Treatment of orbital inflammation with rituximab in Wegener's granulomatosis

To study the efficacy of rituximab therapy for the treatment of orbital inflammation in patients with Wegener's granulomatosis (WG). Ten WG patients with orbital inflammation were included in this case-series. None had symptoms suggestive of extra-orbital disease activity. Immunosuppressive medication (mycophenolate and prednisolone) was administered to 3 patients at the time of rituximab therapy. Three patients had previously been treated with anti-tumour-necrosis-factor-alpha antibodies, and one of these patients had also received cyclophosphamide as treatment for orbital inflammation. All patients were treated with 1000 mg of rituximab administered twice with an interval of 14 days between the infusions. Six months after therapy, a physical examination and a control computerised tomography (CT) scan was performed. All patients had orbital inflammation demonstrated by CT-scan before treatment (3 had bilateral and 7 unilateral orbital involvement). Orbital symptoms at study baseline included pain, pressure sensation behind the eyes, epiphora, diplopia, and affection of the visual acuity. Nine out of ten patients experienced subjective improvement. Four patients (seven eyes) with visual impairment responded to therapy, and the improvement in visual acuity was sustained throughout follow-up (median duration of follow-up: 17 months; range: 6-18 months). At the time of the control CT-scan, size-reduction of the orbital mass was observed in two patients, while the size of the orbital mass was unchanged in eight patients. Rituximab therapy has positive effects on symptoms, visual acuity and/or granuloma size in some WG patients with orbital inflammation. Treatment with rituximab should be considered in WG patients with this serious manifestation of the disease.