Behçet's disease: an unusual case with bilateral obliterating retinal panarteritis and ischemic optic atrophy

Suspected Simultaneous Bilateral Anterior Ischemic Optic Neuropathy in a Patient with Behçet's Disease

AIM

To report a 47-year-old Japanese woman with a one-year history of Behçet's disease who complained of sudden bilateral visual loss with concurrent anterior ischemic optic neuropathy (AION).

CASE REPORT

The patient's Snellen visual acuity was 0.1 (OD) and 0.3 (OS) of onset. There was bilateral mild anterior chamber inflammation. Bilateral optic disc pale swelling was observed without retinal exudates and edema. Fluorescein angiography demonstrated bilateral hypofluorescence of the optic disc in early frames but with no distinct retinal vasculitis. Visual field showed bilateral relative central scotoma and right altitudinal hemianopsia. Laboratory examination revealed an ESR of 26 mm in the first hour with a C-reactive protein level of < 0.3 mg/dl. Periocular injection of triamcinolone acetonide in both eyes without systemic corticosteroid administration improved her visual acuity to 0.7 (OD) and 1.2 (OS) within 45 days of onset. Bilateral optic disc swelling gradually resolved. In the early stages, fluorescein angiography demonstrated normal optic disc filling in both eyes. There was a residual right central scotoma on visual field.

CONCLUSION

We observed an extremely rare case of simultaneous bilateral AION with Behçet's disease with marked visual recovery within 45 days of onset.

Heidelberg retina tomograph in ocular Behçet's disease

PURPOSE

To compare the optic disc topography of patients with ocular Behçet's disease (BD) with age-matched controls, using Heidelberg retina tomograph (HRT).

METHODS

This study included 32 patients (51 eyes) with ocular BD (active and/or inactive), 38 patients (74 eyes) with nonocular BD, and 62 normal subjects (62 eyes). All patients and control group underwent complete ophthalmologic evaluation. Intraocular pressure was less than 22 mmHg in patients and in the control group. The optic nerve heads of all subjects were imaged with the HRT (software 2.01a-M). The following stereometric parameters were calculated for each patient: disc area, cup area, cup/disc area ratio, rim area, height variation contour, cup volume, rim volume, mean cup depth, cup shape measure, mean RNFL thickness, and RNFL cross-sectional area. Differences among the groups were evaluated by Kruskal-Wallis variance analysis. When the Kruskal-Wallis test revealed a significant difference between groups, multiple comparison tests were used to find out which groups differed from which others.

RESULTS

The mean disc area was significantly smaller (P<0.05) in patients with ocular and nonocular BD. The mean cup area, mean cup depth, and mean cup volume were significantly smaller (P<0.05) in patients with ocular BD. No significant differences were found between the groups in terms of the other stereometric parameters (P>0.05).

CONCLUSION

A small disc and cup may be an additional risk factor for retinal vaso-occlusion in ocular Behçet's disease.

A bad eye and a sore lip

A 48-year-old woman developed painful visual loss in the left eye, meningismus, and painful oral ulcers. Magnetic resonance imaging of the brain with gadolinium demonstrated enhancement of the left optic nerve. Lumbar puncture showed a lymphocytic pleocytosis, and a biopsy specimen of one of the oral ulcerations was consistent with Behçet's disease. Epidemiologic factors and diagnostic criteria for Behçet's disease are discussed.

Demyelination of retinal myelinated nerve fibers in Behcet's disease

A 39 year-old Behcet's patient had demyelination of retinal myelinated nerve fibers after recurrent papillitis and vitritis. Oral Prednisolone, cyclosporine, and later periocular corticosteroids and oral colchicine were used but demyelination continued over a 5 year-period. A pseudobulbar palsy with urinary incontinence and pyramidal tract signs developed and azathioprine and corticosteroids were used. Demyelination of retinal nerve fibers stopped and while treatment was underway, the central nervous system (CNS) signs were stable. While the ocular pathology of Behcet's can mirror the CNS signs, indeed optic nerve ischemic demyelination may signal the potential for CNS involvement; azathioprine with prednisone may be more effective in the long-term for optic nerve and CNS involvement than cyclosporine with prednisone.

Cyclosporine effects on optic nerve and retinal vasculitis in Behçet's disease

In a prospective, open clinical trial, we studied long-term effects of cyclosporine (CsA) on the optic nerve and retinal vasculitis in 14 Behçet's disease patients. Patients were treated with CsA and corticosteroids for a mean period of 42 months, with a range of 36 to 52 months. They received an initial CsA dosage of 7 mg/kg/day for three days, followed by 5 mg/kg/day, and prednisone 1 mg/kg/day for three to five days, tapered to 0.4 mg/kg/day. CsA was tapered when clinical response was noted. Improvement occurred in visual acuity and visual field defects secondary to papillitis, optic neuritis, macular neuroretinitis, and retinal phlebitis, but not with retinal arteritis. Despite a 12/14 (85%) exacerbation rate, no permanent liver or renal lab tests abnormalities were noted. Intermittent, low-dose CsA therapy may be considered in treatment of acute retinal and optic nerve vasculitis assisted with Behçet's disease.

Retinal vasculitis in Lyme borreliosis

Three patients with retinal vasculitis are reported who were found to be seroreactive for Lyme borreliosis. Careful investigation revealed no other apparent etiology for the angiitis, and improvement of the retinal vasculitis on tetracycline therapy was documented by fluorescein angiography in one of them. Two cases of retinal vasculitis were presented at the International Conference on Lyme Borreliosis in Stockholm 18-21 June 1990, and two cases of cerebral vasculitis due to Borrelia burgdorferi have been published. To our knowledge, this is the first published report of retinal vasculitis occurring in patients seroreactive for Lyme borreliosis. Although further investigation will be necessary to prove a cause-and-effect relationship, ophthalmologists encountering patients with otherwise unexplained cases of retinal vasculitis, or Eales disease, are encouraged to study these patients carefully for the possibility of Borrelia burgdorferi infection.