Current status in the treatment of orbital myositis

A Case of Idiopathic Orbital Inflammation With Elevated Anti-Mumps Immunoglobulin M Antibody

A 21-year-old female presented with periocular swelling, diplopia, and painful ophthalmoplegia in the OS. Orbital magnetic resonance imaging revealed an enhanced soft tissue mass involving the left medial rectus muscle. Laboratory test results revealed leukocytosis, elevated reactive C-reactive protein, and positive serum levels of anti-mumps immunoglobulin M (IgM) antibody without systemic manifestations of mumps infection. The clinical course was refractory, and the patient showed a poor response to high-dose steroids. An incisional biopsy revealed stromal fibrosis with focal lymphoid aggregates, indicating sclerosing inflammation. Myopathy of the medial rectus progressed to superior, inferior, and lateral recti involvement of the left orbit. Immunosuppressive agents, including steroids, were administered for 22 months after disease onset. The mumps IgM antibody level was positive for over 5 months and became negative upon testing performed 1 year after the first visit.

Magnetic Resonance Imaging of Idiopathic Orbital Myositis

PURPOSE

To characterize the qualitative and quantitative features of idiopathic orbital myositis (IOM) on MRI.

METHODS

This was a multicenter retrospective study of patients with active IOM with MRI. Patients with incomplete clinical records, poor-quality or interval scans without active myositis, and specific orbital myositis (i.e., orbital myositis secondary to an identified condition) were excluded. An enlargement ratio was calculated by dividing the diameters of the affected extraocular muscle (EOM) by the contralateral unaffected EOM.

RESULTS

Twenty-four patients (mean age: 44.4 ± 17.8 years-old, male: 11) between 2011 and 2022 were included. One case (4.2%) was pediatric (17 years old), and 6 cases presented with recurrence. Active IOM was characterized by fusiform EOM enlargement, high T2 signal, and contrast enhancement. Average maximal EOM diameters ranged from 4.6 to 7.7 mm (enlargement ratio: 1.4-2.2). Eighteen (75%) patients had single EOM involvement, most commonly the medial rectus. Other ipsilateral structures affected included focal orbital fat (16/24, 66.7%) and lacrimal gland (8/24, 33.3%). Contralateral changes in the EOM and/or lacrimal gland were observed in 7 patients (29.2%). Patients presenting with recurrence were likely to develop ongoing recurrent episodes (p = 0.003).

CONCLUSIONS

Various radiological patterns of involvement described including EOM enlargement, contrast enhancement, abnormal signal, and involvement of other orbital structures are indicative of active IOM. IOM remains a heterogeneous spectrum of acute and chronic clinico-radiological presentations. Inflammation may involve other ipsilateral or contralateral orbital structures or may be bilateral despite presenting clinically as unilateral disease. Quantitative measurements may have utility in differentiating IOM from other causes of orbital myositis.

Efficacy of Infliximab in Disease Control of Refractory Orbital Myositis

PURPOSE

Orbital myositis is a common cause of orbital inflammation with localized involvement of the extra ocular muscles. This study aimed to assess the value of infliximab in controlling orbital myositis and reducing its relapse rate.

METHODS

We conducted a retrospective review of the medical records of all consecutive patients with orbital myositis treated with infliximab between 2007 and 2016. We examined change in corticosteroid and immunomodulatory doses as well as relapse rates following treatment with infliximab.

RESULTS

The study included seven patients with an average follow up of 19 ± 13.4 months. The mean dose of systemic corticosteroid was reduced from 28.57 ± 14.35 mg/day at the time of infliximab initiation to 7.00 ± 6.83 mg/day at final follow-up (p = .003). Long-term remission was achieved in 85.7% (n = 6).

CONCLUSION

This study supports the role of infliximab in treating refractory orbital myositis and this was associated with clinical improvement, decreasing relapse rate with dose reduction of conventional treatment.

[Differential diagnosis of IgG4-related disease]

IgG4-related disease is a chronic autoimmune fibro-inflammatory disease characterized by the presence of lymphoplasmacytic infiltrate, storiform fibrosis, obliterating phlebitis, increased number of IgG4+ cells in tissue, and, in most cases, an elevated serum IgG4 level. This disease often affects the pancreas, salivary glands and lymph nodes, but can involve almost any tissue. Its etiology is still unclear, the central role in the pathogenesis belongs to B-lymphocytes, T2-helpers, interleukins 1-β, 4, 5, 10, 13 and tumor growth factor 1-β. The ambiguous clinical picture and frequent simultaneous involvement of several organs make it difficult to diagnose, so biopsy plays a leading role in making a diagnosis. The characteristic microscopic picture, the presence of certain populations of lymphocytes are key criteria in establishing the correct diagnosis.

Orbital myositis as an initial manifestation of Behcet's disease

Purpose

We report the case of a 32-year-old woman with orbital myositis prior to onset of Behcet's disease (BD).

Observations

A 32-year-old woman was referred to our hospital for a complaint of right eyelid swelling, eye pain, and diplopia. Her best-corrected visual acuity was 20/32 on the right, and 20/16 on the left. She was diagnosed as idiopathic orbital inflammation, and received two pulses of intravenous administration of methylprednisolone, followed by oral prednisolone. Three months later, she developed bilateral orbital myositis, and received one more pulse therapy, followed by oral prednisolone and cyclosporin. About one year after the first visit, oral aphthae, genital ulcers, and folliculitis-like skin rash appeared, and the physician diagnosed incomplete type BD. The patient had no uveitis during the disease course. Orbital inflammation and systemic manifestations of BD were ultimately well controlled with small doses of prednisolone.

Conclusion and importance

BD may develop during the course of orbital inflammation.

Extraocular muscle enlargement

Extraocular muscle enlargement can occur secondary to a range of orbital and systemic diseases. Although the most common cause of extraocular muscle enlargement is thyroid eye disease, a range of other inflammatory, infective, neoplastic, and vascular conditions can alter the size and shape of the extraocular muscles. Imaging with computed tomography and magnetic resonance imaging plays an essential role in the workup of these conditions. This article provides an image-rich review of the wide range of pathology that can cause enlargement of the extraocular muscles.

Idiopathic Orbital Myositis Revisited

PURPOSE OF REVIEW

To review current knowledge regarding idiopathic orbital myositis.

RECENT FINDINGS

Recent publications have focused on possible causes of orbital myositis and the process to reach a diagnosis of idiopathic orbital myositis. With inflamed and enlarged extraocular muscles, features to distinguish between competing diagnostic possibilities are based on imaging in the context of history and clinical signs. Idiopathic orbital myositis is characterized by the clinical triad of acute onset of orbital pain exacerbated on eye movement, double vision, and redness or swelling of the eyelids or conjunctiva, along with the radiological finding of homogeneous, fusiform enlargement of one or more extraocular muscles. In atypical or inconclusive clinico-radiological findings for a diagnosis of idiopathic orbital myositis, or where the clinical behavior changes or fails to respond to corticosteroid treatment, a systemic and oncologic work-up and muscle biopsy are warranted to exclude specific local or systemic disease as cause of the inflamed and enlarged muscle. As our understanding of idiopathic orbital myositis evolves, the diagnostic focus is shifting toward earlier identification of underlying local or systemic disease through systemic work-up and muscle biopsy.

IgG4-related disease in patients with idiopathic orbital inflammation

Background

To identify the prevalence of positive IgG4 immunostaining in orbital tissue among patients previously diagnosed with nongranulomatous idiopathic orbital inflammation (IOI) and to compare the clinical characteristics of patients with and without IgG4-positive cells.

Methods

A retrospective review of all patients with a histopathologic diagnosis of IOI was performed. Immunohistochemical staining was performed to identify IgG-positive cells and IgG4-positive cells. Multivariate analysis was performed using likelihood ratio-test logistic regression on the differences between IgG4-related disease (IgG4-RD) and non-IgG4-RD.

Results

Of the 45 patients included, 21 patients (46.7%) had IgG4-positive cells, with 52.4% being male and a mean age of 55.9 ± 13.4 years. Bilateral ocular adnexal involvement (adjusted odds ratio [aOR] = 9.45; P = 0.016) and infraorbital nerve enlargement (aOR = 12.11; P = 0.008) were frequently found in IgG4-RD patients. Complete remission occurred in 23.8% of IgG4-RD patients and 41.7% of non-IgG4-RD patients. IgG4-RD patients had more frequent recurrent disease than non-IgG4-RD patients.

Conclusions

Nearly 50% of IgG4-RD patients were previously diagnosed with biopsy-proven IOI. IgG4-RD was more frequent in patients with bilateral disease and infraorbital nerve enlargement, showing the importance of tissue biopsy in these patients. Immunohistochemistry studies of all histopathology slides showing nongranulomatous IOI are highly recommended to evaluate for IgG4-RD.

A Case of Idiopathic Orbital Inflammation Presenting as Isolated Myositis of the Inferior Oblique Muscle

Purpose: To report a case of idiopathic orbital inflammation presenting with isolated myositis of the inferior oblique muscle. Case summary: A 54‐year‐old man presented with swelling on the left lower lid, pain on superonasal and inferonasal gaze, and binocular diplopia for 2 months. His head was tilted to the right by about 5° and mild conjunctival injection and 3 mm narrowing of palpebral fissure of the left eye compared to the other eye were observed. Eight prism diopter (PD) left hypertropia and 4 PD intermittent esotropia were noted on primary gaze, which worsened on leftward gaze, downward gaze, and left head tilt. Orbital magnetic resonance imaging (MRI) showed enhanced hypertrophy of the left inferior oblique muscle. Systemic work‐up for possible inflammatory diseases yielded negative results. Therefore, a presumptive diagnosis of idiopathic isolated myositis of the left inferior oblique muscle was made. The patient was treated with 60 mg of oral corticosteroid per day for the first week, and the dose was tapered for 1 month as the symptoms reduced. Two months later, the patient became free from any symptoms and follow-up orbital MRI showed a significant decrease in size of the left inferior oblique muscle. There have been no signs of recurrence for 7 months. Conclusions: A presumptive diagnosis of idiopathic isolated myositis of the inferior oblique muscle was made in a patient with swelling of the left lower lid and binocular diplopia based on orbital MRI and systemic work‐up. Good results were achieved with oral corticosteroid therapy.

Periphlebitis of the Superior Ophthalmic Vein

Isolated orbital periphlebitis in the context of nonspecific orbital inflammation is rare. This case series describes 3 patients with periphlebitis of the superior ophthalmic vein, 2 of which were confirmed with pathology. All 3 cases had a history of Graves hyperthyroidism. Superior ophthalmic vein periphlebitis is a rare form of orbital inflammation presenting with proptosis and motility restriction yet few inflammatory signs. It may be associated with autoimmune hyperthyroidism and represent a rare feature of thyroid eye disease, or perhaps could be an overlap syndrome between thyroid eye disease and nonspecific orbital inflammation. Treatment response is variable and may require a prolonged course of steroids or other immunosuppressive medications.

Bilateral idiopathic orbital pseudotumour in a child: a case report

Background

Idiopathic orbital pseudotumour is rare in children. We report a case of bilateral paediatric idiopathic orbital pseudotumour and review the characteristics of this case.

Case presentation

A 14-year-old female patient presented at our Department of Pulmonary and Critical Care Medicine (PCCM) with complaints of recurrent severe cold and cough for 3 weeks, which had been treated with an intravenous antibiotic. Meanwhile, the patient developed swelling of both eyelids during the period of cold and cough, but her symptoms did not improve after the ocular administration of tobramycin dexamethasone eye drops. The patient was referred from the respiratory medicine ward to our department because of gradually worsening ocular pain, visual deterioration, increased intraocular pressure and serious nausea/vomiting within 24 h of hospitalization. The diagnosis of bilateral idiopathic orbital pseudotumour was made ultimately because of the course of the disease, exclusion of diagnoses such as bacterial ocular infection or malignant tumours and subsequent evidence from orbital magnetic resonance imaging (MRI). Favourable progress in the ocular tension and eyelid swelling was achieved through treatment with intravenous dexamethasone. The binocular intraocular pressure gradually declined to approximately 15 mmHg, and there was favourable progression in the patient’s vision to 20/40 in both eyes on the ninth day of hospitalization.

Conclusions

Our patient developed rapidly progressive acute orbital signs and symptoms and anterior inflammation, such as pain, proptosis, limited ductions, periorbital oedema, chemosis, vision loss and high intraocular pressure. This case highlights that idiopathic orbital pseudotumour is an uncommon but important cause of acute orbital syndrome in children.

Tacrolimus for Treating Orbital and Cranial Form of Idiopathic Inflammatory Pseudotumors

Background and Purpose

Orbital and cranial form of idiopathic inflammatory pseudotumors (IIPs) are rare disorders with heterogeneous clinical presentations. Corticosteroids have been the first-line treatment for IIPs, but they are not always effective.

Methods

We reviewed the medical records of three patients with orbital or cranial form of IIP who were treated with tacrolimus as an adjuvant treatment.

Results

The three patients showed favorable outcomes with the addition of tacrolimus, which is a calcineurin inhibitor that inhibits T-cell activation and T-cell-dependent B-cell activation.

Conclusions

Tacrolimus may be a safe and effective immunosuppressant for refractory or relapsing form of orbital or cranial IIPs.

Non-specific orbital inflammation: Current understanding and unmet needs

Non-specific orbital inflammation (NSOI) is a noninfectious inflammatory condition of the orbit. Although it is generally considered the most common diagnosis derived from an orbital biopsy, it is a diagnosis of exclusion, meaning that the diagnosis requires exclusion of a systemic process or another identifiable etiology of orbital inflammation. The clinical diagnosis of NSOI is ill-defined, but it is typically characterized by acute orbital signs and symptoms, including pain, proptosis, periorbital edema, chemosis, diplopia, and less commonly visual disturbance. NSOI poses a diagnostic and therapeutic challenge: The clinical presentations and histological findings are heterogeneous, and there are no specific diagnostic criteria or treatment guidelines. The etiology and pathogenesis of NSOI are poorly understood. Here we recapitulate our current clinical understanding of NSOI, with an emphasis on the most recent findings on clinical characteristics, imaging findings, and treatment outcomes. Furthermore, gene expression profiling of NSOI and its implications are presented and discussed.

Treatment of idiopathic orbital myositis with frequent relapses: First case with tacrolimus and review of literature

A 41-year-old man presented with a 2-year history of recurrent painful ophthalmoplegia. Previous brain magnetic resonance imaging showed isolated enlargement of extraocular muscles with enhancement. A diagnosis of idiopathic orbital myositis (IOM) was given. Though the patient initially responded dramatically to corticosteroid, he began developing steroid resistance from his third attack and experienced frequent relapses. Therefore, tacrolimus was added to his regimen. The patient had full symptom recovery after tacrolimus and reported no relapses in the 1-year follow-up. This is the first case showing the efficacy of tacrolimus in treatment of IOM. Our case illustrates the importance of immunosuppressive agents in IOM patient refractory to steroid for both symptom control and relapse prevention.

Clinical Features of Ocular Motility in Idiopathic Orbital Myositis

: Objective: To elucidate the clinical features of ocular motility and the risk factors for recurrence in idiopathic orbital myositis.

METHODS

The medical records of 31 patients diagnosed with idiopathic orbital inflammation between 2003 and 2019 were retrospectively reviewed. All patients were initially treated with corticosteroids. Treatment outcome and ocular motility were noted.

RESULTS

Twenty-six patients (84%) had unilateral involvement and five patients (16%) were bilateral. Of the 31 patients, 22 patients (71%) showed ocular motility limitation. The mean grading scale of extraocular muscle (EOM) limitation was -1.65 ± 1.80. EOM limitation was found in the same direction of the most affected muscle in 14 patients (64%), while 8 patients (36%) showed duction limitation in the opposite direction. Nine patients (35%) suffered from recurrence. Recurrence was more likely to occur in patients with multiple muscle involvement (p < 0.001). The interval to relapse of symptoms after discontinuation of steroids was significantly shorter in patients with multiple recurrences compared to those with a single recurrence (1.8 ± 0.8 weeks versus 6.0 ± 1.4 weeks, p = 0.020).

CONCLUSIONS

Idiopathic orbital myositis showed variable degrees of ocular motility limitation, and limitation in the same direction of the action of the affected muscle was more frequent. Recurrent myositis was more likely to have multiple muscle involvement. Rapid relapse of symptoms after discontinuation of steroids was a significant indicator of multiple recurrences.

Orbital pseudotumor as the presenting symptom of Crohn's disease in a male child

Purpose

This report will describe a case of orbital pseudotumor that is associated with underlying Crohn's disease in a pediatric patient.

Observations

An 8-year-old male with a past medical history of chronic constipation who presented to the ophthalmologist in July 2017 with a 7-month history double vision, left upper lid ptosis, left abducens nerve palsy, and an abnormal thyroid test. The patient's family history was negative for any autoimmune disease including, juvenile idiopathic arthritis, rheumatoid arthritis, thyroid disease, type 1 diabetes mellitus or inflammatory bowel disease. Diagnosis of orbital pseudotumor of the left eye was made based on CT scan findings and he was then treated with a one-week course of oral prednisone. After resolution of his initial symptoms, he presented a month later with swelling in his left eye and was treated with a 6-month steroid taper with resolution of symptoms. In June 2018, the patient presented with swelling in his right eye and was treated with prednisone plus steroid sparing agents. Extraocular muscle biopsy was negative for IgG4 related disease, fungal infection, or malignant lymphoma and workup for sarcoidosis and granulomatosis with polyangiitis was unremarkable. In September 2018, the patient presented with bloody stools, diagnosed and treated for a perirectal abscess. Subsequent colonoscopy performed in January 2019 confirmed Crohn's disease. He is currently undergoing treatment with adalimumab and is in remission in terms of orbital pseudotumor.

Conclusion and Importance

In conclusion, although the association between orbital pseudotumor and Crohn's disease is very rare, medical professionals should remember this connection when a patient presents with idiopathic orbital pseudotumor. To rule out this possibility, we recommend a thorough history of GI findings should be taken on the initial patient encounter. Crohn's disease may be an underlying cause of certain cases of orbital pseudotumor, and treatment and control of the underlying Crohn's disease may help to reduce recurrence rates of orbital pseudotumor. Additional studies need to be performed to better understand the association between the two diseases.

Clinical characteristics, histopathology, and treatment outcomes in adult and pediatric patients with nonspecific orbital inflammation

Purpose

To evaluate the clinical characteristics, histopathology, and treatment outcomes in adult and pediatric patients with nonspecific orbital inflammation (NSOI).

Methods

This retrospective study evaluates 76 patients with NSOI. The patients were categorized in 9 groups according to the site of involvement and histopathology results. These groups included: anterior involvement, dacryoadenitis, myositis, perineural involvement, acute fat involvement, focal mass, orbital apex involvement, diffuse sclerosing form, and multiple tissue involvement. The course of the disease was categorized as acute, subacute, or chronic. The cases with symptom duration of less than 1 week were classified as acute, 1 week to 1 month as subacute, and more than 1 month as chronic.

Results

36 (47.4%) patients were males. The mean age was 41.68 ± 17.62 (6-75) years. The most common signs and symptoms were periorbital pain, periorbital edema, decreased ocular movements or diplopia, and conjunctival injection. The most common group was dacryoadenitis in 29 (38.1%) cases. The most common form of disease was the acute involvement (50% of patients). Most of the patients were treated by oral corticosteroids. Duration of follow-up was 7.17 ± 6.26 months. Recurrence occurred in 9 (11.8%) of patients during the follow-up period.

Conclusions

This study presents a new categorization in which multiple tissue involvements were separated. Some of the NSOI features differ between adults and children. In most patients, treatment especially with corticosteroids, resolves the clinical findings.

Idiopathic Orbital Inflammation: Review of Literature and New Advances

Idiopathic orbital inflammation (IOI) is a benign inflammatory condition usually confined to the orbit but extraorbital extension can also occur. IOI has been classified into categories including anterior, diffuse, posterior or apical, myositis, and dacryoadenitis. Other rare types of IOI include periscleritis, perineuritis, and focal mass. Diagnosis is based on careful history, clinical findings, computed tomography, and magnetic resonance imaging findings. An orbital biopsy is usually done for accessible orbital lesions such as dacryoadenitis. For other types such as myositis and apical IOI where surgery is difficult or dangerous, orbital biopsy is not initially considered. The mainstay of therapy consists of systemic corticosteroids, but other options including external beam radiotherapy, antimetabolites, alkylating agents, T-cell/calcineurin inhibitors, lymphocyte inhibitors, tumor necrosis factor-α inhibitors, and surgical debulking have also been used.

Long-term adverse event: inflammatory orbitopathy induced by pembrolizumab in a patient with metastatic melanoma

The recent advent of immune checkpoint inhibitors (ICI), including anti-programmed cell death 1 protein (anti-PD-1) agents has revolutionized the therapeutic approach of metastatic malignancies. Yet, ICI can disrupt immune tolerance resulting in enhanced immune activation in normal tissues with significant toxicity. A dysregulated activation of T-cells directed to normal tissues stands as the main mechanism of immune-related adverse events (irAE). To date, only two cases of immune-related inflammatory orbitopathy related to anti-PD-1 agents have been reported. This rare immune adverse event usually occurred early after ICI initiation. Here, we report the first case of late inflammatory orbitopathy occurring in a melanoma patient treated with pembrolizumab. Consequently, the occurrence of irAE under ICI should be monitored, even late after treatment instauration.

[Management of orbital inflammation in internal medicine. Proposal for a diagnostic work-up]

Inflammatory orbitopathies relate to an inflammatory state originating within the orbit and its adnexes, except the inner ocular globe. Orbital inflammation (OI) may be either localized manifestation of a proven or like autoimmune disease, or local response from immune system against infectious, structural or tumoral antigens. We review the clinical manifestations of OI, which provide helpful clues to the diagnosis and describe the inflammatory, infectious and neoplastic conditions classically associated with OI. Autoimmune diseases are probably the most common causes of OI associated with a bilateral dacryoadenitis (e.g., sarcoidosis, granulomatosis with polyangiitis, IgG4-related disease). We focused on a major part of the IgG4-RD spectrum, the IgG4-related orbital disease which has been recently described and the idiopathic orbital inflammation syndrome that one should consider in patients 40 years of age or older with non specific inflammation OI on biopsy but without underlying local or systemic disease. An algorithm for the diagnostic approach of OI was proposed. If systemic explorations fail to diagnose an underlying disease, histopathologic control is required for distinguishing non-specific OI from other differential diagnosis, especially lymphoma. In the cases of pure myositic locations and posteriorly located tumours where biopsy could damage to the optic nerve, analysis of orbital lesions in T2W IRM sequence may be helpful to distinguish idiopathic OI (IOI) from lymphoma. When the diagnostic work-up fails, a corticosteroid trial could be used, but its beneficial effect has to be cautiously interpretated before definitively diagnosing IOI. Finally, treatments used in main infllammatory orbitopathies were also reviewed.

The 2017 Doyne Lecture: the orbit as a window to systemic disease

A very large number of disorders affect the orbit, and many of these occur in the setting of systemic disease. This lecture covers selected aspects of orbital diseases with systemic associations in which the author has a particular clinical or research interest. Spontaneous orbital haemorrhage often occurs in the presence of bleeding diatheses. Thrombosis of orbital veins and ischaemic necrosis of orbital and ocular adnexal tissues occur with thrombophilic disorders, vasculitis, and certain bacterial and fungal infections. Non-infectious orbital inflammation commonly occurs with specific inflammatory diseases, including Graves' disease, IgG4-related disease, sarcoidosis, Sjögren's syndrome and granulomatosis with polyangiitis, all of which have systemic manifestations. IgG4-related ophthalmic disease is commoner than all these except Graves' orbitopathy. Some of these orbital inflammatory diseases are associated with an increased risk of B-cell lymphoma, usually marginal zone lymphoma of MALT type. Ocular adnexal lymphoma also has an association with infectious agents including Helicobacter pylori and Chlamydia psittaci. Orbital metastasis may be the first presentation of systemic malignancy. A number of orbital neoplasms occur in the setting of familial cancer syndromes, including Neurofibromatosis types 1 and 2. Study of the genetics and molecular biology of orbital diseases such as Graves' orbitopathy and idiopathic orbital inflammatory disease will yield useful information on their diagnosis and management.

Intralesional corticosteroid injections as treatment for non-infectious orbital inflammation

A retrospective single-center chart review identified 19 patients treated with intralesional corticosteroid injection between 2007 and 2015 for orbital inflammatory disease. Patients were treated in the office, or intraoperatively at the time of orbital exploration and biopsy, with 5-40 mg of triamcinolone acetonide. Average follow up time was 2.44 years. Information recorded included visual acuity and eyelid position measurements, pre-injection treatment, post-injection treatment, complications, and exam findings. Nine of the identified patients received intraoperative injections, 9 in the office setting, and one received an injection in each. Eight patients (42.1%) were on oral corticosteroids prior to the injection. All patients showed initial clinical improvement after 1-2 injections and no more than a 1-2 line difference in visual acuity. Overall, six patients (31.6%) required repeat injections due to recurrence of inflammation, and seven (36.8%) required additional oral corticosteroids beyond the initial taper. Patients pre-treated with oral corticosteroids were more likely to need repeat injections (83.3% vs 16.7% respectively, p = 0.04). Compared to injections performed in the office setting, intraoperative injections were associated with fewer repeat injections (0% vs. 60.0% respectively, p = 0.01) and less need for post-injection oral steroids (0% vs. 58.3% respectively, p < 0.01). There were no systemic or permanent side effects observed from the injections. Two patients (10.5%) had transient post-injection intraocular pressure elevation, which resolved. Intralesional orbital corticosteroid injection is an effective first-line and adjunctive treatment for localized and diffuse non-infectious orbital inflammation.

Consensus on Diagnostic Criteria of Idiopathic Orbital Inflammation Using a Modified Delphi Approach

Importance

Current practice to diagnose idiopathic orbital inflammation (IOI) is inconsistent, leading to frequent misdiagnosis of other orbital entities, including cancer. By specifying criteria, diagnosis of orbital inflammation will be improved.

Objective

To define a set of criteria specific for the diagnosis of IOI.

Design, Setting, and Participants

A 3-round modified Delphi process with an expert panel was conducted from June 8, 2015, to January 25, 2016. Fifty-three orbital scientist experts, identified through membership in the Orbital Society, were invited to participate in on online survey and they scored, using 5-point Likert scales, items that are eligible as diagnostic criteria from the literature and from personal experience. The items were clustered around the anatomic subtypes of IOI: idiopathic dacryoadenitis and idiopathic orbital fat inflammation (2 nonmyositic IOIs), and idiopathic orbital myositis (myositic IOI). Items with dissensus were rescored in the second round, and all items with consensus (median, ≥4; interquartile range, ≤1) were ranked by importance in the third round.

Main Outcomes and Measures

Consensus on items to be included in the criteria.

Results

Of the 53 experts invited to participate, a multinational panel of 35 (66%) individuals with a mean (SD) years of experience of 31 (11) years were included. Consensus was achieved on 7 of 14 clinical and radiologic items and 5 of 7 pathologic items related to diagnosis of nonmyositic IOI, and 11 of 14 clinical and radiologic items and 1 of 5 pathologic items for myositic IOI. There was agreement among panelists to focus on surgical tissue biopsy results in the diagnosis of nonmyositic IOI and on a trial with systemic corticosteroids in myositic IOI. Panelists agreed that a maximum number of 30 IgG4-positive plasma cells per high-power field in the orbital tissue is compatible with the diagnosis of IOI.

Conclusions and Relevance

An international panel of experts endorsed consensus diagnostic criteria of IOI. These criteria define a level of exclusion suggested for diagnosis and include tissue biopsy for lesions not confined to the extraocular muscles. This consensus is a step toward developing guidelines for the management of IOI, which needs to be followed by validation studies of the criteria.

Orbital Inflammation in Pregnant Women

OBJECTIVE

To analyze overlaps between pregnancy and orbital inflammation (OI).

DESIGN

Retrospective observational case series.

METHODS

Eight new cases from 1997 to 2015 and 2 previously published cases were identified for inclusion in this investigation to provide the fullest clinical picture. Medical records, imaging studies, and the results of biopsies were reviewed.

RESULTS

Three categories of association were discovered: (1) OI arising for the first time during pregnancy (5 cases); (2) OI arising within 3 months of delivery (2 cases); and (3) previously diagnosed OI reactivated or exacerbated by pregnancy (3 cases). One patient had a preexistent systemic autoimmune disease and another's was later diagnosed. One patient had attacks during sequential pregnancies. Findings included eyelid swelling and erythema, conjunctival chemosis, pain on eye movement, minimal diplopia, the usual absence of proptosis, and general preservation of visual acuity. Imaging studies disclosed extraocular muscle swelling (8 cases), most frequently of a single lateral rectus muscle. There were 2 cases of dacryoadenitis; 1 of these and an additional case displayed inflammation of the retrobulbar fat. Corticosteroids effected resolution of most symptoms. Singleton births were normal with the exceptions of an intrauterine fetal demise owing to acrania and a molar pregnancy.

CONCLUSION

OI usually affects a single rectus muscle (typically the lateral) and, less often, the lacrimal gland and is often mild when it arises during or after pregnancy. Independent systemic autoimmune disease is an uncommon feature. Corticosteroids were efficacious except in 1 case with severe orbital scarring. No definitive causal relationships between pregnancy and OI could be established based on the clinical data.

[Rationale for a diagnostic approach in non-Graves' orbital inflammation--Report of 61 patients]

INTRODUCTION

Orbital inflammatory syndromes include a wide variety of inflammatory intraorbital processes which are very different in terms of clinical presentation and prognosis. We currently prefer to differentiate so-called "specific" inflammations, for which an etiology is able to be identified, from idiopathic orbital inflammatory syndromes (IOIS), for which the etiology remains unknown and the histology is nonspecific.

PURPOSE

To propose an efficient diagnostic approach for clinicians managing patients with non-Graves' orbital inflammations.

MATERIALS AND METHODS

This is a retrospective and prospective study concerning 61 patients managed by the medical team for non-Graves' orbital inflammations between May, 1999 and May, 2013 in the ophthalmology departments of Nice and Limoges university hospitals in France. Seventeen specific inflammations, 19 orbital lymphomas and 25 idiopathic orbital inflammatory syndromes were included. Patients were divided into two groups. Thirty-six patients (group 1) underwent primary biopsy, while for the other 25 (group 2), therapy was begun empirically without biopsy. We could therefore compare both approaches in terms of diagnostic efficiency and time until identification of a specific etiology.

RESULTS

Our statistical results show that an approach without primary biopsy leads to a number of specific diagnoses statistically much lower than that obtained by the approach with primary biopsy. Also, the risk of missing a specific inflammation (with as a consequence an inappropriate treatment and a risk of functional sequelae as well as a fatal risk of missing a lymphoproliferative pathology) is very clearly higher in the case of not performing primary biopsy. Finally, the average time elapsed between the initial consultation with the ophthalmologist and a specific diagnosis was one month in the case of the first approach, while this delay was almost three times higher with the second approach, with a mean of 2.91 months (P<0.01).

DISCUSSION

Our study shows that biopsy should be the mainstay of diagnostic management. A trial of empiric treatment is only performed first in myositis or in locations where biopsy could jeopardize functional prognosis. It should only be done after biopsy in all other cases. Of course, in all cases of relapse or recurrence after treatment, biopsy should be performed or repeated.

CONCLUSION

The diagnostic work-up of a patient with an orbital inflammatory process must of course include blood testing and orbital imaging, but also a systematic primary biopsy for histological examination in the vast majority of cases. It must be repeated at least in the case of any doubt about the diagnosis or in the case of any recurrence or resistance to treatment.

"Orbiting around" the orbital myositis: clinical features, differential diagnosis and therapy

Orbital myositis (OM) is a rare disease whose clinical heterogeneity and different treatment options represent a diagnostic and therapeutic challenge. We aim to review the state of knowledge on OM, also describing a cohort of patients diagnosed in our centre, to highlight some remarkable clinical features. A literature review was conducted in PubMed and Medline databases. The herein described cohort is composed of seven OM patients, diagnosed according to clinical, laboratory and neuroradiological features, whose clinical data were retrospectively analysed. OM is a non-infectious, inflammatory process primarily involving extraocular eye-muscles. It typically presents as an acute to sub-acute, painful ophthalmoplegia with signs of ocular inflammation, but atypical cases without pain or with a chronic progression have been described. The wide range of OM mimicking diseases make a prompt diagnosis challenging but orbit MRI provides valuable clues for differential diagnosis. Timely treatment is greatly important as OM promptly responds to steroids; nevertheless, partial recovery or relapses often occur. In refractory, recurrent or steroid-intolerant cases other therapeutic options (radiotherapy, immunosuppressants, immunoglobulins) can be adopted, but the most effective therapeutic management is yet to be established. In this review, we provide a detailed clinical description of OM, considering the main differential diagnoses and suggesting the most useful investigations. In light of the currently available data on therapy efficacy, we propose a therapeutic algorithm that may guide neurologists in OM patients' management.

Idiopathic orbital myositis

PURPOSE

There is a paucity of reliable data and limited experience on the clinical features and therapeutic outcomes of orbital myositis. The purpose of this study was to collate data on the clinical features, imaging, diagnosis, and therapeutic effects of case reports from patients with myositis of idiopathic orbital inflammation pseudotumor in a tertiary eye hospital in China.

METHODS

A retrospective study was performed on the records of 44 Chinese patients with orbital myositis. Data were obtained from the period of January 1, 2000, to August 31, 2010, from patients treated at the Eye Hospital of the Zhongshan Ophthalmic Center at Sun Yat-sen University, Guangzhou, China.

RESULTS

Twenty-five patients were women and 19 men. The mean age was 39.1 years (range, 11-77 years). Right eyes were involved in 18 cases, left in 17 cases, and both eyes in 9 cases. Dysfunctions of the affected muscles included pure paretic (20.5%), pure restrictive (45.5%), or mixed paretic-restrictive (34.1%). The ratio of acute to subacute stage was 1:3. The rank order of affected muscles was as follows: superior rectus (29.1%), lateral rectus (25.6%), medial rectus (24.4%), inferior rectus (19.8%), and superior oblique (1.16%). The proportion of single muscle involvement was 37.5%, and tendon involvement was seen in 40.9% of the muscles. All patients were treated with systemic corticosteroids (prednisone or dexamethasone). Full recovery was achieved in 38.6% of patients, whereas 59.1% achieved partial recovery with an average of 6.4 recurrences (range, 2.0-8.0 recurrences). Recurrences occurred in 81.8% of the patients.

CONCLUSIONS

Orbital myositis occurs in multiple clinical manifestations and may be recurrent. Imaging is an important technique for use in diagnosis. Systemic corticosteroid represents an effective approach for treatment.

Ocular myositis

Ocular myositis frequently manifests with orbital pain and diplopia. The diagnosis of ocular myositis falls within the overall classification of idiopathic orbital inflammatory diseases, defined as non-infective non-specific orbital inflammation without identifiable local or systemic causes. Orbital myositis may form part of more widespread systemic inflammatory processes such as Crohn's disease and the more recently described IgG4-related disease. There is also a broad range of ophthalmic differential diagnoses. Diagnosis, assessment and management of ocular myositis requires the cooperation of ophthalmologists and rheumatologists/immunologists in order to achieve the best patient outcomes. The current literature and avenues of future research are reviewed.

[Clinical features and management of acute myositis in idiopathic orbital inflammation]

Acute myositis is the second most common component of non-specific orbital inflammation. We will describe its clinical features and natural history. This is a retrospective study of 10 cases. The diagnosis of acute myositis was based on clinical and imaging criteria. Our study includes five men and five women. The average age was 35.8 years (17-59 years). Clinical symptoms were: pain increased on eye movement (10/10), diplopia (4/10), proptosis (6/10), visual loss (3/10), lid edema (6/10), conjunctival hyperemia (7/10), anterior scleritis (2/10), episcleritis (2/10), chemosis (4/10), upper lid retraction (1/10), limitation of eye movement (3/10), fundus abnormalities (2/10). Imaging showed thickening of one or more extraocular muscles (10/10). Recovery was complete with anti-inflammatory therapy in six patients. Three patients experienced recurrence, and one patient had a clinical rebound upon tapering the treatment. Acute myositis can be defined by pain on eye movement, signs of inflammation, and extraocular muscle thickening on imaging. If the clinical presentation is typical, histopathological analysis can be deferred but remains necessary in cases of poor response to treatment, chronic duration or suspicion of tumor infiltration. The diagnosis of acute myositis may be suspected in the presence of consistent, well-defined clinical signs. Contiguous inflammation is often associated. Treatment is based on steroids or non-steroidal treatment anti-inflammatory therapy, administered alone or consecutively. Recurrences are frequent but do not alter the final prognosis.

Lateral rectus myositis mimicking an abducens nerve palsy in a pregnant woman

Myositis is a rare unknown inflammatory disorder of the skeletal muscle tissue. Generalized inflammatory myopathies, polymyositis, and dermatomyositis have been reported during pregnancy. Isolated orbital myositis in pregnancy has not been previously described in the literature. The authors report a case of left isolated orbital myositis in a primigravida at 38 weeks gestation affecting the patient's left lateral rectus muscle. MRI of the orbit was consistent with the diagnosis. She showed remarkable clinical improvement with oral corticosteroids therapy.

A comparison of benign and inflammatory manifestations of Tolosa-Hunt syndrome

BACKGROUND

Tolosa-Hunt syndrome (THS) manifests as a benign or an inflammatory type disease. The nosography differences between these types remain to be elucidated. We aimed to analyze and compare the clinical presentations of benign and inflammatory THS.

METHODS

The ward patients who presented with THS from January 1990 to May 2011 were retrospectively reviewed. THS was diagnosed according to the recommendations of the International Headache Society.

RESULTS

Of the 53 THS cases (49 patients), 30 (56.6%) were classified as benign and 23 (43.4%) as inflammatory THS. There were strong similarities between the groups in terms of clinical manifestations, laboratory findings, responses to glucocorticoid treatment, and outcomes. However, patients with inflammatory THS tended to be younger (mean age, 43.4 years; P 0.05) and have optic nerve dysfunction (56.5%; P 0.05) and longer disease duration (2.3 ± 1.0 months; P 0.05) compared to those with benign THS (mean age, 56.4 years; mean disease duration, 1.6 ± 0.7 months). The patients with additional involvement of both the optic nerve and the second division of the trigeminal nerve experienced a longer disease duration ( P 0.05). Additionally, patients with orbital pseudotumors had diplopia that responded poorly to treatment with glucocorticoids ( P 0.05). High-dose (>0.5 mg/kg/day) and low-dose (≤0.5 mg/kg/day) prednisolone were equally effective in relieving symptoms in both groups ( P > 0.05).

CONCLUSION

Benign and inflammatory THS were highly similar in terms of nosography. The responses to glucocorticoid treatment were generally good except in patients with orbital pseudotumors.

Painless orbital myositis

Idiopathic orbital inflammation is the third most common orbital disease, following Graves orbitopathy and lymphoproliferative diseases. We present a 11 year old girl with 15 days history of painless diplopia. There was no history of fluctuation of symptoms, drooping of eye lids or diminished vision. She had near total restricted extra-ocular movements and mild proptosis of the right eye. There was no conjunctival injection, chemosis, or bulb pain. There was no eyelid retraction or lid lag. Rest of the neurological examination was unremarkable.Erythrocyte sedimentation rate was raised with eosinophilia. Antinuclear antibodies were positive. Liver, renal and thyroid functions were normal. Antithyroid, double stranded deoxyribonucleic acid and acetylcholine receptor antibodies were negative. Repetitive nerve stimulation was negative. Magnetic resonance imaging (MRI) of the orbit was typical of orbital myositis. The patient responded to oral steroids. Orbital myositis can present as painless diplopia. MRI of orbit is diagnostic in orbital myositis.