Ocular manifestations in a case of granulomatosis with polyangiitis

An ophthalmology consult was sent for a patient admitted to the medicine ward. The patient was a 29-year-old male, a known case of granulomatosis with polyangiitis (GPA). The patient had a finger-counting vision in the right eye and 20/20 best-corrected visual acuity in the left eye. The intraocular pressure was within normal limits. On slit-lamp examination, the right eye had temporal scleromalacia [Figure 1] which was the cause of watering. There was no thinning on anterior segment optical coherence tomography [Figure 2]. Fundus evaluation showed old central retinal artery occlusion (CRAO) [Figures 3 and 4]. The patient was completely fine 10 months ago when he had lower gastrointestinal bleed. The patient had undergone exploratory laparotomy and repair of perforations and pulse steroids. The patient was already on oral steroids. Erythrocyte sedimentation rate, Antineutrophil cytoplasmic antibodies (ANCA), and high-sensitivity C-reactive protein were strongly positive. However, the patient had mucocutaneous candidiasis, and tuberculosis was also confirmed.Figure 1: Clinical picture of the right eye of the patient showing scleromalacia temporallyFigure 2: Anterior segment optical coherence tomography showing the absence of scleral thinningFigure 3: Fundus picture showing old central retinal artery occlusionFigure 4: Macular optical coherence tomography showing scarred maculaThe patient gave a history of painless vision loss in the right eye 8 months ago which could have been CRAO. The patient was started on topical steroids with antibiotic cover. The patient's condition worsened, and the patient could not be followed on slit lamp as he was bedridden. The patient was lost to follow-up after discharge. Scleromalacia is a known manifestation of GPA, reported in 27% of patients.[1] CRAO, however, has not been reported much.[2] The ocular manifestations in GPA are often difficult to treat due to concomitant comorbidities. Many patients are suffering from tuberculosis, and it is tricky to use immunosuppressants in them. A multidisciplinary approach is needed. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.