Association of Inflammatory Eye Disease With Granuloma Annulare? FREE

To our knowledge, 3 reports in the literature document the presence of uveitis in patients with granuloma annulare (GA) (Table). Oz et al¹ first reported this association in a 51-year-old woman with anterior uveitis, an inflammatory disease of the iris and ciliary body. Rahimi and Moinfar² later reported a similar case of anterior uveitis and biopsy-proven GA. Resolution of both skin and ocular disease occurred after administration of topical and systemic corticosteroids; however, these 2 patients relapsed once topical and systemic steroids were tapered.

In the largest study to date, van Kooij et al³ described 8 patients with bilateral, chronic, intermediate uveitis and biopsy-proven localized GA. Of note, intermediate uveitis is much less common than anterior uveitis and is characterized by inflammation of the peripheral retina, pars plana, and vitreous rather than of the anterior uvea. Seven of the patients described had evidence of severe retinal vasculitis complicated by cystoid macular edema, cataract, and glaucoma. One patient required laser photocoagulation for treatment of ischemic retinopathy secondary to vasculitis. These authors proposed that patients diagnosed with GA should undergo a screening evaluation for uveitis and that ophthalmologists should become familiar with the classic presentation of GA. These reports prompted us to question whether screening a cohort of patients with GA would reveal any past or present evidence of uveitis.

This was a cross-sectional study approved by the University of Louisville institutional review board. A medical records database search was performed within a private practice associated with the Division of Dermatology using the diagnosis of GA and covering the dates January 1, 2003, through October 31, 2005. Patients older than 18 years with the pathologic and/or clinical diagnosis of GA were contacted and scheduled for a voluntary ophthalmologic examination to evaluate them for any signs of either past or present uveitis. All patients signed informed consent forms.

Patient medical charts were reviewed for pertinent clinical data including sex, age, lesion morphologic characteristics and distribution, duration, and medical history. The diagnosis and classification of uveitis was based on the consensus opinions of the Standardization of Uveitis Nomenclature Working Group.⁴

Sixty-six patients were diagnosed with GA from January 1, 2003, to October 31, 2005. Nineteen patients underwent an ophthalmologic examination. The average age of the patients at the time of the ophthalmologic examination was 52 years (range, 18-70 years). In 15 cases (79%), the diagnosis of GA had been confirmed by biopsy. Disease duration for any presentation of GA ranged from 9 months to 17 years (mean duration, 3.7 years).

Of the 19 patients examined, only 1 had any evidence of past uveitis. That patient denied any history of other autoimmune diseases and reported a 40-year history of recurrent anterior uveitis, but only a 4-year history of GA. Results of HLA antigen typing, if ever performed, were unknown to the patient. The right eye had developed more severe sequelae of uveitis, including cataract and glaucoma, while involvement of the left eye was minimal. Of note, there had been an unrelated laceration to the cornea of the right eye as well as a failed epikeratoplasty following a cataract extraction that left the patient's right eye aphakic.

Uveitis is an inflammatory eye disease primarily involving the uvea (ie, iris, ciliary body, and choroid) as well as adjacent tissues. The prevalence is estimated at less than 1%, making it a relatively rare disease.⁵ It most commonly involves the anterior uvea, but varies in onset, severity, course, and location within the eye. While there are known systemic infectious and autoimmune diseases with uveitic manifestations, most uveitis cases are idiopathic in origin.⁶

Our cross-sectional study of 19 patients with GA revealed only 1 case of chronic asymmetric anterior uveitis; however, the onset of the 2 diseases was temporally offset by roughly 40 years, making an association between them unlikely. Because the prevalence of uveitis is less than 1% in the general population, it is difficult to assess whether there is an overall higher prevalence among patients with GA. We were unable to establish statistical conclusions in our study owing to the small sample size and cross-sectional design. A larger, multicenter, longitudinal, prospective study would likely be needed to provide any statistically valuable data or to identify an association, if one exists.

While there may be an association between GA and uveitis, it is likely rare and restricted to certain subsets of these 2 diseases. Based on our limited findings in this study, we do not recommend a screening eye examination for uveitis in patients with GA.

Correspondence: Dr Callen, 310 E Broadway, Ste 2A, Louisville, KY 40202 (jefca@aol.com).

Author Contributions: Drs Kaplan and Callen had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Brey, Purkiss, and Callen. Acquisition of data: Brey, Purkiss, and Sehgal. Analysis and interpretation of data: Purkiss and Kaplan. Drafting of the manuscript: Brey and Purkiss. Critical revision of the manuscript for important intellectual content: Purkiss, Sehgal, Kaplan, and Callen. Statistical analysis: Purkiss. Obtained funding: Kaplan. Administrative, technical, and material support: Pur kiss and Kaplan. Study supervision: Kaplan and Callen.

Financial Disclosure: None reported.

Funding/Support: This study was supported by funding from Research to Prevent Blindness, New York, New York (Drs Purkiss, Sehgal, and Kaplan), and the Commonwealth of Kentucky Research Challenge Trust Fund, Frankfort (Dr Kaplan).

Disclaimer: Dr Callen is the associate editor of Archives of Dermatology; he was not involved in the editorial evaluation or editorial decision to accept this work for publication.