Ocular Sarcoidosis

[Interdisciplinary Management of Orbital Diseases]

Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.

Quality assurance in corneal transplants: Donor cornea assessment and oversight

The cornea is the most frequently transplanted human tissue, and corneal transplantation represents the most successful allogeneic transplant worldwide. In order to obtain good surgical outcome and visual rehabilitation and to ensure the safety of the recipient, accurate screening of donors and donor tissues is necessary throughout the process. This mitigates the risks of transmission to the recipient, including infectious diseases and environmental contaminants, and ensures high optical and functional quality of the tissues. The process can be divided into 3 stages: (1) donor evaluation and selection before tissue harvest performed by the retrieval team, (2) tissue analysis during the storage phase conducted by the eye bank technicians after the retrieval, and, (3) tissue quality checks undertaken by the surgeons in the operating room before transplantation. Although process improvements over the years have greatly enhanced safety, quality, and outcome of the corneal transplants, a lack of standardization between centers during certain phases of the process still remains, and may impact on the quality and number of transplanted corneas. Here we detail the donor screening process for the retrieval teams, eye bank operators. and ophthalmic surgeons and examine the limitations associated with each of these stages.

Tattoo-Induced Exacerbations of Systemic Disease and Uveitis

Purpose: To examine an underreported and underdiagnosed phenomenon with implications for the pathophysiological mechanisms of tattoo-induced uveitis. Methods: Two cases highlighting the clinical presentation of tattoo-related uveitis were evaluated. Results: A 28-year-old man with biopsy-proven sarcoidosis and ocular manifestations presented with worsening retinal vasculitis after acquiring a red-ink tattoo. Each subsequent flare followed acquisition of a new tattoo. A 31-year-old woman without systemic sarcoidosis presented with multiple episodes of bilateral intermediate uveitis and macular edema concurrent with inflammatory granulomas to recently acquired black-ink tattoos. A skin biopsy in both patients showed cutaneous noncaseating granulomas. Conclusions: These cases add to those reported in the literature and emphasize the importance of understanding the modifiable factors of inflammatory ocular disease. Future study is necessary to understand the mechanisms of tattoo-related uveitis.

Bilateral retinal vasculitis due to presumed sarcoidosis with rickettsial retinitis

OBJECTIVE

To describe a case of bilateral retinal vasculitis due to presumed sarcoidosis and rickettsial retinitis complicated with neovascularization with tear biomarker analysis.

METHODS

A retrospective case report.

RESULTS

A 16-year-old male presented with bilateral retinal vasculitis and retinitis in both eyes with inferotemporal quadrant neovascularization in the right eye. Multimodal imaging revealed the presence of active inflammation in both eyes. Weil Felix test was positive with raised ACE levels. This patient was treated with local and systemic steroids, doxycycline, and laser photocoagulation followed by oral methotrexate therapy which resulted in clinical resolution with recovery of visual acuity. Tear biomarker analysis showed raised sICAM-1 and MMP-9 levels in both eyes which significantly reduced following treatment.

CONCLUSION

Ocular sarcoidosis with rickettsial infection is a rare association. Tear biomarkers correlated well with clinical and imaging manifestations. High index of suspicion and aggressive anti-inflammatory therapy can help control inflammation and restore good vision.

Organ involvement in newly diagnosed sarcoidosis patients in the Netherlands: The first large European multicentre prospective study

BACKGROUND

Clinical presentation and prevalence of organ involvement is highly variable in sarcoidosis and depends on ethnic, genetic and geographical factors. These data are not extensively studied in a Dutch population.

AIM

To determine the prevalence of organ involvement and the indication for systemic immunosuppressive therapy in newly diagnosed sarcoidosis patients in the Netherlands.

METHODS

Two large Dutch teaching hospitals participated in this prospective cohort study. All adult patients with newly diagnosed sarcoidosis were prospectively included and a standardized work-up was performed. Organ involvement was defined using the WASOG instrument.

RESULTS

Between 2015 and 2020, a total of 330 patients were included, 55% were male, mean age was 46 (SD 14) years. Most of them were white (76%). Pulmonary involvement including thoracic lymph node enlargement was present in 316 patients (96%). Pulmonary parenchymal disease was present in 156 patients (47%). Ten patients (3%) had radiological signs of pulmonary fibrosis. Cutaneous sarcoidosis was present in 74 patients (23%). Routine ophthalmological screening revealed uveitis in 29 patients (12%, n = 256)). Cardiac and neurosarcoidosis were diagnosed in respectively five (2%) and six patients (2%). Renal involvement was observed in 11 (3%) patients. Hypercalcaemia and hypercalciuria were observed in 29 (10%) and 48 (26%, n = 182) patients, respectively. Hepatic involvement was found in 6 patients (2%). In 30% of the patients, systemic immunosuppressive treatment was started at diagnosis.

CONCLUSIONS

High-risk organ involvement in sarcoidosis is uncommon at diagnosis. Indication for systemic immunosuppressive therapy was present in a minority of patients.

Choroidal manifestations of non-ocular sarcoidosis: an enhanced depth imaging OCT study

BACKGROUND

Although choroidal thickening was reported as a sign of active inflammation in ocular sarcoidosis, there has been no research on the choroidal changes in non-ocular sarcoidosis (defined as systemic sarcoidosis without overt clinical signs of ocular involvement). Therefore, this study aimed to investigate choroidal structural changes in patients with non-ocular sarcoidosis.

METHODS

This retrospective case-control study was conducted at Asan Medical Center, a tertiary referral center. We evaluated 30 eyes with non-ocular sarcoidosis and their age- and spherical equivalent-matched healthy control eyes. The subfoveal choroidal thickness, area ratio (Sattler layer-choriocapillaris complex [SLCC] area to Haller layer [HL] area), and choroidal vascularity index (CVI, luminal area to choroidal area) were analyzed using enhanced depth imaging in optical coherence tomography. Systemic and ocular factors associated with the choroidal thickness were investigated.

RESULTS

Compared with the healthy control group, the non-ocular sarcoidosis group had significantly thicker subfoveal choroid (total and all sublayers [SLCC and HL]) and lower area ratio. There were no significant differences in the CVIs at all sublayers between groups. In the non-ocular sarcoidosis group, eyes under oral steroid treatment had thinner choroid than eyes under observation. In the control group, eyes with older age and more myopic spherical equivalent had thinner choroidal thickness.

CONCLUSION

Total and all sublayers of the subfoveal choroid were significantly thicker without significant vascularity changes in non-ocular sarcoidosis eyes than in healthy control eyes. The degree of choroidal thickening was disproportionally greater at HL than at SLCC. These characteristic choroidal changes may be the subclinical manifestations in non-ocular sarcoidosis.

Diagnostic delay of sarcoidosis: an integrated systematic review

BACKGROUND

Sarcoidosis is a chronic inflammatory granulomatous disease of unknown cause. Delays in diagnosis can result in disease progression and poorer outcomes for patients. Our aim was to review the current literature to determine the overall diagnostic delay of sarcoidosis, factors associated with diagnostic delay, and the experiences of people with sarcoidosis of diagnostic delay.

METHODS

Three databases (PubMed/Medline, Scopus, and ProQuest) and grey literature sources were searched. Random effects inverse variance meta-analysis was used to pool mean diagnostic delay in all types of sarcoidosis subgroup analysis. Diagnostic delay was defined as the time from reported onset of symptoms to diagnosis of sarcoidosis.

RESULTS

We identified 374 titles, of which 29 studies were included in the review, with an overall sample of 1531 (694 females, 837 males). The overall mean diagnostic delay in all types of sarcoidosis was 7.93 months (95% CI 1.21 to 14.64 months). Meta-aggregation of factors related to diagnostic delay in the included studies identified three categories: (1) the complex and rare features of sarcoidosis, (2) healthcare factors and (3) patient-centred factors. Meta-aggregation of outcomes reported in case studies revealed that the three most frequent outcomes associated with diagnostic delay were: (1) incorrect diagnosis, (2) incorrect treatment and (3) development of complications/disease progression. There was no significant difference in diagnostic delay between countries with gatekeeper health systems (where consumers are referred from a primary care clinician to specialist care) and countries with non-gatekeeper systems. No qualitative studies examining people's experiences of diagnostic delay were identified.

CONCLUSION

The mean diagnostic delay for sarcoidosis is almost 8 months, which has objective consequences for patient management. On the other hand, there is a paucity of evidence about the experience of diagnostic delay in sarcoidosis and factors related to this. Gaining an understanding of people's experiences while seeking a diagnosis of sarcoidosis is vital to gain insight into factors that may contribute to delays, and subsequently inform strategies, tools and training activities aimed at increasing clinician and public awareness about this rare condition.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42022307236.

Role of screening for uveitis in subjects with sarcoidosis

BACKGROUND AND OBJECTIVES

Ocular involvement is common in sarcoidosis. Our study aimed to evaluate the role of screening for uveitis in subjects with sarcoidosis.

METHODS

Retrospective case series of 88 subjects with a pre-existing diagnosis of sarcoidosis, with no previous diagnosis of uveitis, reviewed by Ophthalmology at Auckland District Health Board between January 2016 and May 2022.

RESULTS

Among those undergoing a screening examination, uveitis was observed in 27.8% (15 out of 54 subjects). In those presenting with acute eye symptoms, uveitis was observed in 94.1% (32 out of 34 subjects). Sarcoid uveitis was diagnosed in a total of 50 out of 88 subjects (56.8%). 45 subjects required ocular treatment. Sarcoid uveitis was observed in 6 out of 27 subjects (22.2%) who were entirely asymptomatic at screening. On multivariate analysis, blurring of vision (OR 26.2 p < 0.001), eye pain (OR 7.3 p = 0.014) and respiratory disease (OR 7.1 p = 0.044) were associated with increased risk of sarcoid uveitis. In the 41 subjects with no uveitis at initial examination, 3 subjects (7.3%) subsequently developed uveitis.

CONCLUSION

Our study highlights the importance of ophthalmic screening of all patients with systemic sarcoidosis, even in asymptomatic patients. With a high correlation of ocular symptoms in diagnosis of sarcoid uveitis, ophthalmologists should educate patients to look out for the development of symptoms of ocular inflammation, and clinicians who continue follow up for systemic sarcoidosis should remind patients to watch carefully for these symptoms to facilitate timely diagnosis and intervention.

Older Woman With Proptosis, Ptosis, and Blurred Vision

A woman in her early 70s with a history of coronary artery disease, hypertension, and colon polyps presented to oculoplastic surgery with 1 week of progressive right-sided proptosis, headache, right eyelid ptosis, and blurry vision. Outside magnetic resonance imaging demonstrated an infiltrative mass involving right greater than left orbital apices, the right optic nerve, and right extraocular muscles. What would you do next?

Ocular Sarcoidosis

Sarcoidosis frequently affects the eye and can do so in many different ways. Sarcoidosis causing uveitis can have distinctive features that facilitate identifying sarcoidosis as the cause of the uveitis. Progress is being made in elucidating ocular sarcoidosis, as for example, by transcriptomics, genetics, therapy, and imaging.

Clinical Pharmacology in Sarcoidosis: How to Use and Monitor Sarcoidosis Medications

When sarcoidosis needs treatment, pharmacotherapy is usually required. Although glucocorticoids work reliably and relatively quickly for sarcoidosis, these drugs are associated with numerous significant side effects. Such side effects are common in sarcoidosis patients, as the disease frequently has a chronic course and glucocorticoid treatment courses are often prolonged. For these reasons, corticosteroid-sparing and corticosteroid-replacing therapies are often required for sarcoidosis. Unfortunately, many healthcare providers who care for sarcoidosis patients are not familiar with the use of these agents. In this manuscript, we provide a review of the pharmacotherapy of sarcoidosis. We discuss the mechanism of action, dosing, side-effect profile, approach to monitoring and patient counselling concerning glucocorticoids, and the common alternative drugs recommended for use in the recent European Respiratory Society (Lausanne, Switzerland) Sarcoidosis Treatment Guidelines. We also discuss the use of these agents in special situations including hepatic insufficiency, renal insufficiency, pregnancy, breastfeeding, vaccination, and drug-drug interactions. It is hoped that this manuscript will provide valuable practical guidance to clinicians who care for sarcoidosis patients.

Diagnosing and Managing Uveitis Associated with Immune Checkpoint Inhibitors: A Review

This review aims to provide an understanding of the diagnostic and therapeutic challenges of uveitis associated with immune checkpoint inhibitors (ICI). In the wake of these molecules being increasingly employed as a treatment against different cancers, cases of uveitis post-ICI therapy have also been increasingly reported in the literature, warranting an extensive exploration of the clinical presentations, risk factors, and pathophysiological mechanisms of ICI-induced uveitis. This review further provides an understanding of the association between ICIs and uveitis, and assesses the efficacy of current diagnostic tools, underscoring the need for advanced techniques to enable early detection and accurate assessment. Further, it investigates the therapeutic strategies for ICI-related uveitis, weighing the benefits and limitations of existing treatment regimens, and discussing current challenges and emerging therapies in the context of their potential efficacy and side effects. Through an overview of the short-term and long-term outcomes, this article suggests recommendations and emphasizes the importance of multidisciplinary collaboration between ophthalmologists and oncologists. Finally, the review highlights promising avenues for future research and development in the field, potentially informing transformative approaches in the ocular assessment of patients under immunotherapy and the management of uveitis following ICI therapy.

Propensity-Matched Analysis of the Risk of Age-Related Macular Degeneration with Systemic Immune-Mediated Inflammatory Disease

PURPOSE

The pathogenesis of age-related macular degeneration (AMD) involves aberrant complement activation and is a leading cause of vision loss worldwide. Complement aberrations are also implicated in many systemic immune-mediated inflammatory diseases (IMIDs), but the relationship between AMD and these conditions remains undescribed. The aim of this study is to first assess the association between AMD and IMIDs, and then assess the risk of AMD in patients with specific IMIDs associated with AMD.

DESIGN

Cross-sectional study and cohort study.

SUBJECTS AND CONTROLS

Patients with AMD were compared with control patients with cataracts and no AMD to ensure evaluation by an ophthalmologist. Patients with IMIDs were compared with patients without IMIDs but with cataracts.

METHODS

This study used deidentified data from a national database (2006-2023), using International Classification of Diseases 10 codes to select for IMIDs. Propensity score matching was based on patients on age, sex, race, ethnicity, and smoking. Odds ratios were generated for IMIDs and compared between AMD and control patients. For IMIDs associated with AMD, the risk of AMD in patients with the IMID versus patients without IMIDs was determined utilizing a cohort study design.

MAIN OUTCOME MEASURES

Odds ratio of IMID, risk ratios (RRs), and 95% confidence intervals (CIs) of AMD diagnosis, given an IMID.

RESULTS

After propensity score matching, AMD and control cohorts (n = 217 197 each) had a mean ± standard deviation age of 74.7 ± 10.4 years, were 56% female, and 9% of patients smoked. Age-related macular degeneration showed associations with systemic lupus erythematosus (SLE), Crohn's disease, ulcerative colitis, rheumatoid arthritis (RA), psoriasis, sarcoidosis, scleroderma, giant cell arteritis, and vasculitis. Cohorts for each positively associated IMID were created and matched to control cohorts with no IMID history. Patients with RA (RR, 1.40; 95% CI, 1.30-1.49), SLE (RR, 1.73; 95% CI, 1.37-2.18), Crohn's disease (RR, 1.42; 95% CI, 1.20-1.71), ulcerative colitis (RR, 1.45; 95% CI, 1.29-1.63), psoriasis (RR, 1.48; 95% CI, 1.37-1.60), vasculitis (RR, 1.48; 95% CI, 1.33-1.64), scleroderma (RR, 1.65; 95% CI, 1.35-2.02), and sarcoidosis (RR, 1.42; 95% CI, 1.24-1.62) showed a higher risk of developing AMD compared with controls.

CONCLUSIONS

The results suggest that there is an increased risk of developing AMD in patients with RA, SLE, Crohn's disease, ulcerative colitis, psoriasis, vasculitis, scleroderma, and sarcoidosis compared with patients with no IMIDs.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Isolated Optic Disc Granuloma as a Presenting Sign of Sarcoidosis

PURPOSE

To report a case of an optic disc granuloma secondary to sarcoidosis in the absence of any systemic symptoms nor evident signs of intraocular inflammation at the time of presentation.

METHODS

Retrospective case report.

RESULTS

A 59-year-old Caucasian woman with previously unrevealing systemic work up was referred to the uveitis service for persistent optic disc edema of the right eye for over 1 year. Fundoscopic examination revealed an optic disc granuloma with associated hyper-reflectivity on OCT and high surface reflectivity with medium internal reflectivity on B-scan ultrasound. CT chest was negative, however, a PET scan demonstrated extensive FDG activity in the mediastinum and bilateral hilum, consistent with a diagnosis of sarcoidosis.

CONCLUSION

Optic nerve head granulomas can rarely present as the only clinical sign of sarcoidosis. In these cases, additional imaging modalities may be needed to make the appropriate diagnosis.

Characteristics, Etiology, and Clinical Outcome of Retinal Vasculitis in Tertiary Hospital in Thailand

OBJECTIVE

To analyze characteristics, etiology, and outcome of retinal vasculitis in Central Thailand.

METHODS

A retrospective cohort study.

RESULTS

Retinal vasculitis was found in 10% of uveitis, 74 from 741 uveitis, noninfectious (64.9%) and infectious group (35.1%). The most common cause was Behcet's disease (48.6%). Behcet's disease was the most common cause of all types of vascular leakage on angiography, including capillary (80.4%), venous (56.3%), and arterial leakage (56%). Final visual acuity was 0.86 ± 0.97 logMAR. Cataract was the most frequent complication (42.5%). Acute clinical course (p = .025) and retinal neovascularization (p = .031) were associated with infectious group. Forty-three percent of vasculitis complicated by ischemia required photocoagulation (33%) and anti-VEGF injection (17%). Furthermore, 17% of vasculitis underwent vitrectomy.

CONCLUSION

One-half of the retinal vasculitis in Central Thailand were Behcet's disease. Acute onset and retinal neovascularization may suggest infectious etiology. Retinal ischemia should be cautious and undergo early interventions to prevent sight-threatening complications.

Cardiac Screening and Disease Characteristics of Patients with Ocular Sarcoidosis

PURPOSE

This is a retrospective nonrandomized cohort study investigating the prevalence, timing, and type of cardiac sarcoidosis indications on electrocardiogram in patients with diagnosed or suspected ocular sarcoidosis.

METHODS

Medical histories of individuals seen from 2005 to 2020 at two centers with diagnosed or suspected ocular sarcoidosis were searched, and statistical methods were used to evaluate the relevance of each aspect obtained.

RESULTS

Approximately 16% of the individuals in our cohort showed signs of cardiac sarcoidosis on ECG, primarily bundle branch blocks, and premature ventricular contractions, close to the time of their initial ocular sarcoidosis documentation. Males exhibited higher rates of clinically significant extra-pulmonary sarcoidosis. No other demographic differences were found.

CONCLUSIONS

Our findings highlight the importance for further differentiation of non-infectious sarcoidosis and the utility of electrocardiogram screening. Studies with larger cohorts of ocular sarcoidosis might be needed to elucidate demographic differences within this patient population.

Risk Factors for Chalazion Diagnosis and Subsequent Surgical Excision

PURPOSE

To identify factors associated with chalazion diagnosis and surgical excision.

METHODS

Patients with an incident chalazion diagnosis from 2002 to 2019 were compared 1:5 with matched controls. Multivariable logistic regression was performed to identify variables associated with diagnosis and surgical excision.

RESULTS

Chalazion patients (n = 134,959) and controls (678,160) were analyzed. Risk factors for diagnosis included female sex, non-white race, northeast location, conditions affecting periocular skin and tear film (blepharitis, meibomian gland dysfunction, rosacea, pterygium), non-ocular inflammatory conditions (gastritis, inflammatory bowel disease, sarcoidosis, seborrheic dermatitis, Graves' disease), and smoking (p < .001 for all comparisons). Thirteen percent of patients with chalazion underwent subsequent surgical excision. Diabetes and systemic sclerosis diagnoses decreased odds of diagnosis (p < .001). Male sex, rosacea diagnosis, Black and Hispanic race, antibiotic use, and doxycycline use increased odds of surgery (p < .001).

CONCLUSION

Female sex, non-white race, conditions affecting periocular skin and the tear film, several non-ocular inflammatory conditions, and smoking were risk factors for chalazion diagnosis. Male sex, rosacea diagnosis, Black and Hispanic race, antibiotic use, and doxycycline use were risk factors for surgical intervention for chalazion. Our results prompt further study of these variables and their relationship to chalazion diagnosis to understand physiology and improve clinical outcomes. Furthermore, the results of this study suggest early recognition and treatment of concomitant rosacea may serve an important role in the management of chalazion and in the prevention of surgical intervention.

Ocular and eyelid involvement in collagen vascular diseases. Part II. Dermatomyositis, scleroderma, and sarcoidosis

Collagen vascular disease is a heterogeneous group of autoimmune diseases that affect multiple organ systems. Sjögren syndrome, dermatomyositis, scleroderma, systemic lupus erythematosus, and sarcoidosis are collagen vascular diseases that often present with characteristic cutaneous manifestations. Although less known, various ocular manifestations that affect both external and internal structures of the eye can also be seen in these conditions. Multidisciplinary management between dermatologists and ophthalmologists is essential in the early diagnosis and management of collagen vascular diseases affecting both the skin and eye. In part II of our series, we discuss the ocular manifestations, diagnosis, and therapeutic options of dermatomyositis, scleroderma, and sarcoidosis.

Clinical manifestations and associated factors of uveitis in patients with pulmonary sarcoidosis: a case control study

Sarcoidosis, an idiopathic and inflammatory disease, affects various organs and can manifest as uveitis. Due to limited evidence, researchers investigated the risk factors associated with uveitis in patients with pulmonary sarcoidosis. A retrospective study was conducted on 71 pulmonary sarcoidosis patients, including 19 with uveitis and 52 without. Data on involved organs, imaging findings, spirometry, and analyses from blood and bronchoalveolar lavage fluid were collected. Logistic regression models were used for multivariate analysis. Among the 71 newly diagnosed pulmonary sarcoidosis patients, uveitis was observed in 19 patients (26.8%). No significant differences were found in clinical characteristics between patients with and without uveitis. Fewer patients with uveitis presented lung parenchymal lesions (P = 0.043). In multivariate analysis, skin lesions (aOR 7.619, 95% CI 1.277-45.472, P = 0.026) and ophthalmic symptoms (aOR 4.065, 95% CI 1.192-13.863, P = 0.025) were associated with uveitis. Absence of uveitis was related to lung parenchymal lesions (aOR 0.233, 95% CI 0.062-0.883, P = 0.032). Approximately one-quarter of patients with an initial diagnosis of pulmonary sarcoidosis were diagnosed with uveitis. Presence of skin lesions, ophthalmic symptoms, and absence of lung parenchymal lesions were related to uveitis. These results need to be clarified by further studies to confirm the clinical role of early ophthalmologic screening for pulmonary sarcoidosis patients with these factors.

Fully Automatic, Semiautomatic, and Manual Corneal Nerve Fiber Analysis in Patients With Sarcoidosis

Purpose

No guidelines are available on the preferred method for analyzing corneal confocal microscopy (CCM) data. Manual, semiautomatic, and automatic analyzes are all currently in use. The purpose of the present study was threefold. First, we aimed to investigate the different methods for CCM analysis in patients with and without small fiber neuropathy (SFN). Second, to determine the correlation of different methods for measuring corneal nerve fiber length (CNFL) and nerve fiber area (NFA). Finally, we investigated the added value of automatic NFA analysis.

Methods

We included 20 healthy controls and 80 patients with sarcoidosis, 31 with established SFN and 49 without SFN. The CNFL was measured using CCMetrics, ACCMetrics, and NeuronJ. NFA was measured with NFA FIJI and ACCMetrics NFA.

Results

CNFL and NFA could not distinguish sarcoidosis with and without SFN or healthy controls. CCMetrics, NeuronJ, and ACCMetrics CNFL highly correlated. Also, NFA FIJI and ACCMetrics NFA highly correlated. Reproducing a nonlinear formula between CNFL and NFA confirmed the quadratic relation between NFA FIJI and ACCMetrics CNFL. CCMetrics and NeuronJ instead showed a square root relationship and seem to be less comparable owing to differences between automatic and manual techniques.

Conclusions

ACCMetrics can be used for fully automatic analysis of CCM images to optimize efficiency. However, CNFL and NFA do not seem to have a discriminatory value for SFN in sarcoidosis. Further research is needed to determine the added value and normative values of NFA in CCM analysis.

Translational Relevance

Our study improves the knowledge about CCM software and pathophysiology of SFN.

Bilateral Dacryoadenitis As the First Presentation in an Undiagnosed Sarcoidosis Patient

Sarcoidosis is an idiopathic multisystem disorder associated with hilar lymphadenopathy and noncaseating granulomas that can affect any organ. Ocular involvement is less common; however, sarcoidosis is a known cause of uveitis, dry eye, and conjunctival nodules. We report a case of a 36-year-old male with an occupational history of dust exposure presenting to the ophthalmology clinic with bilateral painless upper eyelid swelling of one-week duration. The diagnosis of sarcoidosis was suspected based on clinical examination, laboratory analysis, and imaging showing mediastinal lymphadenopathy, further confirmed by pathologic examination showing noncaseating granulomas with the presence of some asteroid and Schaumann bodies. A treatment plan consisting of prednisone, folic acid, and azathioprine was effective for the patient, though azathioprine was eventually changed to methotrexate due to an allergic reaction. The patient is on a maintenance dose of methotrexate and is asymptomatic after a year of careful management and follow-up. This case emphasizes the significance of considering sarcoidosis as a differential diagnosis in patients presenting with bilateral dacryoadenitis.

Genetic predisposition to sarcoidosis

Sarcoidosis is a complex systemic disease with clinical heterogeneity based on varying phenotypes and natural history. The detailed etiology of sarcoidosis remains unknown, but genetic predisposition as well as environmental exposures play a significant role in disease pathogenesis. We performed a comprehensive review of germline genetic (DNA) and transcriptomic (RNA) studies of sarcoidosis, including both previous studies and more recent findings. In this review, we provide an assessment of the following: genetic variants in sarcoidosis susceptibility and phenotypes, ancestry- and sex-specific genetic variants in sarcoidosis, shared genetic architecture between sarcoidosis and other diseases, and gene-environment interactions in sarcoidosis. We also highlight the unmet needs in sarcoidosis genetic studies, including the pressing requirement to include diverse populations and have consistent definitions of phenotypes in the sarcoidosis research community to help advance the application of genetic predisposition to sarcoidosis disease risk and manifestations.

Ocular sarcoidosis in adults and children: update on clinical manifestation and diagnosis

Sarcoidosis-associated uveitis, is the predominant ocular sarcoidosis presentation, which affects both adults and children. For adults, international ocular sarcoidosis criteria (IWOS) and sarcoidosis-associated uveitis criteria (SUN) are defined. However, for children they are not yet established internationally. Due to the specificity of pediatric manifestations of sarcoidosis, this task is even more challenging. In children, sarcoidosis is subdivided into Blau syndrome and early-onset sarcoidosis (BS/EOS) affecting younger children (< 5 years) and the one affecting older children with clinical presentation resembling adults. Differential diagnosis, clinical work-up as well as diagnostic criteria should be adapted to each age group. In this article, we review the clinical manifestation of sarcoidosis-associated uveitis in adults and children and the sensitivity and specificity of various ocular sarcoidosis diagnostic modalities, including chest X-ray and CT, FDG PET-CT, gallium-67 scintigraphy, bronchoalveolar lavage fluid, genetic testing for NOD2 mutations and serum biomarkers, such as ACE, lysozyme and IL2R.

Coexistence of open-angle glaucoma and sarcoidosis-associated optic neuropathy

BACKGROUND

In cases with advanced glaucomatous disc changes, further changes associated with other optic neuropathies cannot be easily identified. We present a case of preexisting open-angle glaucoma and concurrent involvement of sarcoidosis-associated optic neuropathy.

CASE PRESENTATION

A 53-year-old man presented with gradual visual loss in his left eye, which began 1 year ago and accelerated 3 months ago. The best-corrected visual acuity in the right eye was 20/20 and counting fingers in the left. Intraocular pressures (IOP) were 12 mmHg in the right eye and 34 mmHg in the left. We diagnosed him with advanced open-angle glaucoma in the left eye based on the advanced glaucomatous cupping of the left optic disc. The IOP in the left eye dropped to 10 mmHg and was well controlled with antiglaucomatous medication; however, his left optic disc developed pallor 3 months after the treatment. The patient was revealed to be diagnosed with sarcoidosis a month ago and had been treated with systemic corticosteroids thereafter by a pulmonologist. Orbital magnetic resonance imaging revealed sarcoidosis-associated optic neuropathy in the left eye. Subsequently, optic neuropathy occurred in his right eye.

CONCLUSIONS

In eyes with advanced glaucomatous disc change, detecting the coexistence of other optic neuropathies can be difficult. This report highlights the importance of careful ophthalmic examinations and investigation for etiologies of other optic neuropathies if non-glaucomatous changes are suspected even in eyes with advanced glaucoma.

Sarcoidal Granuloma Annulare-Like Dermatitis and Vasculitis With Granulomatous Features: An Atypical Case of Giant Cell Arteritis

ABSTRACT

Giant cell arteritis (GCA) is a diagnosis that clinicians should not miss because of the accompanying risk of irreversible vision loss. GCA can present without the classic symptoms of headache and temporal artery tenderness, which may lead to a delay in diagnosis. Cutaneous findings, although rare, have been associated with GCA. Accordingly, it is imperative to be aware of the broad clinical and histological presentations of GCA, including the cutaneous findings, because they may prove to be harbingers of impending disease. We present a unique case of GCA where 2 distinct cutaneous morphologies, sarcoidal granuloma annulare-like dermatitis and leukocytoclastic vasculitis with granulomatous features, presented simultaneously before the classic symptoms of headache and unilateral vision loss.

Retinitis Pigmentosa Masquerades: Case Series and Review of the Literature

Retinitis pigmentosa (RP) displays a broad range of phenotypic variations, often overlapping with acquired retinal diseases. Timely recognition and differentiation of RP masquerades is paramount due to the treatable nature of many such conditions. This review seeks to present examples of pseudo-RP cases and provide a comprehensive overview of RP masquerades. We first present two pseudo-RP cases, including comprehensive clinical histories and multimodal retinal imaging, to highlight the important role of accurate diagnoses that subsequently steered effective intervention. Subsequently, we conduct an in-depth review of RP masquerades to provide valuable insights into their key distinguishing features and management considerations. The recent approval of ocular gene therapy and the development of investigational gene-based treatments have brought genetic testing to the forefront for RP patients. However, it is important to note that genetic testing currently lacks utility as a screening tool for inherited retinal diseases (IRDs), including RP. The integrity of a precise clinical assessment remains indispensable for the diagnosis of both RP and RP masquerade conditions, thereby facilitating prompt intervention and appropriate management strategies.

Neurosarcoidosis: Diagnostic Challenges and Mimics A Review

PURPOSE OF REVIEW

Neurosarcoidosis is a rare manifestation of sarcoidosis that is challenging to diagnose. Biopsy confirmation of granulomas is not sufficient, as other granulomatous diseases can present similarly. This review is intended to guide the clinician in identifying key conditions to exclude prior to concluding a diagnosis of neurosarcoidosis.

RECENT FINDINGS

Although new biomarkers are being studied, there are no reliable tests for neurosarcoidosis. Advances in serum testing and imaging have improved the diagnosis for key mimics of neurosarcoidosis in certain clinical scenarios, but biopsy remains an important method of differentiation. Key mimics of neurosarcoidosis in all cases include infections (tuberculosis, fungal), autoimmune disease (vasculitis, IgG4-related disease), and lymphoma. As neurosarcoidosis can affect any part of the nervous system, patients should have a unique differential diagnosis tailored to their clinical presentation. Although biopsy can assist with excluding mimics, diagnosis is ultimately clinical.

Sarcoidosis of the lacrimal gland: the prominence of the differential diagnosis

Sarcoidosis is a multisystem disease that can involve any organ; lungs, lymph nodes and skin are the most involved. Compatible clinical and imaging features, the identification of non-caseous granulomas on biopsy and the exclusion of other causes of granulomatous disorders help formulate the diagnosis of sarcoidosis. A bilateral symmetrical hilar lymphadenopathy together with the typical perilymphatic distribution of nodules is typically visible on high-resolution CT.The average age is 48 years. Ocular sarcoidosis is not rare, it is reported in 25% of cases. Half of the sarcoidosis patients resolve spontaneously; treatment is only indicated in cases with severe symptoms or signs of organ damage. Classical treatments are based on the use of corticosteroids and immunosuppressive therapies, sometimes combined.

Sarcoidosis-Related Uveitis: A Review

Sarcoidosis is an inflammatory disease that involves the eyes in 10-55% of cases, sometimes without systemic involvement. All eye structures can be affected, but uveitis is the most common ocular manifestation and causes vision loss. The typical ophthalmological appearance of these uveitis is granulomatous (in cases with anterior involvement), which are usually bilateral and with synechiae. Posterior involvement includes vitritis, vasculitis and choroidal lesions. Tuberculosis is a classic differential diagnosis to be wary of, especially in people who have spent time in endemic areas. The diagnosis is based on histology with the presence of non-caseating epithelioid granulomas. However, due to the technical difficulty and yield of biopsies, the diagnosis of ocular sarcoidosis is often based on clinico-radiological features. The international criteria for the diagnosis of ocular sarcoidosis have recently been revised. Corticosteroids remain the first-line treatment for sarcoidosis, but up to 30% of patients require high doses, justifying the use of corticosteroid-sparing treatments. In these cases, immunosuppressive treatments such as methotrexate may be introduced. More recent biotherapies such as anti-TNF are also very effective (as they are in other non-infectious uveitis etiologies).

Ocular manifestations of common pulmonary diseases: a narrative review

Several pulmonary disorders can cause ocular involvement. Understanding these manifestations is critical for early diagnosis and treatment. Hence, we set out to examine the most common ocular manifestations of asthma, chronic obstructive pulmonary disease (COPD), sarcoidosis, obstructive sleep apnea (OSA), and lung cancer. Allergic keratoconjunctivitis and dry eye are two ocular manifestations of bronchial asthma. The inhaled corticosteroids used to treat asthma can cause cataract formation. COPD is associated with ocular microvascular changes as a result of chronic hypoxia and systemic inflammation spillover into the eyes. Its clinical significance, however, is unknown. Ocular involvement is common in sarcoidosis, occurring in 20% of cases of pulmonary sarcoidosis. It can affect nearly any anatomical structure of the eye. Obstructive sleep apnea has been linked to floppy eye syndrome, glaucoma, non-arteritic anterior ischemic optic neuropathy, keratoconus, retinal vein occlusion, and central serous retinopathy, according to research. However, while an association has been established, causality has yet to be established. The effect of positive airway pressure (PAP) therapy used to treat OSA on the aforementioned ocular conditions is unknown. PAP therapy can cause eye irritation and dryness. Lung cancer can affect the eyes through direct nerve invasion, ocular metastasis, or as part of a paraneoplastic syndrome. The goal of this narrative review is to raise awareness about the link between ocular and pulmonary disorders in order to aid in the early detection and treatment of these conditions.

Sarcoidosis

Sarcoidosis is a disease of unknown cause characterized by granulomatous inflammation. Although the lung is almost universally involved, any organ can be affected. Complex pathogenesis and protean clinical manifestations are additional features of the disease. The diagnosis is one of exclusion, although the presence of noncaseating granulomas at disease sites is a prerequisite in most cases. The management of sarcoidosis requires a multidisciplinary approach, particularly when the heart, the brain, or the eyes are involved. The paucity of effective therapies and the lack of reliable predictors of disease behavior greatly contribute to making sarcoidosis a challenging disease to manage.

[Sarcoid uveitis: Ophthalmologist's and internist's viewpoints]

Sarcoidosis is one of the leading causes of inflammatory eye disease. All ocular structures can be affected, but uveitis is the main manifestation responsible for vision loss in ocular sarcoidosis. Typical sarcoid anterior uveitis presents with mutton-fat keratic precipitates, iris nodules, and posterior synechiae. Posterior involvement includes vitritis, vasculitis, and choroidal lesions. Cystoid macular edema is the most important and sight-threatening consequence of sarcoid uveitis. Patients with clinically isolated uveitis at diagnosis rarely develop other organ involvement. Even though, ocular sarcoidosis can have a severe impact on visual prognosis, early diagnosis and a wider range of available therapies (including intravitreal implants) have lessened the functional impact of the disease, particularly in the last decade. Corticosteroids are the cornerstone of treatment for sarcoidosis, but up to 30% of patients achieve remission with requiring high-dose systemic steroids. In these cases, the use of steroid-sparing immunosuppressive therapy (such as methotrexate) is unavoidable. Among these immunosuppressive treatments, anti TNF-α drugs have been a revolution in the management of non-infectious uveitis.

Bilateral eyelid swelling as the presenting sign of subcutaneous sarcoidosis

An 18-year-old Black female presented with a 2-year history of bilateral upper eyelid swelling and the recent onset of multiple subcutaneous nodules on the arms. She had previously undergone evaluation and treatment for presumed angioedema. Biopsies of the eyelid and an arm nodule demonstrated non-necrotizing granulomatous inflammation with special stains negative for acid-fast bacilli and fungi, and the patient was diagnosed with subcutaneous sarcoidosis. The isolated finding of bilateral eyelid swelling 2 years prior to the onset of additional cutaneous findings led to a significant delay in diagnosis, highlighting the importance of considering sarcoidosis in the differential diagnosis for bilateral eyelid swelling.

Visual outcomes and factors predictive of visual loss in Behcet's disease in Sultan Qaboos University Hospital, Oman

PURPOSE

This study aimed to evaluate the visual outcomes and associated factors in Omani patients with Behcet's disease (BD).

METHODOLOGY

This is a descriptive retrospective analytical cohort study. All Omani patients of age 5-65 years with a confirmed clinical diagnosis of BD having ocular manifestation who attended the Rheumatology and Ophthalmology clinics at Sultan Qaboos University Hospital, Oman from January 2018 to October 2020. The demographic data, clinical findings, systemic, and ocular examination of all the recruited patients were retrieved from the electronic patient record.

RESULTS

The study included 31 male and 16 female participants. The median age is 29.7 ± 10.6 years. Most patients with ocular manifestations presented in the third decade of their life (21-30 years' age). The most common ocular manifestations in our study were uveitis (91.5%) followed by vitritis (40.4%), and retinal vasculitis (36.2%). The most common ocular complications in order of frequency were cataract (27.7%), posterior synechiae (23.4%), and cystoid macular edema (21.2%). In this study, 22.7% of the patients with BD-related ocular manifestations reported severe visual loss. In addition, when adding the patients with severe visual loss secondary to complications such as secondary glaucoma and optic nerve atrophy, the severe visual loss cumulatively reported being 50% for both groups.

CONCLUSION

The clinical characteristics of ocular manifestations in BD in Oman are similar to data from studies that have been conducted in other countries. However, our study found that the severity of ocular manifestations was more dominant among females. This study finding can be helpful for clinicians to predict ocular manifestations of BD to plan a timely follow-up and subsequently prevent further severe complications or visual loss.

Vitreoretinal surgery in the management of infectious and non-infectious uveitis - a narrative review

PURPOSE

This study aims to conduct a narrative review about the current role of vitreoretinal surgery in the management of infectious and non-infectious uveitis.

METHODS

This review was performed based on a search of the PubMed database or on relevant published papers according to our current knowledge.

RESULTS

A total of 91 articles were identified in the literature review. With the advance of microincision vitrectomy surgery (MIVS), pars plana vitrectomy (PPV) has gained increasing popularity in the management of infectious and non-infectious uveitis. For diagnostic purposes, larger amounts of sample can be obtained by MIVS than traditional vitreous aspiration using needles. For treatment purposes, PPV removes vitreous opacities, decreases inflammatory cytokines and mediators of inflammation, and tackles related complications, including hypotony, epiretinal membrane, macular holes, and retinal detachment. Achieving optimum control of inflammation prior to surgery is important for surgical interventions for non-emergent therapeutic indications and complications of uveitis. Peri-operative inflammation management is essential for decreasing the risk of surgical intervention. An overall complication rate of 42-54% was reported with cataract to be the leading cause of complications.

CONCLUSION

Most reports affirm the role of PPV in the management of infectious and non-infectious uveitis, although the quality of data remains limited by a lack of applying standardized reporting outcomes, limitations in study design, and a paucity of prospective data.

Ocular sarcoidosis prevalence and clinical features in the Northern Ireland population

BACKGROUND/OBJECTIVES

To record the prevalence of ocular sarcoidosis (OS) cases present in Northern Ireland as diagnosed using the International Workshop on Ocular Sarcoidosis (IWOS) classification, 2019. There are currently no data regarding OS in this population.

SUBJECTS/METHODS

Retrospective case review of OS cases as identified by IWOS criteria 2019. Mid-year population estimates were used to calculate disease prevalence. Additional data collected included uveitis features, ocular complications and the presence of ocular only or multi-system disease.

RESULTS

A total of 86 patients were identified meeting the criteria for a diagnosis of OS, and the prevalence of OS in Northern Ireland was estimated to be 4.5 cases per 100,000. The most common type of uveitis was panuveitis in 36% of cases, and the most common ocular complication was ocular hypertension in 36% of cases and detectable glaucomatous changes in 10%. Overall, 80% of cases presenting with ocular only sarcoidosis subsequently developed second organ involvement at a rate of 14%/person-years. The most common extra-ocular site of sarcoidosis was pulmonary.

CONCLUSIONS

The Northern Ireland population has a relatively high prevalence of OS compared with other European countries. OS presenting with only ocular involvement progressed to second organ involvement in 80% of patients at a rate of 14%/person-years. Raised intra-ocular pressure with or without glaucomatous damage was a frequent finding. Thoracic CT imaging should be requested if clinical suspicion of OS exists and the presence of lymphopenia has utility in diagnosis with concurrent use of systemic ACE inhibitors.

Choroidal sarcoid granuloma: a case report and review of the literature

Background

Choroidal sarcoid granulomas are often diagnosed in patients without a prior history of sarcoidosis. They are often mistaken for choroidal metastasis, choroidal nevi, amelanotic choroidal melanomas, and uveal lymphomas; however, are easily treatable when accurately identified.

Observations

We searched PubMed, Medline, and Scopus for English-Language case reports published before September 2021. Additionally, we presented a case of a 45-year-old woman with a right-sided amelanotic choroidal mass whose diagnosis was delayed by a COVID-19 infection. Of the 26 cases reported in the literature, 46% were female, 38% were African American, and 19% had bilateral involvement. There was a mean age of 42.15 years and a mean follow-up period of 27 months. The most common complaint was of a progressive, painless blurring of vision, and only five patients had been previously diagnosed with sarcoidosis. The choroidal granulomas were typically described as yellow lesions, single or multiple, found temporal to or at the macula. Most patients were administered steroids, with 69% receiving them systemically, 5% topically, and 8% locally with a triamcinolone injection. All patients reported symptomatic improvement at their final follow-up with resolution of the mass in 65% of patients and improved visual acuity in 76%.

Conclusion

Primary testing including fundoscopy, fluorescein angiography, fundus autofluorescence, A/B-scan, and OCT are useful for diagnosis, differentiation from other choroidal lesions, and monitoring treatment response. Steroids are a mainstay of treatment for sarcoidosis and are effective at treating choroidal granulomas. Therefore, early recognition and diagnosis of choroidal granulomas is imperative as treatment can be curative and sight-sparing.

Subretinal peripapillary biopsy-proven sarcoidosis: a case report

BACKGROUND

To report a case of a subretinal, unilateral, peripapillary granuloma that was diagnosed as sarcoidosis by a 27-gauge pars plana vitrectomy subretinal biopsy. Sarcoidosis is a chronic idiopathic granulomatous inflammatory disease, that has ocular involvement in 10-80% of patients. It is often mistaken for many other primary ocular diseases because the condition can involve any structure in or around the eye. Previous case reports of peripapillary sarcoidosis have either been limited to the choroid or presented with additional ocular and systemic signs, hence have not required an intraocular biopsy.

CASE PRESENTATION

A 54-year-old Filipino male presented with a 6-month history of painless blurred vision in his right eye. Fundus examination revealed a large white peripapillary lesion. Enhanced-depth imaging optical coherence tomography confirmed the subretinal location of the mass. Indocyanine green angiography demonstrated absolute hypofluorescent blockage with satellite lesions. A whole-body positron emission tomography scan demonstrated widespread lymphadenopathy, but investigations including an inguinal lymph node biopsy were inconclusive. Following growth of the peripapillary lesion and worsening vision, a 27-gauge pars plana vitrectomy subretinal biopsy was performed which confirmed sarcoidosis. He was treated with oral corticosteroids and transitioned to long term immunotherapy with methotrexate.

CONCLUSIONS

Sarcoidosis can present in the subretinal space, around the optic nerve without other ocular findings.

Sarcoid Uveitis: An Intriguing Challenger

The purpose of our work is to describe the actual knowledge concerning etiopathogenesis, clinical manifestations, diagnostic procedures, complications and therapy of ocular sarcoidosis (OS). The study is based on a recent literature review and on the experience of our tertiary referral center. Data were retrospectively analyzed from the electronic medical records of 235 patients (461 eyes) suffering from a biopsy-proven ocular sarcoidosis. Middle-aged females presenting bilateral ocular involvement are mainly affected; eye involvement at onset is present in one-third of subjects. Uveitis subtype presentation ranges widely among different studies: panuveitis and multiple chorioretinal granulomas, retinal segmental vasculitis, intermediate uveitis and vitreitis, anterior uveitis with granulomatous mutton-fat keratic precipitates, iris nodules, and synechiae are the main ocular features. The most important complications are cataract, glaucoma, cystoid macular edema (CME), and epiretinal membrane. Therapy is based on the disease localization and the severity of systemic or ocular involvement. Local, intravitreal, or systemic steroids are the mainstay of treatment; refractory or partially responsive disease has to be treated with conventional and biologic immunosuppressants. In conclusion, we summarize the current knowledge and assessment of ophthalmological inflammatory manifestations (mainly uveitis) of OS, which permit an early diagnostic assay and a prompt treatment.

Prevalence, clinical profile, investigations, and visual outcome of sarcoid intermediate uveitis in a tertiary eye care center in South India

Purpose:

To report the prevalence, clinical profile, investigations, and visual outcomes of sarcoid intermediate uveitis in a tertiary eye care center in South India.

Methods:

Retrospective, observational case series. Records of 29 patients with sarcoid intermediate uveitis were retrieved. Complete ophthalmic evaluation and systemic examination by a pulmonologist with appropriate laboratory investigations were done. Results were analyzed using SPSS software.

Results:

Mean age group was 42.14 ± 11.31 years. The bilateral presentation was more common and females were more affected than males. Anterior chamber cells and flares in 22.4% of cases (N = 11 eyes), posterior synechiae in 20.4% (N = 10 eyes), and both small and mutton fat keratic precipitates in 14.2% of cases (N = 7 eyes) were noted; only one eye had Busacca nodules similar to other granulomatous uveitis. Cystoid macular edemas were present in three eyes. Treatment with oral steroids and systemic immunosuppression resulted in good visual recovery. The mean presenting visual acuity in right and left eye were 0.2 and 0.3, respectively. The mean final visual acuity in right and left eye was 0.1 and 0.3, respectively.

Conclusion:

Sarcoid intermediate uveitis is quite common in a tuberculosis endemic country like India. A complete review of systems with appropriate investigations is essential to prevent visual complications.

Clinical features of ocular sarcoidosis: severe, refractory, and prolonged inflammation

PURPOSE

To clarify the proportion of ocular sarcoidosis with severe, refractory, and prolonged inflammation and their association with ocular complications and visual prognosis.

STUDY DESIGN

Multicenter, retrospective, longitudinal cohort study.

METHODS

Three hundred and twenty-three eyes of 164 patients (45 men; 119 women) with ocular sarcoidosis who visited Hokkaido University Hospital and Yokohama City University Hospital from 2010 to 2015. We newly defined severe, refractory, and prolonged inflammation in ocular sarcoidosis, and investigated their proportions, ocular complications and final visual acuity from medical records of our sarcoidosis patients.

RESULTS

The eyes with severe inflammation numbered 72/323 (22.3%), with refractory inflammation, 80/323 (24.8%), and with prolonged inflammation, 91/323 (28.2%). The number of eyes having neither severe, refractory, nor prolonged inflammation (defined as none) was 114/323 (35.3%). The numbers of eyes that reached irreversible visual dysfunction were 6/72 (8.3%) of those with severe inflammation, 10/80 (12.5%) with refractory inflammation, 12/91 (13.2%) with prolonged inflammation, and 4/114 (6.2%) with none. As complications, cataract (62.2%), glaucoma (28.5%), epiretinal membrane (24.1%), cystoid macular edema (22.6%), vitreous hemorrhage (2.8%), choroidal atrophy (2.5%), macular degeneration (1.2%), macular hole (0.9%) and retinal detachment (0.3%) were identified. Among them, secondary glaucoma (16 eyes) and macular degeneration (4 eyes) were major complications related to irreversible visual dysfunction.

CONCLUSIONS

Although most of the patients with ocular sarcoidosis had a relatively good visual prognosis, some developed severe, refractory, and/or prolonged inflammation related to the development of ocular complications, that resulted in poor visual prognosis.

Case Report: Multiple Ocular Manifestations Assisted the Diagnosis of Systemic Sarcoidosis

SIGNIFICANCE

Sarcoidosis is a variable, multisystem granulomatous disease which can affect many organs including the lungs, lymph nodes and eyes. It is difficult to differentiate sarcoidosis and tuberculosis due to their similar clinical and pathological features.

PURPOSE

To describe a sarcoidosis case with typical ocular and systemic manifestations combined with suspected tuberculosis infection.

CASE REPORT

A 30-year-old Chinese male, initially diagnosed with tuberculosis, presented with typical ocular sarcoidosis during anti-tuberculosis therapy. The ocular surface, anterior chamber, anterior chamber angle, ciliary body, vitreous, optic disc and lacrimal gland of the patient all exhibited manifestations of sarcoidosis, although optic disc involvement has rarely been reported. Typical ocular sarcoidosis manifestations and positive responses to corticosteroid therapy of the patient helped us reach the diagnosis of systemic sarcoidosis. The patient was followed up for 48 months and showed significant improvement of miliary nodules and lymph nodes in both lungs. However, the appearance of uveitis in the right eye persisted due to non-adherence with steroid treatment.

CONCLUSIONS

This case shows the importance of ophthalmic evaluation in the diagnosis and management of sarcoidosis, and supports a possible role of mycobacterium tuberculosis in the pathogenesis of sarcoidosis.

Retinal and pre-retinal nodules: A rare manifestation of probable ocular sarcoidosis

Purpose

To report a case of multiple pre-retinal and intra-retinal lesions in the context of probable sarcoidosis.

Observations

A 31-year-old black woman presented with a bilateral panuveitis and multiple pre-retinal and retinal nodules. The workup showed enlarged mediastinal lymph nodes as well as meningitis with an increased cerebrospinal fluid angiotensin-converting enzyme (ACE) [0.36 UI/L (1.44 × normal)] leading to the diagnosis of probable sarcoidosis. The nodules were hyper-reflective, with posterior shadowing on OCT imaging, and appeared as multiple hypoautofluorescent spots: their characteristics were suggestive of intra and preretinal granulomas. The intraretinal nodules were located in the ganglion cell layer. The posterior segment manifestations were limited to the retina while the choroid appeared uninvolved including on indocyanine green angiograms. The lesions disappeared after corticosteroid treatment.

Conclusions and importance

Retinal and pre-retinal nodules have rarely been reported as the sole posterior manifestations of ocular sarcoidosis without choroidal involvement.

Quantitative Evaluation of Macular Vessel Density Measurement by Optical Coherence Tomography Angiography in Patients with Inactive Ocular Sarcoidosis

PURPOSE

To evaluate the macular vessel density (VD) in inactive ocular sarcoidosis (OS) and investigate the relationship between VD and both disease duration and visual acuity (VA).

METHODS

This cross-sectional study was performed at a tertiary hospital. The macular VDs of patients with OS were obtained using optical coherence tomography angiography and compared with healthy subjects.

RESULTS

Deep whole image macular VD (WI-MVD), parafoveal, and perifoveal VDs were lower in OS group (p = .01, p = .01, p = .02, respectively). Negative correlation between disease duration and both superficial and deep WI-MVD, parafoveal, and perifoveal VDs was obtained (for all p < .05). There was a positive correlation between VA and superficial VD (p < .001, r = 0.848 for WI-MVD).

CONCLUSION

OS affects deep VD significantly. Changes in superficial VD affect VA more. Disease duration is an important factor affecting macular VD.

Investigation of the relationship between ocular sarcoidosis and dry eye

A relationship between ocular sarcoidosis (OcSar) and dry eye (DE) has previously been reported. Here we investigated the tear function in OcSar, and the other uveitis, Vogt–Koyanagi–Harada disease (VKH), to elucidate the association between OcSar and DE. This study involved 27 eyes of 27 female OcSar patients [mean age: 67.3 ± 13.5 (SD) years], 18 eyes of 18 female VKH patients (53.1 ± 14.1 years), and 17 eyes of 17 female healthy control subjects (59.7 ± 9.6 years). In all examined eyes, tear meniscus height (TMH, mm), fluorescein breakup time (FBUT, s), scoring of keratoconjunctival epithelial damage (ED), and the Schirmer 1 test (ST1, mm/5 min) were analyzed. In the OcSar patients, VKH patients, and control subjects, the respective TMH, FBUT, ED, and ST1 values (mean ± SD) were 0.26 ± 0.10, 0.24 ± 0.09, and 0.24 ± 0.08, 4.3 ± 2.5, 7.3 ± 2.9, and 6.3 ± 3.1, 1.1 ± 1.1, 0.7 ± 0.8, and 0.1 ± 0.3, and 12.9 ± 10.5, 21.5 ± 12.1, and 24.3 ± 10.5. Statistically, the ST1 values were significantly lower in the OcSar patients than in the VKH patients (P = 0.004) and control subjects (P = 0.001). ST1 findings revealed that the neural reflex arc and lacrimal gland system, which attenuate the vicious cycle between the tear film and ocular surface epithelium in DE, are significantly impaired in OcSar cases, thus indicating a possible association between OcSar and DE.