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Peñarrocha-Oltra S, Balboa Miró M, Pérez-López M, Ibáñez Flores N. Acquired enophthalmos in idiopathic orbital inflammatory disease. Am J Ophthalmol Case Rep 2024; 33:102005. [PMID: 38380084 PMCID: PMC10876667 DOI: 10.1016/j.ajoc.2024.102005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 01/13/2024] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Purpose To describe a rare case of acquired enophthalmos in a patient with idiopathic orbital inflammatory disease after treatment with systemic corticosteroids. Observations Orbital socket contracture produces a non-traumatic enophthalmos and is most frequently reported as a consequence of orbital trauma or metastatic fibrosis. A previously healthy 64-year-old male presented with 3-month history of binocular diplopia and left proptosis, hypoglobus, supraduction deficit, and compressive neuropathy. Imaging techniques showed a left orbital mass; laboratory tests and biopsy of the mass lead to the diagnosis of idiopathic orbital inflammatory disease. Systemic corticosteroids were administered and, surprisingly, the patient developed left enophthalmos with eyelid retraction. Conclusions and Importance Although extremely unusual, orbital socket contracture can cause enophthalmos and visual morbidity in patients with idiopathic orbital inflammatory disease treated with corticosteroids.
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Naggar A, Toufga Z, Ech-cherif El Kettani N, Jiddane M, Fikri M. Granulomatosis with polyangiitis presenting with unilateral exophthalmos: A case report. Radiol Case Rep 2022; 17:2626-2629. [PMID: 35663807 PMCID: PMC9157215 DOI: 10.1016/j.radcr.2022.03.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/19/2022] [Accepted: 03/20/2022] [Indexed: 10/27/2022] Open
Abstract
We report a case of a patient with no medical history, admitted for right exophthalmos. For whom imaging showed orbital masses without inflammatory signs pointing to a granulomatous origin. However, the histological and immunological workup revealed the diagnosis of Granulomatosis with polyangiitis.
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Affiliation(s)
- Amine Naggar
- Radiology Department, Specialty hospital, Mohamed V University, Rabat, Morocco
| | - Zakaria Toufga
- Radiology Department, Specialty hospital, Mohamed V University, Rabat, Morocco
| | | | - Mohamed Jiddane
- Radiology Department, Specialty hospital, Mohamed V University, Rabat, Morocco
| | - Meriem Fikri
- Radiology Department, Specialty hospital, Mohamed V University, Rabat, Morocco
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3
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Bilateral Enophthalmos as an Unusual Presenting Feature of Non-Hodgkin’s Orbital Lymphoma. Ophthalmic Plast Reconstr Surg 2022; 38:e82-e85. [DOI: 10.1097/iop.0000000000002119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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4
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Cleary JO, Sivarasan N, Burd C, Connor SEJ. Head and neck manifestations of granulomatosis with polyangiitis. Br J Radiol 2021; 94:20200914. [PMID: 33237805 DOI: 10.1259/bjr.20200914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Granulomatosis with polyangiitis is a rare autoimmune condition which causes respiratory tract granulomas, small to medium vessel vasculitis and renal disease. Head and neck manifestations are some of the most common presentations of the condition, with a significant proportion of patients experiencing sinonasal disease alone. The recognition of suggestive imaging findings, in combination with clinical history and serology, aids the diagnosis and appropriate treatment. This pictorial review describes and illustrates the head and neck imaging features of granulomatosis with polyangiitis, highlighting the range of CT and MRI findings of upper aerodigestive tract, orbital and skull-base disease. Recognition of the radiological appearances is of importance, since clinical presentations may be non-specific and limited disease may have negative serology. Imaging features may overlap with other pathologies so important differential diagnoses will be considered, and these are particularly relevant in the context of treatment resistance.
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Affiliation(s)
- Jon O Cleary
- Department of Radiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Nishanth Sivarasan
- Department of Radiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Christian Burd
- Department of Radiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Steve E J Connor
- Department of Radiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Department of Neuroradiology, King's College London NHS Foundation Trust, London, UK.,School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College, London, UK
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5
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TNF-α Inhibitors for the Management of Orbital Inflammatory Conditions. Clin Ophthalmol 2020; 60:103-109. [DOI: 10.1097/iio.0000000000000303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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6
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Ismailova DS, Grusha YO, Abramova YV, Novikov PI, Danilov SS. [Clinical manifestations of orbital lesion in granulomatosis with polyangiitis]. Vestn Oftalmol 2018; 134:178-185. [PMID: 30499515 DOI: 10.17116/oftalma2018134051178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
UNLABELLED One of the most common and potentially threatening manifestations of granulomatosis with polyangiitis (GPA) is orbital lesion. PURPOSE To study the clinical course and prognosis of orbital lesions of various localization in GPA patients. Material and me-thods. The study included 226 patients with GPA, 74 of them with orbital lesion. Ophthalmic examination consisted of visual acuity test, biomicroscopy, ophthalmoscopy, exophthalmometry and ocular mobility test. Visualization was done using multislice computed tomography and/or magnetic resonance tomography and/or ultrasound examination. RESULTS Among the patients of the study group, in 35.1% the lesion was limited to dacryoadenitis, in 4.0% of patients - to myositis, and 70.8% had extensive inflammatory orbital masses. Patients with orbital masses had systemic disease in 51.1%, compared to 7.7% in dacryoadenitis (p=0.00). Clinical progression in patients with orbital masses was characterized by severe exophthalmos, periorbital swelling and hyperemia. Patients with dacryoadenitis, on the contrary, had only mild symptoms. Patients with orbital masses had unfavorable prognosis. There were only three patients with myositis in the study group, so the data on them is limited; their clinical symptoms included light periorbital swelling, exophthalmos, strabismus, painful binocular diplopia and eye movement restriction. The disease was recurring in two cases. CONCLUSION Patients with orbital involvement in GPA may have different course of the disease depending on the localization of inflammation.
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Affiliation(s)
- D S Ismailova
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - Y O Grusha
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, Chair of Ophthalmology, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - Yu V Abramova
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - P I Novikov
- I.M. Sechenov First Moscow State Medical University, University Hospital No. 3, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - S S Danilov
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
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7
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Grusha YO, Ismailova DS, Novikov PI, Kogan EA, Abramova YV, Bulanov NM, Sherstneva LV. [Combination therapy of refractory localized granulomatosis with polyangiitis and orbital involvement]. Vestn Oftalmol 2017; 133:86-91. [PMID: 28524146 DOI: 10.17116/oftalma2017133286-90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Granulomatous orbital cellulitis is one of the most common ocular manifestations of granulomatosis with polyangiitis (Wegener's). The process is often refractory to conventional immunosuppressive therapy and requires a more radical treatment approach. However, surgical experience with this type of patients is limited. There have been just a few reported cases of orbital decompression in such patients and many authors have doubted the appropriateness of the procedure, since it is associated with a high risk of potentially fatal complications. Our experience demonstrates the feasibility and effectiveness of orbital mass removal as to pain relief and exophthalmos reduction.
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Affiliation(s)
- Y O Grusha
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - D S Ismailova
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - P I Novikov
- UCH #3 of I.M. Sechenov First Moscow State Medical University, 11, str.5 Rossolimo St., Moscow, Russian Federation, 119021
| | - E A Kogan
- I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - Yu V Abramova
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021
| | - N M Bulanov
- I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - L V Sherstneva
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
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Kogan EA, Grusha YO, Ismailova DS, Novikov PI, Abramova YV, Meshkov AD, Rizopulu EF. [Refractory form of orbital granulomatosis with polyangiitis: A clinical and morphological study]. Arkh Patol 2017; 79:56-60. [PMID: 28295009 DOI: 10.17116/patol201779156-60] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Orbital granulomatosis with polyangiitis (Wegener's granulomatosis, GPA), which is characterized by granulomatous inflammation with small-vessel vasculitis, can develop in local and generalized forms of the disease. The introduction of current immunosuppressive therapy regimens has improved the prognosis of the disease; however, there are immunosuppressive treatment-refractory forms of GPA, the morphology of which has been inadequately investigated. The paper describes a clinical case of refractory GPA involving the orbit, as evidenced by histological and immunohistochemical examinations. The specific feature of the case is the development of severe fibrosis with the accumulation of mainly type III collagen and the persistence of granulomatous inflammation and productive-destructive vasculitis.
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Affiliation(s)
- E A Kogan
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ya O Grusha
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Research Institute of Eye Diseases, Moscow, Russia
| | - D S Ismailova
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Research Institute of Eye Diseases, Moscow, Russia
| | - P I Novikov
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia; University Clinical Hospital Three, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - A D Meshkov
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia; University Clinical Hospital Three, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - E F Rizopulu
- Research Institute of Eye Diseases, Moscow, Russia
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9
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The Many Faces of Granulomatosis With Polyangiitis: A Review of the Head and Neck Imaging Manifestations. AJR Am J Roentgenol 2015; 205:W619-29. [DOI: 10.2214/ajr.14.13864] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Grusha YO, Ismailova DS, Novikov PI, Abramova YV. [Ophthalmologic manifestation of granulomatosis with polyangiitis (Wegener's granulomatosis)]. TERAPEVT ARKH 2015; 87:111-116. [PMID: 27022660 DOI: 10.17116/terarkh20158712111-116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Granulomatosis with polyangiitis (GPA), formerly earlier known as Wegener's granulomatosis, is primary system necrotizing vasculitis of small and medium-sized vessels, which is characterized by the formation of foci of granulomatous inflammation. One of the target organs in GPA is the organ of vision. Its affection may not only reduce quality of life, but also may lead to the severest complications even to fatal outcome. The affection varies in severity from slight inflammation of the ocular superficial structures to severe involvement of all orbital and ocular structures to develop complete blindness, including bilateral one. GPA can affect any portion of the organ of vision. The changes are low specific, which makes early diagnosis and timely adequate therapy difficult. Overall all ophthalmologic manifestations can be divide into 4 groups: 1) lesions of the orbit and appendages; 2) those of the conjunctiva and fibrous tunic of the eyeball: 3) those of the retina: 4) those of the optic nerve. Orbital affection is characterized by the development of granulomas, dacryoadenitis with marked inflammatory infiltration of the surrounding tissues, including oculomotor muscles, and destruction of orbital bony walls. Nonspecific conjunctivitis and episcleritis are commonly encountered. Affection of the fibrous tunic of the eyeball is characterized by the development of necrotizing scleritis, peripheral ulcerative or stromal keratitis. The retina is rarely involved and mainly described as sporadic cases in the literature. The optic nerve is most commonly damaged due to the compression of the orbit by inflamed tissue; the lesion is more infrequently ischemic.
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Affiliation(s)
- Ya O Grusha
- Research Institute of Eye Diseases, Moscow, Russia; I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - D S Ismailova
- Research Institute of Eye Diseases, Moscow, Russia; I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - P I Novikov
- University Clinical Hospital Three, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - Yu V Abramova
- Research Institute of Eye Diseases, Moscow, Russia; I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
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Bitik B, Kılıç L, Küçükşahin O, Şahin K, Tufan A, Karadağ Ö, Pay S, Ateş A, Ucar M, Tutar H, Karaaslan Y, Yilmaz S, Ertenli AI, Konuk O, Turgay M, Goker B. Retro-orbital granuloma associated with granulomatosis with polyangiitis: a series of nine cases. Rheumatol Int 2014; 35:1083-92. [DOI: 10.1007/s00296-014-3179-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022]
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12
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Isa H, Lightman S, Pusey CD, Taylor SRJ. Ocular manifestations of Wegener’s granulomatosis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.11.62] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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13
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Taylor SRJ, Salama AD, Pusey CD, Lightman S. Ocular manifestations of Wegener’s granulomatosis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2.1.91] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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14
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McCulley TJ. Sphenoid sinus expansion: a radiographic sign of intracranial hypotension and the sunken eyes, sagging brain syndrome (an American Ophthalmological Society thesis). TRANSACTIONS OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY 2013; 111:145-154. [PMID: 24167328 PMCID: PMC3797832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PURPOSE To test the hypothesis that in patient with sunken eyes, sagging brain syndrome, bone remodeling is not limited to the orbits. Volumetric analysis of the sphenoid sinus is performed in this study. METHODS In this university-based retrospective case-control study, the dimensions of the sphenoid sinus were measured in four patients (2 males, 2 females; mean age 26.3 years, range 16-38 years) out of five individuals identified with sunken eyes, sagging brain syndrome. Three measurements were taken: the distance between the orbital apices, the posterior extension of the sphenoid sinus posterior to the orbital apices, and the maximal horizontal width. The mean of each was determined and compared to that of the control group (5 males, 5 females; mean age 35.6 years, range 23-45 years). RESULTS Posterior extension and width of the sphenoid sinus were markedly larger in the enophthalmic patients than in the control group: posterior extension (26.3 ± 4.1 mm vs 13.4 ± 6.3 mm, P=.0015, Student's t test), width (39.2 ± 8.7 mm vs 25.1 ± 6.9 mm, P=.0035, Student's t test). Mean distance between the orbital apices was slightly greater (36.3 ± 1.7 mm vs 34.1 ± 2.1 mm, P=.047, Student's t test). CONCLUSIONS Skull remodeling occurring in association with intracranial hypotension after ventriculoperitoneal shunting is not limited to the orbits. In this study we have demonstrated expansion of the sphenoid sinus. This finding adds to our knowledge and understanding of the scope of the sunken eyes, sagging brain syndrome and elucidates a clinically useful radiographic sign.
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Affiliation(s)
- Timothy J McCulley
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
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15
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Holle JU, Voigt C, Both M, Holl-Ulrich K, Nölle B, Laudien M, Moosig F, Gross WL. Orbital masses in granulomatosis with polyangiitis are associated with a refractory course and a high burden of local damage. Rheumatology (Oxford) 2013; 52:875-82. [DOI: 10.1093/rheumatology/kes382] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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16
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Denniston AK, Gayed M, Carruthers D, Gordon C, Murray PI. Rheumatic Disease. Retina 2013. [DOI: 10.1016/b978-1-4557-0737-9.00080-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Soriano A, Vullo ML, Casale M, Quattrocchi C, Afeltra A. Meningeal Involvement in Wegener Granulomatosis: Case Report and Review of the Literature. Int J Immunopathol Pharmacol 2012; 25:1137-41. [DOI: 10.1177/039463201202500431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Wegener Granulomatosis (WG) is a multisystem autoimmune disorder characterized by necrotizing granulomatous vasculitis that most commonly involves the upper respiratory tract, lungs, and kidneys. The involvement of the central nervous system (CNS) is infrequent and can cause stroke, cranial nerve abnormalities, cerebrovascular events, seizures, and meningeal involvement. Meningeal involvement is rare and may occur due to local vasculitis, directly spread from adjacent disease in the skull base, paranasal or orbital region. We describe the case of a 20-year-old Caucasian man who was diagnosed with sinonasal WG with frontal focal meningeal involvement. A literature review on diagnosis and treatment of meningeal involvement in course of WG was carried out. The importance of an early diagnosis and treatment of localized WG has been emphasized, in order to avoid the progression to a severe form of disease, especially in younger patients and in paucisymptomatic cases.
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Affiliation(s)
- A. Soriano
- Department of Rheumatology and Clinical Medicine, Campus Bio-Medico University, Rome, Italy
| | - M. Lo Vullo
- Department of Rheumatology and Clinical Medicine, Campus Bio-Medico University, Rome, Italy
| | - M. Casale
- Department of Otolaryngology, Campus Bio-Medico University, Rome, Italy
| | - C.C. Quattrocchi
- Department of Radiology, Campus Bio-Medico University, Rome, Italy
| | - A. Afeltra
- Department of Rheumatology and Clinical Medicine, Campus Bio-Medico University, Rome, Italy
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Abstract
Non-infectious vasculitides comprise a large number of diseases. Many of these diseases can cause inflammation within the orbit and a clinical presentation, which mimics numerous other processes. Orbital disease can often be the initial presentation of a systemic process and early diagnosis can help prevent long-term, potentially fatal consequences. The evaluation and treatment of non-infectious orbital vasculitides are often complicated and require a thorough understanding of the disease and underlying systemic associations. The long-term prognosis visually and systemically must be weighed against the risks and benefits of the treatment regimen. A large variety of corticosteroid formulations currently exist and are the mainstay of initial treatment. Traditional steroid-sparing immunosuppressive agents are also an important arsenal against these vasculitides. Recently, a new class of drugs called biologics, which target the various mediators of the inflammation cascade, may potentially provide more effective and less toxic treatment. This review aims to synthesize the current literature on non-infectious orbital vasculitides.
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Hwang TN, Rofagha S, McDermott MW, Hoyt WF, Horton JC, McCulley TJ. Sunken Eyes, Sagging Brain Syndrome: Bilateral Enophthalmos from Chronic Intracranial Hypotension. Ophthalmology 2011; 118:2286-95. [DOI: 10.1016/j.ophtha.2011.04.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 04/17/2011] [Accepted: 04/26/2011] [Indexed: 10/17/2022] Open
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20
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Santiago YM, Fay A. Wegener’s Granulomatosis of the Orbit: A Review of Clinical Features and Updates in Diagnosis and Treatment. Semin Ophthalmol 2011; 26:349-55. [DOI: 10.3109/08820538.2011.588662] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
In this chapter the presentation and management of common orbital diseases are discussed. An accurate clinical history and assessment are essential, with computed tomography being the imaging of choice. Magnetic resonance imaging provides detail of intrinsic optic nerve disease and orbital apical or intracranial pathology, and ultrasonography is valuable in assessing anterior orbital masses, in particular vascular lesions. Inflammatory lesions require a tissue biopsy before immunosuppression is instituted. Exceptions to this principle are scleritis, myositis, thyroid eye disease, and characteristic orbital apex syndrome, in which delay in immune suppression may jeopardize visual outcome. The term "orbital pseudotumor" is now obsolete. The management of active thyroid eye disease includes immunosuppression and low-dose orbital radiotherapy. Urgent orbital decompression is indicated in the presence of nonresponsive optic neuropathy, and inactive disease is managed by decompression for exophthalmos, and correction of muscle imbalance and lid retraction. Subacute lacrimal gland inflammation, unresponsive to a few weeks of nonsteroidal treatment, may be due to underlying carcinoma and a specialist opinion should be sought without delay. Pleomorphic adenoma, with typical features on imaging, should always be excised intact to avoid subsequent pervasive malignant disease.
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Platnick J, Crum AV, Soohoo S, Cedeño PA, Johnson MH. The globe: infection, inflammation, and systemic disease. Semin Ultrasound CT MR 2011; 32:38-50. [PMID: 21277490 DOI: 10.1053/j.sult.2010.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Joseph Platnick
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
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24
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Stone JH. Wegener's granulomatosis. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00153-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Abstract
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.
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Affiliation(s)
- Anup A Kubal
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
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Holle JU, Laudien M, Gross WL. Clinical Manifestations and Treatment of Wegener's Granulomatosis. Rheum Dis Clin North Am 2010; 36:507-26. [DOI: 10.1016/j.rdc.2010.05.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wegener's granulomatosis: clinical manifestations, differential diagnosis, and management of ocular and systemic disease. Surv Ophthalmol 2010; 55:429-44. [PMID: 20638092 DOI: 10.1016/j.survophthal.2009.12.003] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 12/05/2009] [Accepted: 12/16/2009] [Indexed: 11/22/2022]
Abstract
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.
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Abstract
PURPOSE OF REVIEW This review discusses the use of interventional procedures to treat manifestations of Wegener's granulomatosis caused by tissue damage and scarring. These manifestations include nasal and paranasal sinus disease, middle ear inflammation, nasolacrimal duct obstruction, orbital inflammatory masses, subglottic stenosis, tracheobronchial disease, and end-stage renal disease. RECENT FINDINGS Tissue damage caused by inflammation or a cicatricial process represents one of the major sources of morbidity for patients with Wegener's granulomatosis. Some of these manifestations require special interventions used alone or in combination with conventional medical treatment. These interventional procedures may include surgical or endoscopic repair of altered tissue, replacement of damaged organs, or the delivery of topical or injectable medications directly to the site of disease. Distinguishing symptoms caused by active disease from symptoms caused by tissue scarring is challenging and may play a critical role regarding the use of systemic immunosuppressive medications in combination with interventional therapy. SUMMARY Interventional procedures are indicated in certain manifestations of Wegener's granulomatosis. Distinguishing active Wegener's granulomatosis from inactive Wegener's granulomatosis and recognizing disease manifestations that may be amenable to local interventions can greatly improve the quality of life of patients. However, the evidence supporting the use of many of these interventions is based on small case series or individual reports.
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Non-surgical Volume Enhancement with Fillers in the Orbit and Periorbital Tissues: Cosmetic and Functional Considerations. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/978-3-540-85542-2_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
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Manifestations ophtalmologiques de la granulomatose de Wegener. Revue de la littérature à propos d’une observation. Nephrol Ther 2009; 5:603-13. [DOI: 10.1016/j.nephro.2009.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 05/11/2009] [Accepted: 05/12/2009] [Indexed: 11/23/2022]
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Meltzer DE, Chang AHY, Shatzkes DR. Case 152: Orbital Metastatic Disease from Breast Carcinoma. Radiology 2009; 253:893-6. [DOI: 10.1148/radiol.2533081926] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Taylor SRJ, Salama AD, Joshi L, Pusey CD, Lightman SL. Rituximab is effective in the treatment of refractory ophthalmic Wegener's granulomatosis. ACTA ACUST UNITED AC 2009; 60:1540-7. [DOI: 10.1002/art.24454] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
PURPOSE To report three cases of sclerosing Wegener's granulomatosis in the orbit and to compare the histopathological morphology with those of other types of sclerosing orbital inflammation. METHODS We analysed the clinical data along with histopathological specimens from orbital biopsies and from two enucleated eyes. RESULTS All three patients had longstanding inflammation in the orbit and involvement of the paranasal sinuses. Proptosis, impaired ocular motility and reduced visual acuity dominated the clinical picture. All histopathological specimens featured granulomatous inflammation, tissue necrosis, vasculitis and widespread dense fibrosis. In certain areas of all specimens the fibrous tissue was arranged in characteristic concentric, onionskin-like whorls of collagen around obliterated small blood vessels. CONCLUSIONS Wegener's granulomatosis may lead to orbital fibrosis and sclerosis. The stromal changes and cellular infiltrate resemble the non-specific orbital inflammation previously termed orbital pseudotumour. We present the first 'onionskin' lesions in association with Wegener's granulomatosis in the orbit. This latter morphology may represent an abnormal fibrotic reaction in inflammatory tissue.
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Affiliation(s)
- Christoffer Ostri
- Department of Neuroscience and Pharmacology, Eye Pathology Section, University of Copenhagen, Copenhagen, Denmark
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Abstract
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.
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Affiliation(s)
- Paul A Athanasiov
- Oculoplastic and Orbital Division, Department of Ophthalmology and Visual Sciences, University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia.
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Abstract
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.
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Affiliation(s)
- L K Gordon
- Jules Stein Eye Institute, University of California at Los Angeles and Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA.
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Pakrou N, Selva D, Leibovitch I. Wegener’s Granulomatosis: Ophthalmic Manifestations and Management. Semin Arthritis Rheum 2006; 35:284-92. [PMID: 16616151 DOI: 10.1016/j.semarthrit.2005.12.003] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Nima Pakrou
- Department of Ophthalmology and Visual Sciences, Royal Adelaide Hospital, Adelaide, Australia
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Aries PM, Hellmich B, Voswinkel J, Both M, Nölle B, Holl-Ulrich K, Lamprecht P, Gross WL. Lack of efficacy of rituximab in Wegener's granulomatosis with refractory granulomatous manifestations. Ann Rheum Dis 2005; 65:853-8. [PMID: 16269425 PMCID: PMC1798224 DOI: 10.1136/ard.2005.044420] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the safety and efficacy of rituximab (RTX) in patients with refractory Wegener's granulomatosis (WG). PATIENTS AND METHODS Eight consecutive patients with active refractory WG were included. In all patients disease activity had persisted despite standard treatment with cyclophosphamide and prednisolone, as well as tumour necrosis factor alpha blockade 3 months before inclusion in the study. Patients had particular granulomatous manifestations like retro-orbital granulomata (n=5), nodules of the lungs (n=1), and subglottic stenosis (n=2). RTX was given intravenously every 4th week in combination with the standard treatment in five patients and with methotrexate in two others. Disease extent and activity were monitored clinically by interdisciplinary care, immunodiagnostics (ANCA serology, B cells by flow cytometry), and magnetic resonance imaging. RESULTS Beneficial response and a reduction in disease activity were seen in three patients, two of whom went into complete remission. In three other patients, disease activity remained unchanged while the disease progressed in the remaining two patients. In all patients peripheral blood B cells fell to zero during treatment with RTX. cANCA titres remained unchanged in all except one patient. CONCLUSION In this pilot study, B lymphocyte depletion was not associated with a change of the ANCA titres or obvious clinical improvement of refractory granulomatous disease in patients with WG. Further studies are needed to evaluate the role of RTX in WG.
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Affiliation(s)
- P M Aries
- University Hospital Schleswig-Holstein, Campus Luebeck, Department of Rheumatology and Rheumaklinik Bad Bramstedt, Germany.
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