| OCR Text |
Show Ischemic Optic Neuropathy Associated with Crohn's Disease DALE K. HEUER, M.D. WALTER E. GAGER, M.D. FREDERICK H. REESER, M.D. Abstract A 24-year-old man with Crohn's disease suffered bilateral ischemic optic neuropathy following the resolution of an episode of "uveitis." Additional findings of corneal infiltrates, vitritis, retinovascular sheathing, and arthritis suggest an inflammatory basis for his ischemic optic neuropathy. Vasculitis as an extraintestinal manifestation of inflammatory bowel disease is a possible etiology. To our knowledge, the association of ischemic optic neuropathy and inflammatory bowel disease has not been previously reported. Extraintestinal complications of inflammatory bowel disease may present in virtually all organ systems. Those most commonly affected are rheumatologic (arthritis, ankylosing spondylitis, and sacroiliitis), ophthalmic (conjunctivitis, episcleritis, and anterior uveitis), and dermatologic (aphthous stomatitis, erythema nodosum, and pyoderma gangrenosum). The following case report describes a patient with bilateral ischemic optic neuropathy complicating Crohn's disease. To our knowledge, the association of inflammatory bowel disease and ischemic optic neuropathy has not been previously reported. Case Report A 24-year-old white man had been in good ocular health until April 1980, when he noticed redness and watering of his right eye associated with blurred vision. Two days after the onset of these symptoms, "uveitis" was diagnosed by his private ophthalmologist. Inflamase and cycloplegic drops afforded resolution of the patient's symptoms within 2 weeks; however, 1 week after that resolution, he noted "blocked vision" in the lower visual field of his right eye. Ophthalmic reevaluation revealed "papillitis," so he was begun on 40 mg of prednisone daily. Five days later on May 14, 1980, after the pred- From the Department of Ophthalmology, Medical College of Wisconsin. Milwaukee, Wisconsin. September 1982 nisone had failed to afford any improvement, he was referred to the Medical College of Wisconsin Eye Institute for further evaluation. That examination revealed best-corrected visual accuity of 20/ 30 in the right eye and 20/25 in the left. Pseudoisochromatic plates were correctly identified 9/14 with the right eye and 13/14 with the left. There was a right afferent pupillary defect. Applanation pressures were 19 mm Hg in the right eye and 16 mm Hg in the left. The conjunctivae were white and quiet. The right corneal endothelium revealed mild, diffuse pigment dusting and a small, quiescent, white opacity inferonasally. Trace aqueous flare and cells were noted in the right eye. The irides were brown and without rubeosis or transillumination defects. The right lens had minimal pigment on the anterior capsule. There were no cells in the vitreous of either eye. The right optic disc was swollen with blurred margins. There were small overlying splinter hemorrhages with dilated capillaries and minimal venous engorgement (Fig. 1a). The left disc also revealed minimal swelling (Fig. 1b). Neither eye manifested spontaneous venous pulsations. The fundi, including the pars plana regions, were otherwise unremarkable bilaterally. In the right eye, Goldmann perimetry demonstrated an inferior altitudinal defect, denser nasally than temporaIly. Amsler grid examination and Goldmann perimetry were normal in the left eye. Fluorescein angiography revealed evidence of capillary dilation and venous stasis with leakage, especially in the superior halves of both discs, somewhat more marked on the right. Both discs manifested diffuse leakage in the late photographs (Figs. 2a and 2b). High resolution orbital and cranial CT scan was normal. One week later, despite an increased dose of prednisone (60 mg daily), the patient developed blurred vision inferonasally in his left eye. Repeat Goldmann visual fields on May 28, 1980, revealed bilateral inferior altitudinal defects, denser nasally than temporally. Consequently, the patient was given bilateral retroseptal injections of Kenalog 20 mg and his prednisone was further increased to 100 mg daily. 175 Ischemic Optic Neuropdthy I • Figure 1. Bilater,11 optic disc ('dema. mild capillary dilation. and mild venous engorgement. with nerv(' fiber 1,lyer h('morrhages overlying right optic nerve. (d 1 right eye; (b lleft eye. Within 3 weeks, while on a rapidly tapering regimen of prednisone, his papillitis had essentially resolved (Figs. 3a and 3 b); however, mild pallor had already become apparent diffusely in the right disc (Fig. 4 a) and superiorly in the left disc (Fig. 4b). There was also some mild periarteriolar and venular sheathing noted in the right eye. The patient's visual acuity improved to 20/20 bilaterally by July, but repeat Goldmann perimetry on August 28, 1980, revealed persistent bilateral inferior altitudinal defects (Fig. 5). Neuro-ophthalmic consultation at the Bascom Palmer Eye Institute on September 29, 1980, confirmed the patient's bilateral inferior altitudinal visual field defects with diffuse optic atrophy on the right and segmental superior optic atrophy on the left. Notable additional findings were bilateral, rare vitreous cells and bilateral, marginal subepi- Journal of Clinical Neuro-ophthalmology Heuer, Gager, Reeser Figure 2. L.ltc ph.l"'C' tlf fluun....u.·in .1n~ill~r.lIn rl'vt'.llin~ diHl....l' Il'.lk.l~'" .1Hlund both oplll .Ii" '. mol''' prollouIl,'"d "'OUIHJ lh" ri~hl .Ii", ( .• ) ri~ht l'\'l'; 1(') Idl l'y", theliaI corneal infiltrates associated with conjunctival injection. The course of the patient's ocular disease was neither preceded nor accompanied by any neurolOgic symptoms other than the visual loss, He specifically denied any decrement of his visual function associated with exercise or hyperthermia. DUring July or August, 1980, he did notice the September 1982 onset of wrist and temporomandibular joint tenderness. A complete blood count, urinalysis, sedimentation rate, biochemical screen (total protein, albumin, total bilirubin, SGOT, alkaline phosphatase, lDH, creatinine, uric acid, calcium, phosphorous, cholesterol, and glucose), and arthritis screen (uric acid, anti-streptolysin-O, C-reactive protein, and 177 Ischemic Optic Neuropathy Figure 3. Fluorescein angiogram 5 weeks after Fig. :!. revealing resolution of disc edema in the 1,1te photogr,lphs. (.1) right eye; (b) left eye. rheumatoid factor) had been performed by the patient's gastroenterologist on May 12, 1980, and were remarkable only for a sedimentation rate of 44, an alkaline phosphatase of 153 units/liter (adult normal 30-105), and the presence of C-reactive protein. The alkaline phosphatase was repeated on May 22, 1980, at which time it was 42 units/liter. A quantitative immunoglobulin electrophoresis was also obtained on May 22 and revealed an elevated IgM of 400 mg/dl (adult normal 60-250), but IgA and IgG were within normal limits. His VORL and ITA-ABS were both nonreactive. Antinuclear antibody (ANA), total hemolytic complement level (CHso), complement C3, complement C4, cryoglobulin, hemoglobin electrophoresis, and protein electrophoresis were unremarkable; however, these tests were performed only after the patient had completed his course of prednisone. The patient's past history is significant for anorectal disease since the spring of 1976, when he first noticed painful defecation associated with blood on his toilet tissue. A proctologist initially Journal of Clinical Neuro-ophthalmology Heuer, Gager, Reeser 1.. 1 Figure 4. Bil.JtNJI diffusl' optic Jtr,'phy (rn",l' rn.Jrk(,d superiorlv). with mild pc''''.Jrtl'riolJr Jnd vl'nulJr shl'Jthillg ill thl' right "yl'. (,1) right l'Vl'; (h) Idt eY<'. diagnosed fissure-in-ano; however, local symptomatic therapy failed to relieve the patient's discomfort and he subsequently developed some fistulae. A hemorrhoidectomy with excision of fissures and fistulae was successfully performed; however, by August 1976, he had suffered recurrent "cracks." Over the ensuing months his symptoms continued and his stool frequency insidiously increased to 5 to 8 times daily. In Mayor June 1977, a rectal biopsy revealed granulomatous inflammation, establishing the diagnosis of Crohn's disease. The September 1982 patient was referred to a gastroenterologist who initiated longterm therapy with 500 mg of azulfidine 4 times daily. Despite the azulfidine he continued to have painful defecation and, significantly, his stool frequency did not decrease from his usual 5 to 8 times daily. During the fall of 1979, he underwent a I - to 2-month trial of f1agyl, which had a definite local effect, healing his proctitis; however, he developed a low-grade fever, pharyngitis, and fatigue, all of which remitted shortly after the f1agyl had been discontinued. It is note- 179 Ischemic Optic Neuropathy LEFT RIGHT Figure 5. Goldmann visual fields demonstrating persistent bilateral inferior altitudinal defects. worthy that while the patient was taking high doses of prednisone for his ocular symptoms, he noted a definite amelioration of his bowel symptoms, with his stool frequency being decreased to only 2 or 3 times daily. The patient's family ocular history is noncontributory. His family medical history is remarkable only for his father who had diabetes and suffered a fatal myocardial infarction at age 51. Discussion The ophthalmic manifestations of inflammatory bowel disease are protean. They include: orbital congestion and edema, orbital cellulitis, dacryostenosis, lid edema, blepharitis, blepharokeratitis, conjunctivitis, keratoconjunctivitis, dry eye, corneal erosions and ulcers, marginal corneal infiltrates, midperipheral subepithelial keratopathy, keratitis, episcleritis, scleritis, scleromalacia perforans, myositis with extraocular muscle paresis, anterior uveitis, choroiditis, vitritis, retinitis, retinal edema, macular hemorrhage, retinovascular engorgement, peripapillary vascular sheathing, central and branch retinal artery occlusions, neuroretinitis, papillitis, retrobulbar neuritis, and allergic optic neuritis.l-l~ These ocular complications of inflammatory bowel disease may be classified as primary or secondary based on their presumed pathophysiology. Primary manifestations may be immunologically mediated,11 accounting for their frequent association with rheumatologic and dermatolo~ic manifestations of inflammatory bowel disease. I.. 10 They are usually associated with active enteritis or colitis and may respond to medical or surgical treatment of the underlying bowel disease. Secondary disorders are related to the pathophysiologic changes in the bowel itself, such as malabsorption or perforation with fistula and abcess fonnation. Therefore, in contradistinction to the primary group, these complications are related to the severity of the bowel disease and tend to occur or persist even in the absence of active inflammation. Crohn's disease (regional enteritis and granulomatous colitis) and ulcerative colitis comprise a spectrum of relapsing small and large intestinal inflammatory disorders, known collectively as inflammatory bowel disease. Classically the two diseases were differentiated more by their presumed differing intestinal distributions than by their somewhat distinctive morphologic changes: Crohn's disease being a segmental, transmural, chronic inflammation presumably limited to the small intestine, notable for fibrosis and the development of noncaseating granulomas; and ulcerative colitis being a diffuse, superficial, nonspecific inflammation presumably limited to the colon with little fibrosis and no granulomas. However, it has recently been recognized that Crohn's disease can present with colitis, either exclusively or, more commonly, in association with small bowel involvement. Ulcerative colitis affecting the tenninal ileum and the occasional coexistence of the two diseases have also been reported. Most of the reports of ocular complications of "ulcerative colitis" have not been based on appropriate distinctions between Crohn's disease and Journal of Clinical Neuro-ophthalmology ulcerative colitis. Thus it has been suggested that the true prevalence of ocular sequelae of ulcerative colitis has been overestimated, while that of (rohn's disease has perhaps been underestimated." The altitudinal character of this patient's visual field defects implicates ischemia in the distribution of the posterior ciliary arteries affecting the prelaminar portion of the optic nerve. I', The occurrence of ischemic disease of the optic nerve in young patients is usually a reflection of connective tissue disease, juvenile diabetes mellitus, hypertension, systemic arteritis, embolic disease, or migraine phenomena. lo In the absence of these disease processes or any underlying systemic illness (other than Crohn's disease) which might have predisposed this patient to such complications, one must consider a possible relationship between his ischemic optic neuropathy and Crohn's disease. Inflammatory bowel disease can be accompanied by a hypercoaguable state l1 · 13; consequently, the posterior ciliary ischemia might conceivably be attributable to vasoocclusive phenomena. Although evaluation of the patient's coagulation status was not persued, his history of anteceedent anterior uveitis and associated findings of marginal corneal infiltrates, vitritis, retinovascular sheathing, and wrist and temporomandibular joint arthritis militate for an inflammatory basis of his optic nerve ischemia. Vasculitis involving the prelaminar blood supply of his optic nerve is thus a possible etiology of his ischemic optic neuropathy. Vasculitis has been reported as a component of dermatologic comflications of inflammatory bowel disease. 7.12.17-1 This patient's ischemic optic neuropathy can consequently be classified as a primary ophthalmic manifestation of inflammatory bowel disease. It is therefore significant that the activity of his colitis, as reflected by his stool frequency, decreased dramatically while he was being treated with large doses of prednisone. It is interesting to speculate that perhaps the response of his papillitis to the prednisone was predominately the indirect result of ameliorating his colitis. Trademarks and generic names of drugs: Azulfidine-sulfasalazine; F1agyl-metronidazole; Inflamase-prednisolone phosphate; Kenalog.triamcinolone acetonide. References 1. Billson, F.A., de Dombal, F.T., Watkinson, G., and Goligher, J,C: Ocular complications of ulcerative colitis. Gut 8: 102-106, 1967. 2. Crohn, B.B.: Ocular lesions complicating ulcerative colitis. Am. ]. Med. Sci. 169: 260-267, 1925. 3. Daffner, J.E., and Brown, CH.: Regional enteritis: Clinical aspects and diagnosis in 100 patients. Ann. Intern. Med. 49: 580-594, 1958. 4. Ellis, P.P., and Gentry, J.H.: Ocular complications of September 1982 Heuer, Gager, Reeser ulcerative colitis. Am. ]. Ophtha/mo/. 58: 779-785, 1964. 5. Evans, P.J., and Eustace, P.: Scleromalacia perforans associated with Crohn's disease. Br. ]. Ophtha/mo/. 57: 330-335, 1974. 6. Hopkins, D.J., Horan, E., Burton, I.L., Clamp, S.E., de Dombal, FT., and Goligher, J.C: Ocular disorders in a series of 332 patients with Crohn's disease. Br. ]. Ophtha/mo/. 58: 732-737, 1974. 7. Kehoe, E.L., and Newcomer, K.L.: Thromboembolic phenomena in ulcerative colitis. Arch. Intern. Med. 113: 711-715, 1964. 8. Knox, D.L., and Bayless, T.M.: Gastrointestinal and ocular disease. In The Eye <lnd Systemic Disease (2nd I'd.), F.A. Mausolf, Ed. CV. Mosby Company, St. Louis, 1980, pp. 333-344. 9. Knox, D.L., Snip, R.C, and Stark, W.J.: The keratopathy of Crohn's disease. Am. ]. Ophthalmol. 90: 862-865, 1980. 10. Korelitz, B.I., and Coles, R.5.: Uveitis (iritis) associated with ulcerative and granulomatous colitis. Gastroenterology 52: 78-82, 1967. 11. Mayeux, R., and Fahn, 5.: Strokes and ulcerative colitis. Neurology 28: 571-574, 1978. 12. Macou), K.L.: Ocular changes in granulomatous ileocolitis. Arch. Ophtha/mo/. 84: 95-97, 1970. 13. Schneiderman, J,H., Sharpe, J.A., and Sutton, D.M.C: Cerebral and retinal vascular complications of inflammatory bowel disease. Ann. Neurol. 5: 331-337, 1979. 14. Greenstein, A.J,. Janowitz, H.D., and Sachar, D.B.: The extra-intestinal complications of Crohn's disease and ulcerative colitis: A study of 700 patients. Medicine 55: 401-412, 1976. 15. Hayreh, 5.5.: Pathogenesis of visual field defects. Role of the ciliary circulation. Br.]. Ophth<llmol. 54: 289-311, 1970. 16. Burde, R.M.: Ischemic optic neuropathies. In Symposium on Neuro-ophth<l/mology, Transactions of the New Orleans AC<ldemy of Ophthalmology, R.M. BurdI', J.5. Glaser, R.W. Hollenhorst, A Jampolsky, N.J. Schatz, G.B. Udvarhelyi, and H.J.L. Van Dyk, Contributors. CV. Mosby Company, 51. Louis, 1976, pp.25-37. 17. Dyer, N.H., Verbov, J.L.. Dawson, AM., Borrie, P.F., and Stansfeld, AG.: Cutaneous polyarteritis nodosa associated with Crohn's disease. Lancet 1: 648-650, 1970. 18. Johnson, M.L., and Wilson, H.T.H.: Skin lesions in ulcerative colitis. Cut 10: 255-263, 1969. 19. Wackers, F.J.Th., Tytgat, C.N., and Vreeken, J.: Necrotizing vasculitis and ulcerative colitis. Br. Med. ]. 4: 83-84, 1974. 20. Michener, W.M., Whelan, G., Greenstreet, R.I., and Lumer, R.C.: Cornp.uison of the c1inic.l1 fe.ltures of Crohn's disease .lnd ulcerative colitis with onset in childhood or adolescence. C1evel.Jnd CL Quart. 49: 13-lb, 1982. Write for reprints to: Walter E. Gager, M.D., Department of Ophthalmology, Medical College of Wisconsin, 8700 West Wisconsin Avenue, Milwaukee. Wisconsin 53226. 181 |
