Periarteritis nodosa and thrombotic thrombocytopenic purpura with serous retinal detachment in siblings

Systemic Vasculitis and Its Association with the Eye

Vasculitis is a group of diseases characterized by the inflammation of the blood vessel walls. They are classified according to the size of the main vessel involved: large vessel, medium vessel, and small vessel vasculitis. Ophthalmic manifestations are quite common in most of these diseases. Episcleritis and scleritis are the most prevalent manifestation of vasculitis. However, there are certain ocular features characteristic of specific vasculitis entities. Given the severity and potential life-threat of these diseases, knowledge of the ocular manifestations is mandatory for the ophthalmologists.

Near-complete vision recovery from bilateral serous retinal detachment associated with thrombotic thrombocytopenic purpura

Ocular manifestations of thrombotic thrombocytopenic purpura (TTP) are uncommon, and bilateral retinal detachment is a rare presentation of TTP. We report a rare case of bilateral retinal detachment from underlying TTP in a patient presenting with vision loss. A 56-year-old man presented with a 4-day history of bilateral vision loss. Bilateral serous retinal detachment was confirmed using dilated ophthalmoscope examination. Laboratory results were significant for severe thrombocytopenia, peripheral smear revealed numerous schistocytes and ADAMTS13 activity of less than 1%. The patient was treated with plasma exchange (PLEX), prednisone, rituximab and caplacizumab. This case report highlights that prompt treatment of TTP with PLEX, prednisone, rituximab and caplacizumab could result in significant vision recovery.

Multifocal serous detachments as the presenting sign of thrombotic thrombocytopenic purpura

PURPOSE

To report a case of bilateral multifocal serous detachments as the presenting sign of thrombotic thrombocytopenic purpura.

METHODS

Observational case report.

RESULTS

A 59-year-old woman presented with decreased vision and was found to have bilateral multifocal serous detachments. Her review of symptoms prompted further investigations that revealed evidence of acute intravascular hemolysis, renal failure, and cerebral ischemia. This led to the diagnosis of thrombotic thrombocytopenic purpura.

CONCLUSION

Thrombotic thrombocytopenic purpura is a life-threatening condition that may present to an ophthalmologist. Recognizing its ophthalmic manifestations can be life saving for the patient.

Polyarteritis nodosa in Croatian children: a retrospective study over the last 20 years

To analyze the disease characteristics, treatment modalities and outcome of polyarteritis nodosa (PAN) in Croatian children. Cross-sectional study included all children with PAN diagnosed according to EULAR/PRES/PRINTO criteria during the last two decades. PAN was diagnosed in 12 patients (6 girls and 6 boys) mean age (±SD) 11.33 ± 3.08 years. The share of PAN among all vasculitides was 3.8 %. Systemic PAN was diagnosed in 7 children (58 %), microscopic polyangiitis in 3 (25 %), cutaneous PAN in 2 (17 %). The most consistent symptoms were skin involvement (90 %) and arthritis/arthralgia (60 %). The CNS was affected in 33 % of patients. Inflammatory markers (C-reactive protein and erythrocyte sedimentation rate [ESR]) were elevated in all patients, and anti-neutrophil cytoplasmatic antibodies were positive in all patients with microscopic polyangiitis. Therapy mode for all patients was corticosteroids. Immunosuppressive drugs were used as additional therapy for patients with severe symptoms. Two patients (17 %), both suffering from microscopic polyangiitis, died due to renal failure during the follow-up. In comparison with available studies, we found a difference in distribution of childhood polyarteritis nodosa as well as some clinical characteristics (e.g., higher prevalence of neurological and pulmonary symptoms), while other researched features, laboratory and treatment were similar.

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.

[Ophthalmologic manifestations of systemic vasculitis: report of six cases and review of the literature]

PURPOSE

Study of characteristics of ocular involvement in systemic vasculitis.

METHODS

We describe six cases of systemic vasculitis with ocular involvement observed between 1992 and 2000. These cases are compared with those reported in the literature.

RESULTS

Our patients suffered from Wegener's granulomatosis (four cases), periarteritis nodosa and Churg-Strauss syndrome. Ocular manifestations were conjunctivitis, scleritis, orbital pseudotumor, optic neuritis and extraocular muscle palsy. These manifestations are similar to those reported in the literature. Their treatment requires steroids and immunosuppressive drugs. In one of our cases, intravenous immunoglobulins were effective in controlling an optic neuritis.

CONCLUSION

Ocular involvement in systemic vasculitis may concern any orbital structure. It usually occurs during the course of vasculitis but may be one of its first manifestations. It requires an appropriate treatment to prevent ophthalmic complications and especially blindness.

Ophthalmologic manifestations of rheumatic diseases

OBJECTIVES

Detailed review of the manifestations of eye involvement in the context of rheumatic diseases.

METHODS

An OVID Medline search of the rheumatology and ophthalmology English literature related to the eye manifestations of human rheumatic diseases from 1966 to the present was conducted by the authors.

RESULTS

Analysis of 300 recent and consecutive rheumatology consultations from a large Veterans Administration Healthcare System shows that 4% are referred for eye manifestations of suspected rheumatic diseases, most commonly, anterior uveitis and keratoconjunctivitis sicca (KCS). Ocular involvement is common in the rheumatic diseases but varies among the different disorders. A literature review indicated that the most common ocular manifestations of rheumatic diseases include keratoconjunctivitis sicca, anterior uveitis, and scleritis. The most serious eye complications of the inherited connective tissue disorders are lens involvement with cataract formation or subluxation. The most significant side effects of the drugs used to treat rheumatic diseases are the maculopathy associated with anti-malarial agents and cataracts and glaucoma associated with corticosteroid use. Although many of the eye manifestations are easily recognizable, consultation with an ophthalmologist is usually necessary for optimal treatment and prevention of complications.

CONCLUSIONS

The rheumatologist, in coordination with the ophthalmologist, can play a major role in detecting and managing the eye involvement in his patients to save this important sense. Understanding the varied manifestations of eye disease will permit the rheumatologist to better evaluate the activity of the rheumatic disease.

Choroidal filling patterns in sickle cell patients

Two choroidal occlusion syndromes are recognized: the triangular syndrome after ciliary artery occlusions, and the multifocal lesions associated with choroidal arteriolar occlusions. Both syndromes have been described in sickle cell patients. We compared early venous phase fluorescein angiograms of 51 Hb SS or Hb SC patients and 15 age and race matched controls, to test whether geographic early filling defects of the choriocapillaris might be more common in these rheologically impaired patients. We found no difference in occurrence of these filling defects between the two groups, and conclude that choriocapillaris filling defects in the early venous phase only are not pathological.

Bilateral retinal detachments in thrombotic thrombocytopenic purpura

Bilateral serous retinal detachments are rare complications of thrombotic thrombocytopenic purpura (TTP). We report the case of a 28-year-old woman with chronic relapsing TTP with bilateral serous retinal detachments, which resolved after prompt aggressive medical therapy. Unlike several previous reports, the retinal detachments in our patient were unrelated to systemic hypertension.

Retinal detachment after choroidal ischemia

Injection of a 15-micron microsphere suspension through one or two vortex veins of nine monkey eyes caused various degrees of sectorial choroidal ischemia, which were documented by fluorescein angiography and electron microscopy. The severity of the lesions to the fundus depended on the volume of microspheres injected (0.4 to 1.6 ml of a suspension of 600,000 microspheres/ml). Three hours after embolization white patches appeared in the retinal pigment epithelium as well as a posterior pole serous retinal detachment in five eyes. Delayed choroidal filling was noted in the quadrant involved, but a few choriocapillaris units slowly perfused, leading to fluorescein leakage in the serous retinal detachments. Histologic examination showed various types of damage to the retinal pigment epithelium, including vacuolization and cell membrane rupture.

Fluorescein angiography of the choroid in health and disease

Fluorescein angiography of the normal fundus reveals the segmental nature of the choroidal vascular bed. Despite the presence of anatomically demonstrable anastomoses, a segmental distribution is present in vivo up to the choriocapillaris level. Choroidal vascular diseases manifest by localized of diffuse delayed or incomplete filling of the choroid and by the involvement of the overlying retinal pigment epithelium. In the acute phase of choroidal arterial occlusive disease, ophthalmoscopy reveals localized or diffuse edema. Fluorescein angiography of such cases initially shows a delayed perfusion of the involved area followed later on by fluorescein leakage. This late diffusion of the dye is probably related to alterations of the retinal pigment epithelial barrier. The extent of the lesion after resolution of the edema mainly depends on the site and the extent of the occlusion, on the development of collaterals and possibly on the involvement of the choroidal venous circulation. Ophthalmoscopy and fluorescein angiography will reveal localized or diffuse pigmentary changes, sometimes of quite characteristic aspect. This may be associated with local destruction of the choriocapillaris, although normalization of choroidal blood flow may also be observed. Chronic choroidal vascular insufficiency is a possible cause for choroidal sclerosis. Chronic choroidal ischemia is also a possible explanation for peripheral pigmentary changes seen in the elderly.

Choroidal ischemia

Nine patients, seven women and two men, ranging in age from 21 to 86 years, had generalized vascular disease and significant deficits in choroidal perfusion but no retinal vascular changes. Because these perfusion abnormalities can be identified only by fluorescein angiography and the fundus appears to be normal, choroidal ischemia may be more common than has been realized. Infarction of the choroid, retinal pigment epithelium, and outer retina are usually unassociated with retinal detachment; even ischemia severe enough to induce retinal detachment seldom produces significant atrophy.