Wegener's granulomatosis

Vitreous hemorrhage from a ciliary granuloma associated with Wegener granulomatosis

PURPOSE

To report a case of vitreous hemorrhage from ciliary granuloma in Wegener granulomatosis.

METHODS

Interventional case report. An 18-year-old woman with Wegener granulomatosis and episcleral granuloma in her LE had ultrasound biomicroscopy findings of a mass in the pars plana of the ciliary body in the meridian corresponding to the episcleral granuloma.

RESULTS

The patient underwent vitrectomy in the LE for subsequent vitreous hemorrhage. Intraoperatively, the mass was diagnosed as a ciliary granuloma at the pars plana. Dense blood clotting around the ciliary granuloma and subretinal exudation at the ora serrata were observed, with no other changes causative for the vitreous hemorrhage.

CONCLUSIONS

We report a case of vitreous hemorrhage associated with a ciliary granuloma that was revealed by ultrasound biomicroscopy. Careful observation is necessary in eyes with persistent inflammation in Wegener granulomatosis.

Ocular manifestations of vasculitis

Systemic necrotizing vasculitis is characterized by inflammation of blood vessels and often affects the eyes. Ocular manifestations of vasculitis may involve any part of the eye or orbit. The frequency of ocular involvement generally is dependent on the size and type of blood vessels affected by the vasculitis. This article reviews the major types of ocular inflammation and then addresses the ocular manifestations of specific systemic vasculitides.

Australasian orbital and adnexal Wegener's granulomatosis

OBJECTIVE

To report a retrospective case series of 29 Australian and New Zealand patients with orbital and adnexal Wegener's granulomatosis (WG).

DESIGN

Retrospective case series.

PARTICIPANTS

Twenty-nine cases of orbital and adnexal WG were identified.

METHODS

A number of oculoplastic surgeons and other clinicians in Australia and New Zealand was asked about their experience with orbital and adnexal WG. Clinical data regarding these cases were conveyed by means of a questionnaire. Cases of ophthalmic WG without features of orbital or adnexal disease were excluded.

MAIN OUTCOME MEASURES

Data obtained from the questionnaire includes age, gender, limited or generalized disease, antineutrophil cytoplasmic antibody (ANCA) status, symptoms and signs: nasolacrimal obstruction, sinusitis, fistula/orbital bone erosion, orbital mass/proptosis, extraocular muscle/diplopia, visual acuity reduction caused by optic nerve compression, orbital pain, lid edema/erythema, biopsy status, and treatment status.

RESULTS

Twenty-nine patients with orbital and adnexal WG were identified and described. Symptoms included awareness of an orbital mass, epiphora, orbital pain and diplopia. Signs included an orbital mass or proptosis (69%), nasolacrimal duct obstruction (52%), limited ocular rotations (52%), lid erythema and edema (31%), bony destruction (21%), and reduced visual acuity (17%). Two patients had a persistent nasolacrimocanthal fistula. Cytoplasmic pattern antineutrophil cytoplasmic antibodies (c-ANCA) were present in 52% of patients, and in 9 of 10 patients with generalized disease. However, c-ANCA was positive in only 32% (6 of 19) of patients with limited WG. Perinuclear pattern antineutrophil cytoplasmic antibodies (p-ANCA) was positive in 10% of cases.

CONCLUSIONS

To diagnose and treat ophthalmic WG effectively, the clinician must be aware of its protean orbital and adnexal manifestations. WG may occur with or without systemic involvement, and c-ANCA was negative in approximately half our cases. Our cases also demonstrated two orbital fistulae, an observation previously believed to be rare.

Orbital involvement as the first manifestation in classic Wegener's granulomatosis

Wegener's granulomatosis (WG) is a chronic, focal, necrotizing granulomatous angiitis, which mainly affects the upper respiratory tract, the lungs and the kidneys. We present the case of a 26-year-old female patient complaining of pain and increasing swelling of the upper right eyelid with exophthalmos and diplopia as the first manifestation of a classic WG. Computer tomography revealed a homogeneous tumor arising from the right lacrimal gland. Chest x-ray revealed a tumor of the right lung. Microhematuria disclosed a slight renal involvement. Positive ANCA titer and C-ANCA anti-PR3, as well as a positive lung biopsy, confirmed the diagnosis of WG. Treatment with prednisone and cyclophosphamide was initiated. One year later, the patient's condition was good, and the ophthalmological examination was normal. WG should be considered in the differential diagnosis of an orbital tumor. In some rare cases, orbital disease can be the first clinical manifestation of the classic form of WG.

Advances in diagnosis, treatment, and management of orbital and periocular Wegener's granulomatosis

Ophthalmologists are often in a position to diagnose Wegener's granulomatosis and prevent significant morbidity. The past 2 years have seen advances in diagnosis and management strategies for this condition. Orbital magnetic resonance imaging and histologic profiles have been better characterized. Perhaps the greatest advance has been the recognition of promising therapeutic alternatives to the current standard cytotoxic protocol. Trimethoprim-sulfamethoxazole or methotrexate may be valuable in selected patients with limited forms of Wegener's granulomatosis. Finally, new insights into the mechanisms of disease activation and tissue injury may lead to better treatment and long-term prognosis.

Molecular approaches for identification of infectious agents in Wegener's granulomatosis and other vasculitides

The primary symptoms of many vasculitides resemble those of infectious diseases. Patients with Wegener's granulomatosis usually seek medical care for respiratory tract symptoms resembling those caused by infection or allergy. In addition, vasculitis is a well-documented manifestation of infection by some known microbial agents. There have been relatively few controlled studies, however, seeking to identify infectious agents as the triggering factors in systemic vasculitides. Molecular methods offer powerful approaches for the identification of infectious agents in diseases of previously unknown origin. These methods include broad-range amplification of microbial nucleic acid sequences and comparative or subtractive methods, such as differential display and representational difference analysis. Host gene expression profiles (using DNA-chip technology) may also provide clues as to the possible infectious cause of an idiopathic disease. Furthermore, the application of molecular methods may reveal pathologic mechanisms and novel therapeutic strategies for the vasculitides.