Australasian orbital and adnexal Wegener's granulomatosis

The globe: infection, inflammation, and systemic disease

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.

Ocular manifestations of ANCA-associated vasculitis

The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides-Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome-can present with various ophthalmic manifestations. In a subset of patients, these findings may be the earliest indicators of systemic disease. Orbital and anterior segment findings are most common, whereas posterior segment complications such as retinal vasculitis and optic neuropathy occur much less frequently. This article describes the distinguishing features of associated ophthalmic disease, focusing on the manifestations clinicians are most likely to encounter and those with the most significant ocular morbidity. Although the ANCA-associated vasculitides require systemic workup and treatment, this article discusses diagnostic and therapeutic modalities often used concurrently for ophthalmic disease.

Wegener's granulomatosis: clinical manifestations, differential diagnosis, and management of ocular and systemic disease

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.

Ocular disease in patients with ANCA-positive vasculitis

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.

Wegener granulomatosis causing compressive optic neuropathy in a child

Wegener granulomatosis is an uncommon illness in children that is known to cause myriad ophthalmic complications, but it is rarely a cause of compressive optic neuropathy. A 17-year-old Hispanic boy with Wegener granulomatosis developed unilateral loss of vision, pain, and proptosis of the left eye. CT findings revealed enlargement of bilateral lacrimal glands with compression of the left optic nerve. The patient was admitted for high-dose intravenous corticosteroids and daily oral cyclophosphamide treatment. The patient's vision, pain, and proptosis improved dramatically, and he is now stable on mycophenolate mofetil and prednisone.

[Inflammatory diseases of the orbit]

Inflammatory conditions belong to the most important diseases of the orbit. Children and adolescents are mostly affected and the most common cause is secondary pathogen invasion from acute sinusitis. However in adults most cases involve idiopathic orbital inflammation, previously termed pseudotumor orbitae. Clinical presentation may include painful exophthalmus, skin redness and warming, chemosis and disturbed eye motility. The challenge for imaging investigations, mainly a combination of CT scanning and MRI, is to distinguish inflammatory from malignant conditions, to define the extent of lesions and to document possible complications, such as cavernous sinus thrombosis, meningoencephalitis or cerebral abscesses. Serious potential consequences of orbital infections, including loss of vision or death, are still a risk factor and must be averted by avoidance of delays in diagnosis and appropriate clinical management.

Superior oblique myositis as an early feature of orbital Wegener's granulomatosis

A 66-year-old female presented with a 6-month history of increasing right-sided facial pain and diplopia. Right ocular movements were restricted in adduction and downgaze. Superior oblique (SO) enlargement was seen on an initial MRI scan, and subsequent diffuse infiltration was seen on a repeat scan. An elevated cANCA and biopsy of SO confirmed Wegener's granulomatosis (WG). We report a case of SO myositis as a predominant early feature of WG granulomatosis and review the literature regarding extraocular muscle involvement in WG. To our knowledge, early SO involvement has not been reported.

Non-traumatic enophthalmos: a review

Enophthalmos can be defined as a relative, posterior displacement of a normal-sized globe in relation to the bony orbital margin. Non-traumatic enophthalmos has a wide variety of clinical presentations and may be the first manifestation of a number of local or systemic conditions. It may present with cosmetic problems such as deep superior sulcus, pseudoptosis or eyelid retraction; or functional problems such as diplopia or exposure keratopathy. There are three main pathogenic mechanisms: structural alterations in the bony orbit; orbital fat atrophy; and retraction. Evaluation of enophthalmos patients includes orbital imaging and a thorough ophthalmic and systemic examination. In this review, we discuss the presenting features of non-traumatic enophthalmos and include a brief description of the more important causes. An approach to the clinical evaluation of these patients is also discussed together with a brief overview of the principles of management.

Orbital inflammatory disease: a diagnostic and therapeutic challenge

The spectrum of orbital inflammatory disease (OID) ranges broadly from specific disease diagnoses, for example, Wegener's granulomatosis or sarcoidosis, to nonspecific inflammation which may involve one or multiple structures of the orbit. Mimics of idiopathic OID must be considered in a comprehensive differential diagnosis and include malignancies, congenital mass lesions, infectious diseases, and occult or distant trauma. Idiopathic OID may be secondary to an underlying systemic inflammatory disease, which must be diagnosed in order to develop a comprehensive therapeutic plan, or may represent localized pathologic processes without systemic involvement. Evaluation of the patient with suspected OID must include a careful history, physical examination, directed laboratory, and radiologic studies, and may sometimes require tissue for diagnostic studies. Therapeutic options for inflammatory diseases are expanding as biologically targeted agents become available that act on specific segments of the inflammatory cascades. The purpose of this paper is to provide a framework for the evaluation and management of patients with the spectrum of diseases known as OID and to discuss some of the new advances in immunologic monitoring and targeted immune therapies that will likely play an increasingly important role in the care of these patients.

Diagnosis of limited ophthalmic wegener granulomatosis: distinctive pathologic features with ANCA test confirmation

PURPOSE

To describe the clinical and histopathologic finding of very limited ophthalmic Wegener granulomatosis (WG).

METHODS

Thirteen patients with scleritis, orbitopathy, episcleritis, and panuveitis were studied. They presented without evidence of lung or kidney disease, though eight had sinus involvement. We reviewed the biopsies for histopathologic findings consistent with WG, and tested for antineutrophil cytoplasmic antibodies antineutrophil cytoplasmic antibody (ANCA).

RESULTS

WG was suggested by granulomatous foci, collagen necrosis, neutrophils/nuclear dust, plasma cells and infiltrating eosinophils. Granular degeneration of the interstitial collagen; mummification of the collagen with disappearance of fibroblastic nuclei; and a polymorphous infiltrate exhibiting plasma cells, lymphocytes, neutrophils, and eosinophils within the epithelioid granulomas should suggest the diagnosis. ANCA test results supported the diagnosis of WG in all cases.

CONCLUSION

The described histologic characteristics are highly suggestive of WG. These findings along with clinical or laboratory findings, allow the diagnosis of very limited ophthalmic WG in the absence of systemic involvement.

Pharmacological therapy for Wegener's granulomatosis

Wegener's granulomatosis (WG) is the most common pulmonary granulomatous vasculitis and was a uniformly fatal disease prior to the identification of efficacious pharmacological regimens. The pathogenesis of WG remains elusive but proteinase 3-specific anti-neutrophil cytoplasmic antibodies may be involved. Histologically, WG is defined by the triad of small vessel necrotising vasculitis, 'geographic' necrosis and granulomatous inflammation. Organ involvement characteristically includes the upper and lower respiratory tracts and kidney, but virtually any organ can be involved. The severity of the disease varies, ranging from asymptomatic disease to fulminant, fatal vasculitis. Similarly, the degree of organ involvement is highly variable; WG may be limited to a single organ (typically the lungs or upper respiratory tract), or may be systemic. Currently, a regimen consisting of daily cyclophosphamide and corticosteroids, which induces complete remission in the majority of patients, is considered standard therapy. Since approximately 50% of patients experience a relapse following discontinuation of therapy, alternative regimens designed to maintain remissions after using cyclophosphamide and corticosteroids are usually necessary. This 'induction maintenance' approach to treatment has emerged as a central premise in planning therapy for patients with WG.A number of trials have evaluated the efficacy of less toxic immunosuppressants (e.g. methotrexate, azathioprine, mycophenolate mofetil) and antibacterials (i.e. cotrimoxazole [trimethoprim/sulfamethoxazole]) for treating patients with WG, resulting in the identification of effective alternative regimens to induce or maintain remissions in certain sub-populations of patients. Given the efficacy of methotrexate (for early systemic WG) and cotrimoxazole (in WG limited solely to the upper airways) to induce remissions, and the relatively decreased associated morbidity compared with cyclophosphamide, these alternative regimens are preferred in appropriate patients. Similarly, therapeutic options to maintain disease remission that are less toxic than cyclophosphamide should be offered following induction of remission unless a specific contraindication exists. By following this premise, the development of cyclophosphamide-induced morbidities (e.g. haemorrhagic cystitis, uroepithelial cancers and prolonged myelosuppression) may be minimised. Recent investigation has focussed on other immunomodulatory agents (tumour necrosis factor-alpha inhibitors [infliximab and etanercept] and anti-CD20 antibodies [rituximab]) for treating patients with WG. However, the current data are conflicting and difficult to interpret. As a result, these newer agents cannot be recommended for routine use until vigorous clinical study confirms their efficacy.

Wegener’s Granulomatosis: Ophthalmic Manifestations and Management

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.

Masked orbital abscess in Wegener's granulomatosis

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.

Orbital Eosinophilic Angiocentric Fibrosis

OBJECTIVES

To report a patient with a rare case of orbital eosinophilic angiocentric fibrosis (EAF) and to review the literature.

DESIGN

Interventional case report.

METHODS

A 61-year-old man presented with a 6-week history of right periorbital edema and painless proptosis. Examination revealed a nonaxial proptosis, lateral globe displacement, and mild limitation in right eye adduction.

MAIN OUTCOME MEASURES

Clinical course and radiological and histological findings.

RESULTS

Orbital imaging revealed a right medial orbital mass with involvement of middle ethmoidal air cells. An orbital biopsy of the mass demonstrated an inflammatory infiltrate with a marked eosinophilic component, onion skinning of vessels, and surrounding fibrosis. The diagnosis of orbital EAF was made. There was no response to a 3-month treatment course with systemic steroids, but the patient did not want any further surgical interventions.

CONCLUSION

Although orbital EAF is rare, ophthalmologists need to be aware of this entity, as it may invade the orbit from the sinonasal tract or present as a localized orbital mass. The presence of even minimal sinus involvement and the characteristic histopathology are useful in establishing the correct diagnosis.

Orbital socket contracture: a complication of inflammatory orbital disease in patients with Wegener's granulomatosis

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.

Vasculitis of the Lacrimal Sac Wall in Wegener Granulomatosis

A 35-year-old woman with a 4-year history of generalized Wegener granulomatosis (WG) had clinically controlled disease. She was evaluated for a 6-month history of right lacrimal sac mass. On examination, a right chronic dacryocystitis and mucocele were observed. A right external dacryocystorhinostomy was performed. The surgical biopsy specimen from the lacrimal sac showed leukocytoclastic vasculitis with more aggressive damage to the small vessels in the deeper mucosa and focal microhemorrhages. The patient was free of symptoms 1 year after surgery. We believe this is the first report of generalized WG presenting features of an active vasculitis of the lacrimal sac wall on surgical biopsy specimen. We conclude that the lacrimal drainage system can be affected directly by focal WG vasculitis, suggesting that nasolacrimal duct obstruction is not always due to contiguous paranasal disease.

Orbital inflammation

Orbital inflammation is a common problem in adults and children, accounting for the majority of all orbital processes. The presentation may be acute, subacute, or insidious. When the onset is acute, the process can be mistaken for orbital cellulitis. In insidious cases, such as the sclerosing subtype of inflammation, the chronic painless course may prompt concerns about a neoplastic infiltration such as lymphoma. Orbital inflammation can be divided into nonspecific, idiopathic, and other specific diagnoses. The differential diagnosis includes allergic, infectious (fungal, mycobacterial, and parasitic), and neoplastic (lymphoma or metastatic) disease. Orbital inflammation impacts neurologists and neuro-ophthalmologists because all of the entities can cause afferent dysfunction (decreased vision, abnormal color perception, afferent pupillary defect, and visual field defect) and dysmotility. The pattern of motility deficit may mimic the more familiar cranial nerve palsies. Advances in the diagnosis and management of nonspecific orbital inflammation and the specific entities that cause orbital inflammation are discussed.

Wegener's granulomatosis of the orbit: a clinicopathological study of 15 patients

OBJECTIVES

Wegener's granulomatosis is a granulomatous and necrotizing vasculitis that classically involves the respiratory and renal systems. The goal of the study was to define clinical and pathological characteristics in a subgroup of patients with the changes of Wegener's granulomatosis involving the orbit.

STUDY DESIGN

Retrospective study.

METHODS

A database search identified 15 patients with the histological changes of Wegener's granulomatosis of the orbit presenting over a 23-year period. A review of the histological specimens, radiological studies, and patient charts was performed. Additional follow-up data were obtained through patient interviews.

RESULTS

Of 15 patients (median age, 54 y) with Wegener's granulomatosis of the orbit identified, the disease was limited to the orbit in 12 patients; 3 patients had additional sinonasal involvement. All patients underwent various surgical procedures followed by medical treatment (cyclophosphamide and prednisone). Specimens showed characteristic histopathological features of Wegener's granulomatosis. Follow-up data were available for 12 patients with a median period of 5 years. In the group with only orbital involvement, none of the patients developed systemic progression of Wegener's granulomatosis. Only one patient had multiple local recurrences and later developed contralateral orbital Wegener's granulomatosis.

CONCLUSIONS

Wegener's granulomatosis limited to the orbit is a localized form of the disease without systemic progression. Diagnostic surgical procedures followed by aggressive medical treatment results in good outcome, although local recurrence may occur.

Conjunctival ulceration in recurrent Wegener granulomatosis

PURPOSE

To describe a patient with Wegener granulomatosis (WG) previously in remission who developed conjunctival ulceration as the first sign of disease recurrence.

METHODS

Case report and review of the literature.

RESULTS

Twenty-one years after WG was originally diagnosed and with the disease thought to be in remission, a 52-year-old man with complaints of ocular irritation for the previous year was found to have multiple palpebral conjunctival ulcerations of the left eye. Incisional biopsy revealed mixed inflammation consistent with WG. Within 3 months of recognition of his conjunctival ulcers, newly recurrent pulmonary inflammation developed and serologies for cytoplasmic-pattern antineutrophil cytoplasmic antibodies (C-ANCA) became positive.

CONCLUSION

Conjunctival ulceration is a rare manifestation of WG but may presage more widespread disease. Mucosal ulceration in a patient with a previous diagnosis of WG should stimulate an aggressive search for renewed systemic disease activity.