Ocular manifestations and concepts of systemic vasculitides

Granulomatosis with Polyangiitis (GPA)-A Multidisciplinary Approach of a Case Report

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.

Choroidal involvement in systemic vasculitis: a systematic review

Systemic vasculitides are a large group of heterogeneous diseases characterized by inflammatory destruction of blood vessels targeting diverse organs and tissues including the eye. As the most vascularized layer of the eye, the choroid is expected to be affected in multiple systemic rheumatologic diseases with vascular involvement. While there are plenty of studies investigating retinal vascular involvement, choroidal vascular involvement in systemic vasculitides has not been investigated in isolation. However, choroidal manifestations including thickness changes, choroidal vasculitis and ischemia may be the earliest diagnostic features of systemic vasculitic diseases. Thus, multimodal imaging of the choroid may help early detection of choroidal involvement which may also have prognostic implications in these life-threatening diseases. This article aimed to review involvement of the choroid in systemic vasculitic diseases.

Evolving Chest Pain in a Young Male

A 33-year-old Hispanic male with a history of recent orchiectomy for suspected testicular cancer presented to the emergency department with worsening exertional chest pain and dyspnea in the setting of a 2-month history of diffuse myalgias and symmetric polyarthralgias.

Clinical features, visual outcome, and poor prognostic factors in occlusive retinal vasculitis

OBJECTIVE

To investigate the clinical features, treatment, and visual outcome of occlusive retinal vasculitis (ORV), with a focal analysis on prognostic factors associated with poor visual outcome.

METHODS

We conducted a retrospective cohort study in patients diagnosed with ORV with at least 6 months of follow-up. Demographic data, ocular features, best corrected visual acuity (BCVA), fluorescein angiography, therapy regimens, and outcomes were collected from the Massachusetts Eye Research and Surgery Institution database from 2006 to 2017. Multivariate logistic regression was performed to analyze the factors independently predicting poor visual outcome.

RESULTS

Fifty-two patients (69 eyes) were enrolled, 42 with noninfectious cause, 9 with infectious cause, and 1 with masquerade uveitis. Systemic inflammatory diseases, including necrotizing vasculitis, sarcoidosis, multiple sclerosis, systemic lupus erythematosus, and Behçet's disease comprised the causes of ORV. Forty of the 42 patients with noninfectious ORV received immunomodulatory therapy (IMT), and 35 patients (87.5%) were able to achieve steroid-free remission. Compared with the BCVA at the initial visit (0.66 [±0.11] logMAR), there was significant improvement at the most recent visit (0.37 [±0.07] logMAR, p = 0.001). A multivariate analysis demonstrated that optic nerve atrophy, macular ischemia, and poor BCVA at initial presentation were independently correlated with poor visual outcome.

CONCLUSIONS

ORV could be caused by a wide spectrum of systemic inflammatory diseases. Aggressive IMT is preferred to achieve a steroid-free durable remission for noninfectious ORV. Optic nerve atrophy, macular ischemia, and poor BCVA at the initial visit predict a poor visual outcome.

Health system wide "big data" analysis of rheumatologic conditions and scleritis

BACKGROUND

The development of scleritis in the setting of autoimmune conditions has been well documented. Prior series have assessed the relationship between systemic autoimmune disorders and scleritis only in patients referred for rheumatologic or ocular inflammation. This can lead to a referral bias. We reviewed all charts within the electronic medical record (EMR) of a health system for patients with systemic autoimmune and scleritis diagnoses to determine the prevalence of both and which disorders had the highest relative risk of developing scleritis.

METHODS

The EMR was searched for scleritis and systemic inflammatory diagnoses in the past medical history and diagnosis tabs, and for associated disease specific laboratory values. The intersection of scleritis and systemic inflammatory conditions was assessed through searching both SNOMED Clinical Terminology and ICD-10 codes for diagnoses. The prevalence of each autoimmune disorder, scleritis prevalence, the percentage of patients with an autoimmune condition having scleritis, the percentage of patients with scleritis having an autoimmune condition; the relative risk (RR) of scleritis patients having a specific autoimmune disorder were calculated.

RESULTS

A total of 5.9 million charts were searched with autoimmune conditions identified in 148,993 patients. The most common autoimmune conditions overall were HLA-B27-associated diseases (n = 26,680; prevalence 0.45%); rheumatoid arthritis (RA)(N = 19,923; prevalence 0.34%). Conversely, 2702 patients were identified with scleritis (prevalence 0.05%), of which 31.4% had an associated autoimmune condition. Patients with RA represented the highest percentage of patients with an autoimmune condition having scleritis. Granulomatosis with polyangiitis (GPA) represented the highest the percentage of patients with scleritis having an autoimmune condition. Sjogrens was the third most common condition associated with scleritis- making up 4.5% of cases. An association with juvenile idiopathic arthritis (JIA) was seen in 0.3% of patients.

CONCLUSIONS

While this is the largest retrospective review examining the association between autoimmune disease and scleritis, the findings are similar to prior studies with nearly a third of scleritis patients having an underlying autoimmune diagnosis. Limitations of the study included accurate chart coding; having laboratory results within the searchable EMR. Future research is needed to delineate associations of systemic disease with the anatomic location of scleritis using EMR.

Bilateral Anterior Ischaemic Optic Neuropathy as First Manifestation of Henoch-Schönlein Purpura (IgA Vasculitis)

A 46-year-old man was referred to our department complaining of a bilateral progressive decrease in his visual acuity. Fundus examination revealed bilateral optic disc oedema, indicative of anterior ischaemic neuropathy (AION), and a macular star in the right eye. Laboratory analysis showed low haematocrit and haemoglobin, elevated creatinine, and increased erythrocyte segmentation rate and C-reactive protein level. Physical examination revealed the presence of purpuric rash on the trunk and the extremities. During the investigation we performed a complete laboratory and imaging examination for autoimmune collagen diseases, vasculitides and infectious diseases, which were all negative. Histologic findings of renal biopsy were compatible with IgA glomerulonephritis and thus Henoch-Schönlein purpura (HSP) diagnosis was established. The patient was treated with methylprednisolone and cyclophosphamide. Six months later, his renal function and his visual acuity had improved, and the rash had subsided. This is a rare case of AION in a patient with HSP.

Corneal melt secondary to eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare antineutrophil cytoplasmic antibody-associated vasculitis that can affect any organ system. It is most often characterised by chronic airway inflammation along with prominent peripheral blood eosinophilia, although the disease can affect the cardiovascular, gastrointestinal, renal or central nervous systems. Ocular manifestations are uncommon and when they do occur, are varied in their clinical presentations. To the best of our knowledge, this is the first case of corneal melt secondary to EGPA to have been reported.

Characteristics and Visual Outcome of Refractory Retinal Vasculitis Associated With Antineutrophil Cytoplasm Antibody-Associated Vasculitides

PURPOSE

To describe the clinical characteristics, therapies, visual outcomes, and prognoses of patients with retinal vasculitis associated with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV).

DESIGN

Retrospective case series.

METHODS

Patients diagnosed with retinal vasculitis associated with AAV and at least 6 months of follow-up were included. Demographic data, systemic and ocular features, best-corrected visual acuity at the initial visit and latest visit, fluorescein angiography (FA) and indocyanine green angiography (ICGA) findings, therapy regimen, and outcome were collected from the Massachusetts Eye Research and Surgery Institution (MERSI) database from 2006 to 2017.

RESULTS

Fourteen patients (22 eyes) were identified. Twelve had granulomatosis with polyangiitis (GPA) and 1 each had microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). FA showed that AAV affected small-to-medium-size retinal vessels. Seven cases (50%) had both vein/venule and artery/arteriole involvement. Four cases co-presented with choroidal vasculitis. All of them failed various immunomodulatory therapies prior to referral to MERSI. Six patients received rituximab plus prednisone as their final therapy and 5 of them achieved remission. Four patients who failed cyclophosphamide previously were induced into remission by rituximab. Patients were followed for 33.4 ± 25.5 (range 6-84) months. Nine of 14 patients (64.3%) achieved remission at their latest visit. Seventeen of 22 eyes (77.3%) met the criteria for a good (≥20/40) visual outcome.

CONCLUSION

The majority of patients enjoyed a good visual outcome and achieved remission after aggressive treatment. Rituximab should be considered as an initial treatment for patients with refractory retinal vasculitis associated with AAV.

MICROVASCULAR FLOW ABNORMALITIES ASSOCIATED WITH RETINAL VASCULITIS: A Potential of Mechanism of Retinal Injury

PURPOSE

To investigate the structural optical coherence tomography and related microvascular flow characteristics in eyes with retinal vasculitis.

METHODS

Regions involved with perivascular infiltration in eyes with retinal vasculitis, but no evidence of large vessel occlusion were evaluated with optical coherence tomography (OCT), OCT angiography, and fluorescein angiography.

RESULTS

Ten eyes of 5 patients with a variety of etiologies of retinal vasculitis were evaluated. These patients did not have either cotton wool spots or deeper placoid areas of retinal ischemia. Around large vessels there was perivascular infiltration with leakage and staining seen during fluorescein angiography. Structural OCT showed slight thickening with loss of visualization of normal retinal laminations. OCT angiography showed a lack of flow signal in capillary sized vessels in the same areas. Treatment resulted in a rapid thinning of the affected areas, with the inner and middle layers of the retina becoming thinner than surrounding uninvolved areas. OCT angiography did not show a return of capillary perfusion in these regions. The thickness change in the structural OCT as shown by a heat map had a pattern mimicking the original perivascular infiltration around large retinal vessels.

CONCLUSION

Capillary level perfusion abnormalities can develop in regions adjacent to large vessel inflammatory infiltrate that result in retinal thinning without the development of usual stigmata of acute microvascular flow obstruction such as cotton wool spots. This suggests that retinal damage may occur in retinal vasculitis that would not be recognized without using OCT-based imaging modalities.

Optical coherence tomography angiography

Optical coherence tomography (OCT) was one of the biggest advances in ophthalmic imaging. Building on that platform, OCT angiography (OCTA) provides depth resolved images of blood flow in the retina and choroid with levels of detail far exceeding that obtained with older forms of imaging. This new modality is challenging because of the need for new equipment and processing techniques, current limitations of imaging capability, and rapid advancements in both imaging and in our understanding of the imaging and applicable pathophysiology of the retina and choroid. These factors lead to a steep learning curve, even for those with a working understanding dye-based ocular angiography. All for a method of imaging that is a little more than 10 years old. This review begins with a historical account of the development of OCTA, and the methods used in OCTA, including signal processing, image generation, and display techniques. This forms the basis to understand what OCTA images show as well as how image artifacts arise. The anatomy and imaging of specific vascular layers of the eye are reviewed. The integration of OCTA in multimodal imaging in the evaluation of retinal vascular occlusive diseases, diabetic retinopathy, uveitis, inherited diseases, age-related macular degeneration, and disorders of the optic nerve is presented. OCTA is an exciting, disruptive technology. Its use is rapidly expanding in clinical practice as well as for research into the pathophysiology of diseases of the posterior pole.

Optic Neuropathy Secondary to Polyarteritis Nodosa, Case Report, and Diagnostic Challenges

Purpose

To describe a case of optic neuropathy as a primary manifestation of polyarteritis nodosa (PAN) and discuss diagnostic challenges.

Methods

Case report.

Results

A 41-year-old Hispanic man presented with a 2-day history of reduced visual acuity in his left eye. Physical examination revealed a complete visual field loss in the affected eye. Best-corrected visual acuity (BCVA) in the left eye was hand motion, and fundus examination revealed a hyperemic optic disk with blurred margins, swelling, retinal folds, dilated veins, and normal size arteries. BCVA in the right eye was 20/20; no anomalies were seen during examination of the fundus. The patient was started on oral corticosteroids and once the diagnosis of PAN was made, cyclophosphamide was added to the treatment regimen. Six months later, the patient recovered his BCVA to 20/20 in his left eye.

Conclusion

Rarely does optic neuropathy present as a primary manifestation of PAN; nevertheless, it represents an ophthalmologic emergency that requires expeditious anti-inflammatory and immunosuppressive treatment to decrease the probability of permanent visual damage. Unfortunately, diagnosing PAN is challenging as it necessitates a high index of suspicion. In young male patients who present for the first time with diminished visual acuity, ophthalmologists become cornerstones in the suspicion of this diagnosis and should be responsible for continuing the study until a diagnosis is reached to ensure rapid commencement of immunosuppressive treatment.

Small-Caliber Retinal Vasculitis Associated With Giant Cell Arteritis: A New Finding

Giant cell arteritis (GCA) can present with cotton-wool spots in the retina and usually affects medium and large vessels. The authors present herein a 75-year-old man with GCA manifesting with cotton-wool spots and widespread retinal vasculitis affecting small-size retinal arterioles. The retinal vasculitis and the cotton-wool spots resolved after initiation of systemic corticosteroids and his vision returned to normal. GCA can uncommonly present with retinal vasculitis affecting small-size arterioles. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1054-1056.].

Ocular Inflammation in the Setting of Concomitant Systemic Autoimmune Conditions in an Older Male Population

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.

Bilateral retinal ischemic vasculopathy in a pregnant patient

PURPOSE

To present the case of a young Turkish pregnant patient with bilateral, sight-threatening retinal ischemic vasculopathy and systemic signs suggestive of Behçet disease (oral ulceration, arthritis, and pseudofolliculitis).

METHODS

Case report.

RESULTS

Multiple areas of superficial, retinal white lesions and few hemorrhages related to occlusions of small retinal vessels were observed at presentation in the macular zone of both eyes. There was gradual improvement of retinal lesions after the administration of corticosteroids and immunosuppressive treatment.

CONCLUSION

We report the case of a young pregnant patient with bilateral, sight-threatening retinal ischemic vasculopathy and systemic signs of Behçet disease. Although the systemic signs were highly suggestive of Behçet disease, the ocular presentation was unusual for this multisystemic inflammatory disorder. The differential diagnosis included a number of causes of ischemic retinal vasculopathy, such as systemic vasculitis, antiphospholipid syndrome, Susac syndrome, Purtscher-like retinopathy, and a new variant of acute macular neuroretinopathy (paracentral, acute middle maculopathy), which are further discussed.

[Ocular involvement in polyarteritis nodosa: two cases]

INTRODUCTION

Polyarteritis nodosa (PAN) is a systemic vasculitis with polymorphic manifestations. Ocular involvement is rare; we report two such cases.

CASES

The first case was a 56-year-old man with PAN treated with corticosteroids. A year and a half later, during a disease outbreak associated with decreased visual acuity, ocular examination objectified a localized pigment epithelial detachment in the right eye. The outcome was favorable with corticoid bolus followed by azathioprine. The second case was a 41-year-old man presenting with PAN and decreased visual acuity. Ophthalmologic examination showed inferotemporal branch vein occlusion in the right eye with serous retinal detachments in the left eye. The outcome was favorable with intravenous cyclophosphamide followed by azathioprine.

DISCUSSION

The incidence of ocular involvement in PAN varies from 10 to 20%. It is most often associated with vasculitis of retinal and choroidal arteries. Fluorescein angiography is the gold standard of diagnosis. Multifocal acute ischemia of the choriocapillaris is very pathognomonic. Immunosuppressant drugs are effective and should be reserved for severe forms.

Retinal vasculitis in rheumatic diseases: an unseen burden

Retinal vascular inflammation, a potentially blinding condition (herein: retinal vasculitis (RV)) is commonly associated with a heterogeneous group of diseases characterized by systemic inflammatory cell infiltration and/or necrosis of blood vessel walls. RV may arise as an isolated ocular disorder, as part of systemic vasculitis (Wegener's granulomatosis and Adamantiadis-Behcet Disease), or it can be secondary to an underlying connective tissue disease (systemic lupus erythematosus, sarcoidosis, and rheumatoid arthritis), systemic infection, or malignancy. Depending on the type of RV, it can be a potentially disabling condition, in the short or long term. Early diagnosis is the key to successful treatment and better prognosis. However, early diagnosis can be difficult, because these conditions usually present with nonspecific visual symptoms for a long period before diagnostic manifestations occur. The retina should be examined in warranted patients with verified rheumatic disease, since retinal vasculitis may be asymptomatic at the beginning (peripheral retinal disease). RV can be detected clinically (often accompanied by uveitis, scleritis, or macular edema) or revealed on fluorescein fundus angiography, even if minimal signs of retinal vessel inflammation are present. RV may also represent one of the possible extra-articular manifestations of the rheumatic disease. Rheumatologists should be familiar with the ocular manifestations of these disorders, since they may not only be sight-threatening, but more importantly, could be the presenting or even the very first manifestations of active, potentially lethal systemic disease in a patient with nonspecific rheumatologic presentation.

Central retinal artery occlusion in a patient with ANCA-negative Churg-Strauss syndrome

Ocular involvement in Churg-Strauss syndrome is infrequent. We describe the case of a 54-year-old woman with eosinophilia and involvement of the respiratory tract, skin, and peripheral nervous system, fulfilling the American College of Rheumatology criteria for Churg-Strauss syndrome. The patient presented with acute, painless vision loss in her right eye. Central retinal artery occlusion (CRAO) without accompanying retinal vasculitis was diagnosed by angiographic findings and funduscopic findings of retinal whitening with a cherry-red spot. Although her antineutrophil cytoplasmic antibody (ANCA) status was negative, CRAO was thought to be an ocular manifestation of Churg-Strauss syndrome, and appropriate treatment was planned. She was treated with high-dose corticosteroids and anticoagulant therapy. Her macular edema improved, but visual recovery was poor. Specific therapy to alter inflammation, blood coagulation, and rheology reportedly plays an important role in ANCA-positive patients with Churg-Strauss syndrome who develop CRAO. Regardless of ANCA status, high-dose corticosteroids should be considered for CRAO in patients with Churg-Strauss syndrome, as discussed in this case.

Treatment of macular edema because of occlusive vasculitis with bevacizumab (avastin): efficacy of three consecutive monthly injections

PURPOSE

To report the efficacy of intravitreal bevacizumab, administered in a series of three monthly injections followed by a period of observation, in the treatment of cystoid macular edema because of occlusive vasculitis.

METHODS

This is a retrospective review of 13 consecutive eyes of 13 patients with cystoid macular edema because of occlusive vasculitis, which had been unresponsive to other medications and were treated with intravitreal bevacizumab (1.25 mg). The evaluation consisted of a complete ophthalmologic examination, including best-corrected visual acuity measurement, ophthalmoscopy, fluorescein angiography, and optical coherence tomography. The eyes received a series of 3 monthly injections followed by a 3-month observation period.

RESULTS

A significant improvement in foveal thickness and visual acuity was obtained after the first injection, which increased after the second and the third injections and was maintained for 1.5 months after the last injection. The 2 parameters returned to the baseline values 3 months after the last treatment. There were no ocular or systemic adverse effects.

CONCLUSION

Intravitreal injection of bevacizumab seems to be well tolerated and is associated with short-term improvement of visual acuity and decreased retinal thickness in patients with cystoid macular edema because of vasculitis that is resistant to conventional therapy.

Peripheral ulcerative keratitis and necrotizing scleritis initiated by trauma in the setting of mixed cryoglobulinemia

Purpose

To report a case of peripheral ulcerative keratitis and necrotizing scleritis precipitated by trauma in a patient with mixed cryoglobulinemia due to hepatitis C viral infection.

Methods

Case report and literature review.

Results

A 62-year-old man with a history of mixed cryoglobulinemia developed an episode of necrotizing scleritis and peripheral ulcerative keratitis one month after repair of a traumatic scleral defect with patch grafting. This episode resolved following treatment with high-dose corticosteroids and the patient underwent successful repeat patch grafting along with a free conjunctival autograft. This is the second reported case of necrotizing scleritis and peripheral ulcerative keratitis associated with mixed cryoglobulinemia.

Conclusion

Ophthalmologists should be aware of the association between mixed cryoglobulinemia and necrotizing scleritis/peripheral ulcerative keratitis. Patients with this condition experiencing ocular trauma or undergoing ocular surgery should be monitored closely.

Profile of retinal vasculitis in a tertiary eye care center in Eastern India

Aims:

To provide a fact file on the etiology, clinical presentations and management of retinal vasculitis in Eastern India.

Materials and Methods:

Retrospective, record based analysis of retinal vasculitis cases in a tertiary care center in Eastern India from January 2007 to December 2009.

Results:

One hundred and thirteen eyes of 70 patients of retinal vasculitis were included in this study. Sixty (85.7%) patients were male (mean age 33± 11.1 years) and 10 (14.3%) were female (mean age 32.4 ± 13.6 years). Vasculitis was bilateral in 43 (61.4%) and unilateral in 27 (38.6%) patients. Commonest symptoms were dimness of vision (73; 64.6%) and floaters (36; 31.9%). Vascular sheathing (82; 72.6%) and vitritis (51; 45.1%) were commonest signs. Mantoux test was positive in 21 (30%) patients but tuberculosis was confirmed in only four (5.71%) patients. Raised serum angiotensin-converting enzyme level and positive antinuclear antibody level were reported in four (5.71%) patients each. Human leukocyte antigen B5 (HLA B5) marker was present in one (1.4%) patient. However, none of the total 70 patients were found to have a conclusively proven systemic disease attributable as the cause of retinal vasculitis. Oral corticosteroid (60; 85.7%) was the mainstay of treatment. Forty-eight (42.5%) eyes maintained their initial visual acuity and 43 (38%) gained one or more line at mean follow-up of 16.6± 6.3 months.

Conclusion:

Retinal vasculitis cases had similar clinical presentations and common treatment plan. There was no systemic disease association with vasculitis warranting a careful approach in prescribing investigations.

Differential diagnosis of retinal vasculitis

Retinal vaculitis is a sight-threatening inflammatory eye condition that involves the retinal vessels. Detection of retinal vasculitis is made clinically, and confirmed with the help of fundus fluorescein angiography. Active vascular disease is characterized by exudates around retinal vessels resulting in white sheathing or cuffing of the affected vessels. In this review, a practical approach to the diagnosis of retinal vasculitis is discussed based on ophthalmoscopic and fundus fluorescein angiographic findings.

Central retinal artery occlusion in Wegener's granulomatosis: a diagnostic dilemma

PURPOSE

To report a case of central retinal artery occlusion (CRAO) in a patient with biopsy-verified Wegener's granulomatosis (WG) with positive C-ANCA.

METHODS

A 55-year-old woman presented with a 3-day history of acute painless bilateral loss of vision; she also complained of fever and weight loss. Examination showed a CRAO in the left eye and angiographically documented choroidal ischemia in both eyes.

RESULTS

The possibility of systemic vasculitis was not kept in mind until further studies were carried out; methylprednisolone pulse therapy was then started. Renal biopsy disclosed focal and segmental necrotizing vasculitis of the medium-sized arteries, supporting the diagnosis of WG, and cyclophosphamide pulse therapy was administered with gradual improvement, but there was no visual recovery.

CONCLUSION

CRAO as presenting manifestation of WG, in the context of retinal vasculitis, is very uncommon, but we should be aware of WG in the etiology of CRAO. This report shows the difficulty of diagnosing Wegener's granulomatosis; it requires a high index of suspicion, and we should obtain an accurate medical history and repeat serological and histopathological examinations. It emphasizes that inflammation of arteries leads to irreversible retinal infarction, and visual loss may occur.

Plasmapheresis in the management of choroidal vasculitis associated with C-anca positive renal vasculitis

PURPOSE

The purpose of this study was to report the use of plasmapheresis in the management of choroidal vasculitis associated with Wegener granulomatosis.

METHOD

Case report.

PATIENT

A 50-year-old woman with acute renal failure as a result of glomerulonephritis of the Wegener granulomatosis type presented with sudden visual loss. Visual acuities at presentation were counting fingers in the left eye and 6/24 in the right eye. Clinical examination showed significant choroidal ischemia with no evidence of vitritis or anterior segment inflammation. Fluorescein and indocyanine green angiography confirmed choroidal vasculitis.

RESULTS

The patient was treated with a course of seven plasmapheresis sessions, after which she was maintained on prednisolone and mycophenolate. One week after her presentation, vision improved to 6/6 bilaterally. The angiographic appearances resolved, and the patient was maintained on immunosuppression.

CONCLUSION

We believe that the prompt use of plasmapheresis prevented irreversible visual loss in this patient. This case illustrates the dramatic improvement in choroidal perfusion presumably resulting from the removal of a circulating immune factor.

Clinical and immunological features of retinal vasculitis in systemic diseases

BACKGROUND/AIM

Vasculitis is a clinical, pathologic process characterized by inflammation and necrosis of blood vessel occuring anywhere in the body. The aim of the study was to present some clinical and immunologic features of retinal vasculitis in systemic diseases: systemic lupus erythematosus, multiple sclerosis, sarcoidosis, Behcet's diseases, and others.

METHODS

A total of 1 254 peatients with uveitis were included in the study. The immunochemical diagnostic methods were used to determine the pathogenesis of ocular manifestations. Ocular manifestations were examined using biomicroscope, direct or indirect ophtalmoscopy.

RESULTS

Primary retinal vasculitis was diagnosed in 85/1254 (6.8%) of total uveitis. In more than half of the cases of vasculitis (58.8%), both arteries and veins were involved in inflammatory process. Periphlebitis was diagnosed far more commonly (36.5%) than periarteritis (4.7%). Retinal vasculitis associated with systemic lupus erythematosus was characterized by microinfarctions and the consequent foci of inflammatory cells or diseases of large arteries manifesting in vasospasm and occlusions. Cotton wool spots occured in 38.3% and retinal hemorrhages in 34% of the cases. In this study periphlebitis of the retina was one of the less frequent ocular manifestations of multiple sclerosis. Comparing with the other changes of the retinal blood vessels, venous sheating occured in 25.1% and occlusion and vein thrombosis in 43.75% of the cases. Retinal vasculitis associated with chronic sarcoidosis occured in 37.5% of patients with sarcoidosis. The most frequent manifestation of ocular sarcoidosis was intermediary uveitis (43.75%). Anterior granulomatous uveitis occured in 37.5% of patients with sarcoidoses. Immune complexes occured in 13/20 (65%) of the patients. Antiretinal anti-S antibody in the serum occured in 73% of the patients with retinal detachment as a complication of primary disease and in 25% those with vasculitis.

CONCLUSION

Systemic diseases such as Behcet's syndrome, collagen vascular diseases, systemic granulomatous diseases (sarcoidosis and tuberculosis) were the main causes of retinal vasculitis. Knowledge of the symptomatology and pathogenesis of retinal vasculitis is of the major significance for the diagnosis and therapy of the disease.

Retinal Vasculitis

Retinal vasculitis is a sight-threatening intraocular inflammation affecting the retinal vessels. It may occur as an isolated ocular condition, as a manifestation of infectious or neoplastic disorders, or in association with a systemic inflammatory disease. The search for an underlying etiology should be approached in a multidisciplinary fashion based on a thorough history, review of systems, physical examination, and laboratory evaluation. Discrimination between infectious and noninfectious etiologies of retinal vasculitis is important because their treatment is different. This review is based on recently published articles on retinal vasculitis and deals with its clinical diagnosis, its link with systemic diseases, and its laboratory investigation.

Intravitreal Bevacizumab for Macular Edema due to Occlusive Vasculitis

Systemic vasculitides can cause retinal vascular pathology, including cotton-wool spots, retinal hemorrhages, vascular occlusion, and capillary nonperfusion. Two main causes of visual decline include macular edema and retinal neovascularization. Presumably, both of these complications are caused by increased intraocular levels of vascular growth and permeability factors. We report a patient with occlusive retinal vasculitis associated with mixed connective tissue disease who was treated with intravitreal bevacizumab for chronic macular edema. One month after treatment, visual acuity improved from 20/80 to 20/60, and foveal thickness decreased from 543 microns to 306 microns. This effect persisted for at least 3 months after treatment. No complications, including increased retinal ischemia, were observed.

Retinal vasculitis associated with asymptomatic Gardnerella vaginalis infection: a new clinical entity

PURPOSE

To report on 3 cases of retinal vasculitis associated with asymptomatic Gardnerella vaginalis (GV) infection.

METHODS

Review of 3 consecutive patients who presented with central retinal vasculitis without signs or symptoms of systemic disease. The vasculitis involved the central branches of the retinal vessels bilaterally and was steroid-dependent.

RESULTS

During treatment, patients developed clinically significant vaginitis, which the gynecologist considered to be exacerbated by the steroid treatment, leading to its withdrawal. All 3 vaginal specimens were positive for GV. Antibiotic susceptibility testing led to administration of oral ampicillin (2 g/day for 10 days), which resolved both the vaginal infection and the retinal vasculitis.

CONCLUSIONS

Idiopathic retinal vasculitis can be triggered by several agents. In this case series, GV was associated with retinal vasculitis, which was resolved by oral ampicillin. GV infection may be one of a number of triggers of retinal vasculitis. Appropriate treatment and full resolution of ocular inflammation requires exclusion of possible underlying infections.

Sherlock Holmes in the ER (the case of red and the head)

A 58-year-old woman presented with a problem with her peripheral vision. Computed tomography scan showed an occipital hemorrhagic stroke. She subsequently suffered gastrointestinal bleeding and at surgery biopsy of a portion of the middle colic artery aneurysm revealed changes consistent with polyarteritis nodosa.

Unilateral dacryoadenitis as the sole presenting sign of Wegener's granulomatosis

The purpose of this case report is to present a patient in whom acute unilateral dacryoadenitis was the sole presenting sign of Wegener's granulomatosis. An 80-year-old man presented with swelling of the temporal part of his right upper lid. Imaging studies and an incisional biopsy were done. The patient expired from a massive pulmonary hemorrhage before any diagnosis could be reached. Imaging studies revealed an enlarged lacrimal gland. Initially, a presumptive diagnosis of lacrimal gland lymphoma or an idiopathic inflammation was made. The histopathological examination established the diagnosis of Wegener's granulomatosis. This is an unusual case of Wegener's granulomatosis, with a fulminantly fatal conclusion reminding that this disease must be considered in the differential diagnosis of acute unilateral isolated dacryoadenitis in the elderly, and that a rapid diagnosis is mandatory.

Conjunctival involvement in Churg-Strauss syndrome

PURPOSE

To describe an unusual case of Churg-Strauss syndrome (CSS) that presented with a conjunctival nodule and was successfully treated with oral corticosteroids.

METHODS

Case report.

RESULTS

A 30-year-old woman with a history of adult-onset asthma, seasonal allergies, and a lung mass presented with a nodular elevation of the conjunctiva. Excisional biopsy demonstrated necrotizing eosinophilic granulomas. Systemic evaluation revealed peripheral eosinophilia and elevated IgE, consistent with Churg-Strauss syndrome. The patient's symptoms and eosinophilia resolved after an increase in the dose of oral corticosteroids.

CONCLUSIONS

This case describes a unique presentation of conjunctival involvement in CSS that differs from prior case reports by having a small, well-demarcated nodule and lacking signs of active inflammation.

Wegener's granulomatosis presenting with painless bulbar-conjunctival ulcer and central retinal artery occlusion

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.

Ocular vasculitis: a multidisciplinary approach

PURPOSE OF REVIEW

The ophthalmologist has direct visual access to inflamed vessels when examining the retina, and "vasculitis" in ophthalmology has so far mainly referred to retinal vasculitis. In the past few years the means to explore vasculitis in the ocular sphere have improved. Indocyanine green angiography now enables the analysis of choroidal inflammatory vasculopathy as well as vasculitis of the sclera (scleritis) and episclera (episcleritis) in addition to retinal vasculitis. Because vasculitis detected by the ophthalmologist can be the presenting sign of a systemic disease and has to be approached in a multidisciplinary fashion, the emerging term "ocular vasculitis," instead of retinal vasculitis, should be used in the future. The term covers vasculitis affecting all structures of the eye and the periocular tissues as detailed in this article. The ocular findings have to be integrated within the established and accepted classification of systemic vasculitis, which is divided into primary vasculitides, where the vessel itself is the target of the inflammatory reaction, and secondary vasculitides, caused by other inflammatory processes. This review will deal with recently published articles on ocular vasculitis, including its clinical aspects, its link with systemic diseases, and its investigation and management. The discussion will be conducted within the framework of the new classification put forward here.

RECENT FINDINGS

Novel imaging techniques such as indocyanine green angiography have made it possible to explore inflammation of choroidal vessels and of scleral vasculitis in addition to retinal vasculitis, contributing to the global concept of ocular vasculitis. It has been shown, in particular, that the choriocapillaris, a vascular structure adjacent to the retina, can be the site of a primary inflammatory vasculopathy unrecognized so far. Most of the recent articles cited, however, deal not so much with new findings but with the integration of ocular pathologic changes into the systemic diseases they are part of. New knowledge about disease mechanisms and novel therapeutic modalities with biologic agents cited in this review are coming from other fields but have contributed to progress in the management of ocular vasculitis.

SUMMARY

New investigational techniques of vasculitis in ocular structures other than the retina have contributed to the development of the global concept of ocular vasculitis. This review shows the importance of promoting a comprehensive and global classification of ocular vasculitis compatible with the concepts accepted for systemic vasculitis to contribute to its multidisciplinary approach.