A Case of Multiple Cranial Nerve Palsies and Posterior Ischemic Optic Neuropathy secondary to Polyarteritis Nodosa

Title A Case of Multiple Cranial Nerve Palsies and Posterior Ischemic Optic Neuropathy secondary to Polyarteritis Nodosa
Author, Co-Author Heather Worrell, Vanessa Santos-Nevarez, Joseph Miller, Paul Gruosso
Program Number
Great Hall Foyer
Abstract BACKGROUND: Polyarteritis nodosa is a necrotizing vasculitis that affects small and medium-sized arteries. Ocular involvement occurs in 10-20% of patients. The literature has described manifestations such as extraocular muscle palsies, anterior and posterior ischemic optic neuropathies, choroidal ischemia, and retinal artery occlusions. This case discusses a patient diagnosed with polyarteritis nodosa that resulted in multiple cranial nerves palsies and a presumed posterior ischemic optic neuropathy.

CASE REPORT: A 66 year old Caucasian male presented with a complaint of oblique diplopia and blurred vision OS for 2 days. The patient's medical history was remarkable for polyarteritis nodosa with recent lowering of his oral prednisone dosage due to improved symptoms. The entering visual acuities were 20/20-1 OD and 20/100-1 OS. Ocular examination revealed significant extraocular muscle restriction in all gazes and ptosis OS, consistent with cranial nerve III, IV and VI palsies. The left eye had an afferent pupillary defect, significantly reduced color vision, and a red cap desaturation of 50% that was suggestive of an optic neuropathy. However, fundus examination of both eyes revealed normal fundi with pink and distinct optic discs and no evident pallor.  A MRI of the brain and orbits was ordered to rule out infiltrative, inflammatory, or compressive etiologies. The results were unremarkable. Therefore, a diagnosis of presumed posterior ischemic optic neuropathy OS was made. The patient received prompt treatment with prednisone and cyclophosphamide infusions, which resulted in improvement in his extraocular muscle function as well as improved acuity of 20/20-2 OS. CONCLUSION: Ocular involvement may be the initial manifestation of polyarteritis nodosa that prompts a patient to seek medical care. Therefore, it is imperative that optometric physicians are aware of the various ocular complications that may be associated with this potentially life-threatening condition.
Affiliation of Co-Authors C.W. Young VA Hospital, C.W. Young VA Hospital, C.W. Young VA Hospital