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

Development of central retinal artery occlusion accompanied by choroidal folds in a patient with antineutrophil cytoplasmic antibody-associated vasculitis: A case report

RATIONALE

We report a case of central retinal artery occlusion (CRAO) accompanied by choroidal folds in a patient positive for myeloperoxidase (MPO)-antineutrophil cytoplasmic antibody (ANCA).

PATIENT CONCERNS

The study involved a 67-year-old female patient who presented at the Department of Ophthalmology, Osaka Medical College, Takatsuki-City, Osaka, Japan on October 24, 2016 after becoming aware of a sudden decrease of visual acuity (VA) in her right eye. Other than suffering with scleritis 6-months previous, there was no obvious past history.

DIAGNOSIS

Upon examination, the VA in her right eye was hand motion, and the anterior segment of that eye showed thinning of the superior sclera. Macular edema in the inner retina and cherry red spots were observed in the ocular fundus, and optical coherence tomography (OCT) findings showed hyperreflectivity of the inner retina and choroidal folds. Fluorescein angiography (FA) examination of the fundus showed scattered areas of no retinal perfusion, and indocyanine green angiography (IA) findings of the fundus indicated a possible choroidal circulatory disturbance in her right eye. Blood test findings revealed the patient to be positive for MPO-ANCA. Based on the above findings, the patient was diagnosed with CRAO and choroidal circulatory disturbance due to ANCA-associated vasculitis.

INTERVENTIONS

For treatment, steroid semi-pulse therapy was initiated.

OUTCOMES

Post treatment initiation, the fundus features and choroidal folds gradually improved, and her VA slightly improved to 0.08.

LESSONS

Based on the FA, IA, and OCT findings, the present case was considered to have CRAO accompanied by choroidal circulatory disturbance due to ANCA-associated vasculitis, a rare disease that may be complicated by choroidal circulatory disturbances.

Conjunctival geographic ulcer: an overlooked sign of herpes simplex virus infection

Herpes simplex virus (HSV) ocular infection causes significant visual burden worldwide. Despite the fact that dendritic or geographic corneal ulcers are typical findings in HSV epithelial keratitis, conjunctival ulcer as a sign of HSV infection has rarely been reported. Although easily overlooked, this important sign could be enhanced by fluorescein staining. We report two cases of conjunctival geographic ulcers proven to be HSV infection by viral isolation and polymerase chain reaction (PCR). One patient had bilateral disease and blepharitis, and the other had unilateral involvement without skin lesions. With timely diagnosis and proper management, excellent visual outcome can be expected.

The role of conjunctival biopsy in the diagnosis of granulomatosis with polyangiitis

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.

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.

Occlusion de l'artère centrale de la rétine au cours de la granulomatose de Wegener

INTRODUCTION

Almost 50% of patients with Wegener's granulomatosis (WG) develop ocular features, leading to visual loss in 8%. However, central retinal artery occlusion (CRAO) has exceptionally been reported.

EXEGESIS

We report 2 patients with CRAO and WG according to ACR classification criteria. A literature search indicates that CRAO with WG has only been reported in 15 patients. We analyse the 17 cases to discuss systemic manifestations, ocular prognosis and treatment.

CONCLUSION

CRAO is a rare manifestation of WG. Nevertheless, CRAO seems to be associated with vasculitic type of WG. So, a prompt diagnosis could lead to early aggressive regimen to improve visual and general prognosis.