Title : Central retinal artery occlusion in active polyarteritis nodosa: A case report
Abstract:
A 75-year-old woman presented to her GP with a one-month history of bilateral lower leg livedo reticularis extending to the thighs, accompanied by burning dysaesthesia of the soles, weight loss, fatigue and night sweats. Weeks later, she re-presented with a necrotic ulcer on the right toe and was referred to dermatology and rheumatology for further assessment. Initial laboratory investigation showed normal full blood count, renal, thyroid and complement function, with elevated inflammatory markers (ESR 78?mm/h, CRP 65?mg/L). Autoimmune screening was positive for cryoglobulins, lupus anticoagulant and anticardiolipin antibodies, while ANCA, ANA, anti-dsDNA and ENA were negative. Skin biopsy revealed medium-vessel vasculitis with granulomatous inflammation involving the subcutis, confirming polyarteritis nodosa (PAN). She commenced topical corticosteroids only, with no systemic immunosuppression at that stage.
Ten months later she experienced sudden painless right eye vision loss. Visual acuity was 6/60 with a right afferent pupillary defect. Optical coherence tomography showed inner retinal swelling consistent with central retinal artery occlusion (CRAO). Investigations identified no thromboembolic risk factors such as hyperlipidaemia or atrial fibrillation. She was treated with three days of intravenous methylprednisolone followed by tapering oral prednisolone and six months of intravenous cyclophosphamide. Cutaneous lesions resolved but visual acuity remained 6/60. CRAO is most often thromboembolic but systemic vasculitides such as PAN are recognised causes. Ocular involvement occurs in 10–20% of PAN cases and may include CRAO, choroidal infarction and ischaemic optic neuropathy. In this case, absence of embolic risk factors, persistently elevated inflammatory markers and histologically confirmed PAN support a vasculitic aetiology. The delay in initiating systemic immunosuppression may have allowed irreversible ocular injury. Therefore, in patients with systemic vasculitic features, early systemic treatment can preserve vision and prevent further organ damage.
