Isolated levator myositis

IgG4 Staining in Thyroid Eye Disease

IgG4-related ophthalmic disease is increasingly widely recognized. Moreover, IgG4 staining can occur in other inflammatory diseases. The authors report a case of IgG4 staining of an enlarged, inflamed levator palpebrae superioris in a patient with a past history of thyroid eye disease. A 78-year-old woman with quiescent hyperthyroidism had clinical and radiological evidence of levator palpebrae superioris inflammation without superior rectus involvement. A biopsy was consistent with IgG4-related ophthalmic disease. There was a marked but incomplete response to an orbital injection of triamcinolone. The authors discuss the association between thyroid eye disease and IgG4 staining and the diagnostic issues that arise when IgG4-related ophthalmic disease criteria are fulfilled in patients with other orbital inflammatory conditions.

Acute unilateral isolated ptosis

A 64-year-old man presented with a 2-day history of acute onset painless left ptosis. He had no other symptoms; importantly pupils were equal and reactive and eye movements were full. There was no palpable mass or swelling. He was systemically well with no headache, other focal neurological signs, or symptoms of fatigue. CT imaging showed swelling of the levator palpebrae superioris suggestive of myositis. After showing no improvement over 5 days the patient started oral prednisolone 30 mg reducing over 12 weeks. The ptosis resolved quickly and the patient remains symptom free at 6 months follow-up. Acute ptosis may indicate serious pathology. Differential diagnoses include a posterior communicating artery aneurysm causing a partial or complete third nerve palsy, Horner's syndrome, and myasthenia gravis. A careful history and examination must be taken. Orbital myositis typically involves the extraocular muscles causing pain and diplopia. Isolated levator myositis is rare.

Unrecognized side effect of statin treatment: unilateral blepharoptosis

A 43-year-old man receiving statin monotherapy (10 mg atorvastatin) for hypercholesterolemia had unilateral blepharoptosis as the result of isolated myositis of the levator muscle. Statin-induced myositis in the levator muscle should be considered in the differential diagnosis of acquired unilateral blepharoptosis of unknown cause.

Nonthyroid causes of extraocular muscle disease

Extraocular muscle involvement in orbital disease is most frequently seen as a feature of thyroid orbitopathy (Graves' disease). However, a wide range of other conditions may alter the size, shape, and function of these muscles, with characteristic clinical manifestations or abnormalities visible on orbital imaging. The differential diagnosis of muscle disease can be narrowed by careful analysis of clinical features and ancillary tests. Imaging facilitates recognition in many cases, but in some instances, accurate diagnosis requires biopsy. This review highlights the differential diagnoses for diseases of extraocular muscles based on the clinical and investigative records of 103 patients at our institution combined with data from the world literature. We found that the most common nonthyroid causes of muscle disease were inflammatory, vascular, and neoplastic processes (in decreasing order of frequency). Emphasis is placed on investigations that provide a logical approach to, and appropriate management of, disease of the extraocular muscles.