Ocular lesions in relapsing polychondritis and other rheumatoid syndromes. The Edward Jackson memorial lecture

The ocular manifestations of relapsing polychondritis

PURPOSE

Relapsing polychondritis (RPC) is a rare, multi-system, inflammatory disorder. Ocular disease is estimated to occur in 14-67% of patients with RPC, and any ocular structure can be affected. Published case reports and series of RPC were analysed to determine the frequency and nature of the ocular manifestations of RPC, including the age and gender distribution.

METHODS

A literature search of the MEDLINE database for case reports and series on RPC was conducted in October 2021 using search terms [relapsing polychondritis (MeSH Major Topic)] OR [relapsing polychondritis (Title/Abstract)]. Articles were included if the diagnosis of RPC was confirmed using established diagnostic criteria and if the paper described the clinical features of patients with RPC.

RESULTS

546 articles (454 case reports and 92 case series) described the clinical features in a total of 2414 patients with RPC. 49% of patients with RPC had ocular involvement, and this was a presenting feature in 21%. The most common ocular manifestations were scleritis (32%), episcleritis (31%) and uveitis (23%).

CONCLUSION

Many patients with RPC will be seen by an ophthalmologist during the course of their disease. Knowledge and awareness of RPC and its ocular manifestations is therefore essential to enable the ophthalmologist to make the diagnosis.

Aortic involvement in relapsing polychondritis: case-based review

Relapsing polychondritis is a systemic inflammatory disease that mainly affects ears, nose, eyes, joints, and large airway. Relapsing polychondritis may also affect cardiac valves and large vessels with the aorta being most frequently involved. We conducted a systematic literature review to delineate the clinical characteristics, treatment, and outcome of relapsing polychondritis patients with aortic involvement including thoracic and abdominal aorta, aortic valve, and coronary arteries. 113 patients reported in 85 manuscripts were retrieved through the systematic literature search and references of the selected manuscripts. With the addition of a patient from our center, a total of 114 patients were included in the analyses. Aortic vessel involvement was the predominant type of involvement that was identified in 93 (82%) patients, while aortic valve involvement was identified in 41 patients (36%). The median age at aortic involvement was 37 years [IQR: 30-53] with a delay of 5 years [IQR: 1-8] between first relapsing polychondritis symptom and aortic involvement. Nineteen percent of the patients were asymptomatic at the time of aortic involvement diagnosis. The initial treatment was immunosuppressives in 41 patients (56%) and surgery in 28 patients (38%). The mortality ratio was 27% in a 24 month follow-up [IQR: 7.5-54 months]. Aortic dissection or rupture was the most frequent causes of mortality. Concomitant coronary artery involvement suggested a worse outcome. Aortic involvement in relapsing polychondritis is a mortal complication despite medical and surgical treatments. It may be asymptomatic in 19% of the patients which warrants the importance of screening.

Optic Neuropathy Associated With Periostitis in Relapsing Polychondritis

Optic neuropathy is an uncommon manifestation of relapsing polychondritis (RPC), a rare systemic disease affecting cartilaginous and proteoglycan-rich structures. The optic neuropathy has been attributed to ischemia, intrinsic inflammation of the optic nerve, or spread of inflammation to the nerve from adjacent intraconal orbital tissues. We report a case of recurrent corticosteroid-responsive optic neuropathy in which MRI did not show ocular, optic nerve, or intraconal orbital abnormalities but did show periosteal thickening and enhancement in the apical orbit and adjacent intracranial space consistent with periostitis. The periostitis, which is a manifestation of a systemic vasculitis or an autoimmune reaction to progenitors of cartilage, probably caused the optic neuropathy by compression or inflammation. It is important to recognize this mechanism of optic neuropathy as its imaging features may be a subtle yet critical clue to an underlying systemic condition that can be life-threatening if not properly managed.

Anterior scleritis: three case reports and a review of the literature

BACKGROUND

Scleritis is a rare ocular condition involving vasculitis. It can result in severe ocular morbidity and has a high association with underlying systemic disease and mortality. Management can be challenging and under-diagnosis is a concern. Treatment usually requires systemic medications and co-management with a medical specialist in the appropriate field to manage any underlying systemic etiology.

METHODS

Three cases are presented: idiopathic nodular scleritis with complete recovery; bilateral, diffuse anterior scleritis with rheumatoid arthritis; and scleromalacia perforans treated with chemotherapeutic agents and co-managed with a rheumatologist. A search of the English language literature is reported, also.

RESULTS

The reported cases exemplify much of our knowledge regarding scleritis. The literature review focuses on the challenges of an accurate diagnosis and management. Management is challenging and, although standards exist, controversy remains. The literature discusses the relationship of scleritis to underlying systemic disease and the significant implication of this association.

CONCLUSION

Knowledge of scleritis may aid in determining a timely and accurate diagnosis and treatment of both the ocular and any underlying systemic conditions, thus decreasing morbidity and mortality.

Relapsing polychondritis: a clinical review

OBJECTIVE

This study comprehensively reviews the literature related to relapsing polychondritis (RP).

METHODS

A detailed search via MEDLINE (PubMed) was performed using relapsing polychondritis as the key term. Relevant articles were analyzed with a focus on history, epidemiology, etiology, pathogenesis, clinical manifestations, diagnosis, treatment, and prognosis of RP.

RESULTS

RP is a rare episodic and progressive inflammatory disease of presumed autoimmune etiology first described in 1923. RP affects cartilage in multiple organs, such as the ear, nose, larynx, trachea, bronchi, and joints. In addition, it can affect proteoglycan-rich tissues, such as the eyes, aorta, heart, and skin. The diagnosis of RP is based on the presence of clinical criteria. A standardized therapeutic protocol for RP has not been established. Nonsteroidal anti-inflammatory drugs, dapsone and/or colchicine, may control disease activity in some patients. In other patients, immunosuppressive drugs and prednisone have been effective. RP is a potentially lethal disease; pulmonary infection, systemic vasculitis, airway collapse, and renal failure are the most common causes of death. Earlier studies indicate survival rates between 70% at 4 years and 55% at 10 years. In a recent study, a survival rate of 94% at 8 years may be due to improved medical and surgical management.

CONCLUSIONS

RP is a rare, multisystemic, and potentially fatal disease. The pathogenesis and optimal therapeutic approach to patients with RP is poorly understood.

Exudative retinal detachment in relapsing polychondritis : case report and literature review

OBJECTIVE

To report the atypical ocular symptoms (arterialized conjunctival vessels, exudative retinal detachment) that can be the presenting manifestations of relapsing polychondritis.

DESIGN

Observational case report and literature review.

METHODS

A complete ocular and systemic evaluation was performed on a patient with relapsing polychondritis and exudative retinal detachment.

MAIN OUTCOME MEASURES

Retinal, choroidal, and scleral findings.

RESULTS

A 73-year-old man with relapsing polychondritis presented with a unilateral large bullous exudative retinal detachment and marked choroidal and scleral thickening bilaterally.

CONCLUSIONS

Ophthalmologists should consider relapsing polychondritis in the differential diagnosis of exudative retinal detachment. A combination of echographic and laboratory findings can assist in the accurate diagnosis of this rare condition.

Vasculitic peripheral ulcerative keratitis

The onset of peripheral ulcerative keratitis in the course of a connective tissue disorder, such as rheumatoid arthritis, relapsing polychondritis, or systemic lupus erythematosus, may reflect the presence of potentially lethal systemic vasculitis. Moreover, peripheral ulcerative keratitis may be the first sign of systemic necrotizing vasculitis in patients with Wegener's granulomatosis, polyarteritis nodosa, microscopic polyangiitis, or Churg-Strauss syndrome. Although the exact pathogenesis of this severe corneal inflammation and destruction is not well understood, evidence points to a dysfunction in immunoregulation with immune complexes formed in response to autoantigens or to some unknown microbial antigen depositing in scleral and limbal vessels. These events lead to changes that are mainly responsible for the resulting tissue damage. In pauci-immune vasculitides positive for antineutrophil cytoplasmic antibodies, cell-mediated cytotoxicity may play an important role in the pathogenesis of peripheral ulcerative keratitis. Untreated systemic conditions such as those mentioned above may carry a grave prognosis for the eye and may also be life-threatening. Immunosuppressive therapy with corticosteroids and cytotoxic agents is, we believe, mandatory in the treatment of these multisystem disorders associated with vasculitic peripheral ulcerative keratitis.

Ocular manifestations of relapsing polychondritis. Three case histories

Relapsing polychondritis is a rare, presumably inflammatory autoimmune disorder affecting cartilagenous structures throughout the body. The ears, nose, joints, eyes and the respiratory tract are most frequently involved. The main ocular manifestations are episcleritis and scleritis, conjunctivitis, iridocyclitis and chorioretinitis, cataract and corneal infiltrates and melting. Extraocular signs and symptoms often are indicative of the diagnosis. Therapy includes systemic steroids, immunosuppressive drugs and dapsone. Three case histories are reported and the literature of ocular manifestations of relapsing polychondritis is reviewed.

Scleritis in relapsing polychondritis. Response to therapy

The authors reviewed the records of 11 patients with relapsing polychondritis associated with active scleritis and analyzed the immunopathologic characteristics of ocular tissue from three of these. Seven patients (63%) required cytotoxic drugs, alone or in combination with low-dose oral corticosteroids. Only one patient was treated successfully with systemic corticosteroids alone. Two patients were controlled with dapsone and one with an oral nonsteroidal anti-inflammatory drug. Dapsone, which has been reported to be effective in the treatment of relapsing polychondritis, did not control the destructive scleral inflammation in six (75%) of eight patients; two (50%) of four patients with diffuse anterior scleritis were controlled with this drug. Patients with nodular and necrotizing scleritis were controlled with azathioprine and cyclophosphamide, respectively. These data suggest that the ocular manifestations of relapsing polychondritis, especially nodular and necrotizing scleritis, are less amenable to treatment with systemic corticosteroids and/or dapsone and that more potent immunosuppressants (azathioprine and cyclophosphamide) may be required to treat these lesions successfully. Results of histologic and immunofluorescent examination of conjunctival and/or scleral biopsy specimens from three patients confirmed the vasculitic nature of the eye lesions in this disease.

Peripheral corneal disorders

The peripheral cornea is anatomically and physiologically distinct from its central counterpart. The major differences relate to the gradual transition of corneal tissues to those of the conjunctiva, episclera, and sclera; furthermore, the vascular structures, lymphatics, and inflammatory cells from these neighboring structures are intimately associated with the limbus and periphery of the cornea. The peripheral cornea is thereby predisposed to three main classes of disorders which do not normally involve the central cornea. First, local conditions affecting the sclera and conjunctiva may secondarily spread to involve the limbus and peripheral cornea. These include several infectious diseases, as well as hypersensitivity conditions, mass lesions, and degenerations. Second, due to the associated blood vessels and lymphatics, the peripheral cornea may be involved in a variety of systemic diseases, including vasculitides, autoimmune disorders, and abnormal metabolic conditions. Finally, there are several conditions, such as the noninflammatory peripheral degenerations, which primarily affect the peripheral cornea without associated ocular or systemic changes. In this review, we present a classification and discussion of the various disorders which may involve the peripheral cornea.

Ocular and systemic findings in relapsing polychondritis

The ocular and systemic findings in 112 Mayo Clinic patients with relapsing polychondritis were reviewed. The incidence of males and females was equal, with median age at diagnosis of 51 years and the median follow-up of 6 years. Most patients had several organ systems involved at the time of the diagnosis. Twenty-one patients had ocular symptoms at the onset, and 57 developed ocular symptoms during their course. Major ocular complications included proptosis, lid edema, episcleritis/scleritis, corneal infiltrates/thinning, iridocyclitis, retinopathy, and optic neuritis. The major system involvement included otorhinolaryngeal, respiratory, arthritic, renal, cardiovascular, dermatologic, and neurologic diseases. Generally, laboratory studies were not helpful in making the diagnosis but were valuable in monitoring the disease. Based on the experience in these cases, the indications for the various therapeutic modalities are offered.

Ocular involvement in the respiratory vasculitides

The respiratory vasculitides are idiopathic inflammatory syndromes, characteristically involving the pulmonary vasculature as well as that of several other organ systems. The inflammatory response in these diseases is uniformly granulomatous. There are three distinct, recognized respiratory vasculitides: Wegener's granulomatosis, Churg-Strauss syndrome (allergic granulomatosis and angiitis), and lymphomatoid granulomatosis. Each of these entities may have ophthalmic manifestations, and ocular involvement may, in fact, be the presenting sign. The systemic and ocular manifestations, as well as the differential diagnosis and management of each of these entities are discussed.

Melting corneas with collapsing nose

A 31-year-old white woman with relapsing polychondritis presented with profound, diffuse episcleritis, marked conjunctival chemosis, and corneal-limbal inflammation and melting, which was refractory to corticosteroid treatment. With the initiation of chlorambucil the inflammation subsided, leaving an almost normal slit-lamp picture. The associated findings of nasal cartilage and pinna cartilage inflammation helped to establish the diagnosis of relapsing polychondritis in this patient.

Relapsing polychondritis: an ultrastructural study

Ear cartilage from a typical case of relapsing polychondritis was examined with the electron microscope. A large number of dense granules and vesicles, which were compatible with matrix vesicles or lysosomes, surrounded the affected chondrocytes. In less severely damaged chondrocytes, these granules and vesicles appeared to be formed by pinching off of the cytoplasmic processes or by budding from the processes. Calcification of the granules was minimal. In severely damaged chondrocytes, an admixture of these granules and cytoplasmic organelles occurred. It is speculated that many of these dense granules are lysosomal in nature and that they may produce inflammation and reduce the proteoglycan content of cartilage.

Multiple aortic aneurysms in relapsing polychondritis

A patient with relapsing polychondritis and thoracic and abdominal aortic aneurysms is described. The aortic changes were due to aortitis, which primarily involved the media, with increased vascularization, perviascular infiltration of mononuclear cells, increased amounts of collagen and decreased amounts of elastic tissue and sulfated acid mucopolysaccharides. Aortic aneurysms frequently occur in relapsing polychondritis; they are usually in the ascending aorta but may be multiple and involve the abdominal aorta; involvement of the ascending aorta results in aortic regurgitation and left ventricular failure, and involvement of the abdominal aorta may be clinically silent and result in fatal rupture.

Relapsing polychondritis. Electron microscopic study of ear cartilage

Light microscopic and for the first time electron microscopic (EM) studies of involved elastic ear cartilage in a patient with relapsing polychondritis confirm the superficial location of the inflammatory reaction. EM studies of deep cartilage were identical to those on controls except for a rare necrotic cell. Superficial cartilage showed a finely granular electron-dense material. This material, which may be protein, possibly of enzyme or immunoglobulin origin, also surrounded some elastic fibrils. Findings of predominantly superficial changes and the multisystem disease in the present patient and in many others suggest that the cartilage destruction is part of a systemic inflammatory disease.

Relapsing polychondritis and eye disease

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