Horner's syndrome in Wegener's granulomatosis: report of four cases

Ocular manifestations and concepts of systemic vasculitides

Vasculitic disorders are relatively rare. Their etiology and pathophysiology remain enigmatic, leading to confusing nomenclature and multiple classification schemes. Untreated vasculitis can be fatal. Early diagnosis is the key to successful treatment and better prognosis. However, early diagnosis can be difficult; vasculitic conditions usually present with non-specific symptoms for a long period before clinically overt manifestations occur. Ophthalmologists should be familiar with the ocular manifestations of the vasculitic disorders because they may not only be sight-threatening, but more importantly could be the presenting manifestations of active, potentially lethal systemic disease. This review summarizes clinical and ocular manifestations of systemic vasculitic disorders. Furthermore, it discusses general concepts in diagnosis and treatment of these diseases in an effort to provide a practical framework for the ophthalmologist evaluating patients with vasculitis.

Horner's syndrome resulting from a prolonged abnormal posture during a coma

BACKGROUND

Horner's syndrome results from the impairment of the sympathetic nerve supply to the eye and orbit. Other nerve palsies from prolonged unchanged posture are well described, but Horner's syndrome following prolonged lateral flexion has only twice been seen previously and these cases were in association with anaesthesia.

METHODS/RESULTS

A case is described of Horner's syndrome resulting from a prolonged period of unchanged posture from an alcohol-induced coma. A review of the anatomy of Horner's syndrome is presented.

CONCLUSION

To my knowledge, this is the first reported case of Horner's syndrome resulting from a coma.

Wegener's granulomatosis

Clinical manifestations of Wegener's granulomatosis are nonspecific and indistinguishable from a variety of neoplastic, infectious, and inflammatory diseases. Ophthalmic disease is the presenting feature in nearly one sixth of patients with Wegener's granulomatosis and will ultimately develop in a majority. The discovery of antineutrophil cytoplasmic antibodies, particularly antiproteinase-3, has changed the clinical approach to evaluating patients suspected of having Wegener's granulomatosis. These antibodies are distinguished from other related autoantibodies because they produce a coarse granular pattern of cytoplasmic staining on indirect immunofluorescence with ethanol-fixed neutrophils. Treatment of Wegener's granulomatosis with oral cyclophosphamide and corticosteroids has decreased morbidity and improved survival, but side effects from long-term immunosuppressive therapy are common and sometimes serious. The effectiveness of trimethoprim-sulfamethoxazole in decreasing the number and severity of recurrences of Wegener's granulomatosis is being investigated. It remains to be determined if wide use of trimethoprim-sulfamethoxazole in limited Wegener's granulomatosis could further improve the quality of life for some patients.

Neuro-ophthalmic manifestations of meningocerebral inflammation from the limited form of Wegener's granulomatosis

PURPOSE

Wegener's granulomatosis is classically a systemic necrotizing granulomatous vasculitis that involves the upper and lower respiratory tracts and kidneys. Ophthalmologic and neurologic manifestations are common. The limited form of Wegener's granulomatosis may have pathologic characteristics consistent with the disease but lacks the complete clinical triad. We studied the clinical, pathologic, laboratory, and radiologic findings of four patients with Wegener's granulomatosis so that others will recognize the disease, even when it occurs in its limited form.

METHODS

From three clinical centers, a chart review disclosed four patients with neuro-ophthalmic findings and the limited form of Wegener's granulomatosis.

RESULTS

Three men and one woman, ranging in age from 40 to 73 years, were studied. All four patients had ocular motor abnormalities (one with oculomotor and trochlear nerve palsies, one with oculomotor nerve palsy, one with trochlear and abducens nerve palsies, and one with horizontal gaze deviation) in addition to other cranial nerve and cerebral abnormalities. Neuroimaging showed prominent meningeal, as well as intraparenchymal, abnormalities. In all patients, results of antineutrophil cytoplasmic antibody tests were initially negative but in one patient were positive at a late stage of the disease. In all patients, results of a biopsy demonstrated necrotizing granulomatous inflammation consistent with Wegener's granulomatosis.

CONCLUSIONS

Neuro-ophthalmic findings may be the earliest manifestations of the limited form of Wegener's granulomatosis. Extensive meningocerebral inflammation can occur before systemic involvement or laboratory confirmation. Early diagnosis by biopsy of affected tissues may facilitate appropriate treatment and prevent progression of the disease.