflammatory orbital disease, orbital socket contracture occurred during the treatment course with systemic immunosuppressive medications. The orbital socket contracture, presumably caused by orbital fibrosis, led to enophthalmos, restrictive ophthalmopathy, chronic orbital pain, and optic nerve disease and was not responsive to immunosuppressive therapy. Orbital socket contracture has not been previously reported as a complication of inflammatory orbital disease associated with WG and was an important cause of visual morbidity in our cohort of patients.
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Affiliation(s)
- C Talar-Williams
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892, USA.
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Peng YJ, Fang PC, Huang WT. Central retinal artery occlusion in Wegener's granulomatosis: a case report and review of the literature. Can J Ophthalmol 2005; 39:785-9. [PMID: 15696772 DOI: 10.1016/s0008-4182(04)80076-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yi-Jie Peng
- Department of Ophthalmology and Pathology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Costello F, Gilberg S, Karsh J, Burns B, Leonard B. Bilateral Simultaneous Central Retinal Artery Occlusions in Wegener Granulomatosis. J Neuroophthalmol 2005; 25:29-32. [PMID: 15756130 DOI: 10.1097/00041327-200503000-00008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 46-year old woman developed simultaneous central retinal artery occlusions (CRAOs) in Wegener granulomatosis (WG). She had presented six years earlier with xerostomia, skin rash, and arthralgias and received a diagnosis of Sjogren syndrome. Anti-neutrophilic cytoplasmic antibody (ANCA) was negative. Months prior to the CRAOs, she had developed hearing loss, proptosis, and scleritis that were not responsive to prednisone 50 mg/d. The CRAOs occurred while she was being treated at this dose level. ANCA was now positive. This is the 12th case of CRAO in WG and the 6th case of bilateral CRAOs reported in the English literature. It emphasizes that serious irreversible visual complications may occur even when the patient is being treated with substantial corticosteroid doses.
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Affiliation(s)
- Fiona Costello
- The Ottawa Hospital, Department of Ophthalmology, University of Ottawa, Ottawa, Ontario, Canada.
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Abstract
Systemic inflammatory diseases commonly affect the sclera, cornea, retina, and orbit, and can pose a serious threat to sight. They encompass both primary and secondary vasculitic disorders and specific granulomatous inflammatory conditions. As well as direct eye involvement from the systemic inflammatory process, there can be signs of ocular ischaemia due to carotid or ophthalmic arteritis, hypertensive retinopathy, and ocular complications such as chloroquine maculopathy related to anti-inflammatory drug treatment. Additionally, systemic infection relating to the eye, either as the result of primary infective disease processes or infection secondary to immunosuppression, might be mistaken as endogenous intraocular inflammation. Infection can closely mimic the ocular signs of endogenous inflammation, and in selected patients (such as those who have been immunosuppressed to treat vasculitis and who additionally have had invasive surgery, indwelling intravenous catheters, or systemic sepsis), it might be necessary to specifically exclude infection by the sampling and culturing of intraocular fluids and tissue.
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Affiliation(s)
- Peter McCluskey
- Department of Ophthalmology at St Vincent's Hospital and Royal Prince Alfred Hospital, Sydney, Australia.
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45
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Ziakas NG, Boboridis K, Gratsonidis A, Hatzistilianou M, Katriou D, Georgiadis NS. Wegener's granulomatosis of the orbit in a 5-year-old child. Eye (Lond) 2004; 18:658-60. [PMID: 14716328 DOI: 10.1038/sj.eye.6700734] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Weijtens O, Mooy N, Paridaens D. Horner's syndrome as manifestation of Wegener's granulomatosis. Eye (Lond) 2004; 18:846-8. [PMID: 14976543 DOI: 10.1038/sj.eye.6701324] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Robinson MR, Lee SS, Sneller MC, Lerner R, Langford CA, Talar-Williams C, Cox TA, Chan CC, Smith JA. Tarsal-conjunctival disease associated with Wegener's granulomatosis. Ophthalmology 2003; 110:1770-80. [PMID: 13129876 DOI: 10.1016/s0161-6420(03)00616-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To describe the clinical characteristics of tarsal-conjunctival disease in a cohort of patients with Wegener's granulomatosis (WG). DESIGN Retrospective, case-controlled study. PARTICIPANTS The medical records of 82 consecutive WG patients who underwent an eye examination between January 1996 and June 2002 at the National Institutes of Health were reviewed. METHODS Details of the ophthalmic examination, results of medical therapy, and histopathologic analysis results were recorded. Tarsal-conjunctival disease was defined by (1). conjunctival hyperemia and granuloma formation, areas of necrosis, or active fibrovascular changes in the tarsus or conjunctiva, or (2). evidence of inactive fibrovascular scar. The association of tarsal-conjunctival disease with major organ system involvement was assessed using Bayesian methods. MAIN OUTCOME MEASURES The occurrence and clinical characteristics of tarsal-conjunctival disease in a cohort of patients with WG and associations with major organ system involvement. RESULTS Tarsal-conjunctival disease occurred in 13 of 82 patients (16%) with WG examined over a 6.5-year period. The palpebral surface of the upper lid was involved most commonly, showing conjunctival hyperemia in seven patients, granulomatous lesions in three patients, tarsal-conjunctival necrosis in four patients, active fibrovascular proliferation in six patients, and inactive fibrous scar tissue in seven patients. Histopathologic analysis of eyelid biopsy specimens showed granulomatous inflammation, focal necrosis, and areas of occlusive vasculitis in the tarsus and conjunctiva. In reviewing the patterns of organ involvement in patients with and without tarsal-conjunctival disease, the association of subglottic stenosis and nasolacrimal duct obstruction with tarsal-conjunctival disease showed a high probability of clinical significance. CONCLUSIONS Tarsal-conjunctival disease, a previously uncommon finding in patients with WG, was characterized by inflammation of the palpebral conjunctiva and tarsus followed by a fibrovascular proliferation and scar formation. Because of the important association of tarsal-conjunctival disease with subglottic stenosis, which can progress and lead to laryngeal obstruction and respiratory failure, patients with tarsal-conjunctival disease should be referred to an otolaryngologist for evaluation.
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Affiliation(s)
- Michael R Robinson
- National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA.
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Cockerham KP, Cockerham GC, Brown HG, Hidayat AA. Radiosensitive orbital inflammation associated with temporal arteritis. J Neuroophthalmol 2003; 23:117-21. [PMID: 12782922 DOI: 10.1097/00041327-200306000-00002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 75-year-old woman developed acute loss of vision in the OD, ipsilateral periocular pain, an afferent pupillary defect, sectoral optic disc edema, and later ipsilateral proptosis and an intraconal mass. She denied any symptoms of temporal arteritis, and a sedimentation rate was normal. Orbital biopsy demonstrated chronic granulomatous inflammation with perivasculitis. A temporal artery biopsy disclosed findings consistent with temporal arteritis. Following 2000 cGy of external beam radiation, her visual function and orbitopathy completely resolved. This unusual presentation of orbital inflammation in association with temporal arteritis demonstrates that pathologic findings of temporal arteritis may be clinically nonspecific and that external beam radiation may be an effective therapy in this setting.
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Affiliation(s)
- Kimberly P Cockerham
- Allegheny Ophthalmic and Orbital Associates, 420 East North Avenue, Suite 116, Pittsburgh, PA 15212, USA.
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Affiliation(s)
- Leonard A Levin
- Department of Ophthalmology and Visual Sciences, University of Wisconsin Medical School, 600 Highland Avenue, Madison, WI 53792, USA
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Soheilian M, Bagheri A, Aletaha M. Dacryoadenitis as the earliest presenting manifestation of systemic Wegener's granulomatosis. Eur J Ophthalmol 2002; 12:241-3. [PMID: 12113573 DOI: 10.1177/112067210201200313] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To report a case presenting with dacryoadenitis as the earliest manifestation of systemic Wegener's granulomatosis (WG). DESIGN Observational case report. METHODS A 41-year-old woman initially presented symptoms of bilateral dacryoadenitis. She subsequently developed upper and lower respiratory tract involvement, scleritis and keratitis. RESULTS Cytoplasmic antineutrophil antibody (c-ANCA) titer was positive. The lacrimal gland and lung biopsies were consistent with WG. The patient responded well to cyclophosphamide and prednisolone. CONCLUSIONS Dacryoadenitis maybe the earliestpresenting manifestation of WG andprompt immunosuppressive chemotherapy may control it preventing the limited disease from progressing to a complete form and reducing its morbidity and mortality.
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Affiliation(s)
- M Soheilian
- Ophthalmology Department and Eye Research Labbafinejad Medical Center, Shaheed Beheshti University of Medical Sciences, Tehran, Iran.
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