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Musa M, Chukwuyem E, Ojo OM, Topah EK, Spadea L, Salati C, Gagliano C, Zeppieri M. Unveiling Ocular Manifestations in Systemic Lupus Erythematosus. J Clin Med 2024; 13:1047. [PMID: 38398361 PMCID: PMC10889738 DOI: 10.3390/jcm13041047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/29/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
Systemic Lupus Erythematosus (SLE) is a complex autoimmune disorder characterized by immune dysregulation and multi-organ involvement. In this concise brief review, we highlight key insights into Ocular Systemic Lupus Erythematosus (SLE), an intricate autoimmune disorder with diverse organ involvement. Emphasizing the formation of autoantibodies and immune complex deposition, we delve into the inflammation and damage affecting ocular structures. Clinical presentations, ranging from mild dry eye syndrome to severe conditions like retinal vasculitis, necessitate a comprehensive diagnostic approach, including clinical exams, serological testing, and imaging studies. Differential diagnosis involves distinguishing SLE-related ocular manifestations from other autoimmune and non-inflammatory ocular conditions. The multidisciplinary management approach, involving rheumatologists, ophthalmologists, and immunologists, tailors treatment based on ocular involvement severity, encompassing corticosteroids, immunosuppressive agents, and biologics. Follow-up is crucial for monitoring disease progression and treatment response. Future perspectives revolve around advancing molecular understanding, refining diagnostic tools, and exploring targeted therapies. Novel research areas include genetic factors, microbiome composition, and biotechnology for tailored and effective SLE ocular treatments.
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Affiliation(s)
- Mutali Musa
- Department of Optometry, University of Benin, Benin City 300238, Nigeria;
- Centre for Sight Africa, Onitsha 434112, Nigeria
| | | | - Oluwasola Michael Ojo
- School of Optometry and Vision Sciences, College of Health Sciences, University of Ilorin, Ilorin 240003, Nigeria
| | - Efioshiomoshi Kings Topah
- Department of Optometry, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano 700006, Nigeria
| | - Leopoldo Spadea
- Eye Clinic, Policlinico Umberto I, “Sapienza” University of Rome, 00142 Rome, Italy
| | - Carlo Salati
- Department of Ophthalmology, University Hospital of Udine, 33100 Udine, Italy
| | - Caterina Gagliano
- Faculty of Medicine and Surgery, University of Enna “Kore”, Piazza Dell’Università, 94100 Enna, Italy
- Eye Clinic, Catania University San Marco Hospital, Viale Carlo Azeglio Ciampi, 95121 Catania, Italy
| | - Marco Zeppieri
- Department of Ophthalmology, University Hospital of Udine, 33100 Udine, Italy
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Paraskevi VV, Aliki VI, Antigone P, Zoi T, Anastasia ZK, Alexandros DA. Orbital myositis in systemic lupus erythematosus: a case-based review. Rheumatol Int 2022; 42:1453-1460. [PMID: 35441316 DOI: 10.1007/s00296-022-05114-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/08/2022] [Indexed: 11/28/2022]
Abstract
Ocular complications occur in up to one-third of patients with systemic lupus erythematosus (SLE). Among them, orbital myositis (OM) is considered a rare manifestation that affects the extraocular muscles and causes pain and restriction with eye movement. We report a case of OM in a 48-year-old female with SLE and secondary Sjogren's Syndrome, who presented headache, periorbital edema, and painful ocular movements in both eyes, with no other systemic manifestations. An orbital magnetic resonance image revealed thickening of the right medial rectus and left lateral rectus muscles. Laboratory tests were normal and there was no further disease activity. The patient was treated with prednisone 1 mg/Kg/day with a resolution of symptoms. We found 13 additional cases of OM from our literature review (11 SLE patients and 2 with discoid lupus erythematosus). There was a female predominance in these cases with a mean age of 43.6 years (SD ± 16.9). Their main clinical features included eye pain, swelling, proptosis, diplopia, and limitations in extraocular muscles, while in most of them, there was no other active systemic manifestation. Treatment with steroids led to the complete resolution of symptoms in most of these patients. The available evidence suggests that it is essential to have a high index of suspicion for OM in SLE patients even when there is no systemic disease activity so that proper treatment is initiated early.
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Affiliation(s)
- Voulgari V Paraskevi
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, 45110, Ioannina, Greece.
| | - Venetsanopoulou I Aliki
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, 45110, Ioannina, Greece
| | - Pieta Antigone
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, 45110, Ioannina, Greece
| | - Tziortzioti Zoi
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, 45110, Ioannina, Greece
| | - Zikou K Anastasia
- Department of Radiology, Medical School, University of Ioannina, Ioannina, Greece
| | - Drosos A Alexandros
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, 45110, Ioannina, Greece
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Ophthalmic manifestations in patients with collagen vascular disorders: a hospital-based retrospective observational study. Int Ophthalmol 2021; 41:2765-2775. [PMID: 33830371 DOI: 10.1007/s10792-021-01833-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/29/2021] [Indexed: 01/19/2023]
Abstract
AIM To study frequency and characteristics of ocular manifestations in Indian patients with collagen vascular disorders. METHODS The medical records of 73 patients (Males: Females 16:57) aged between 22 and 78 years (mean ± SD = 43.5 ± 12.9 years) with collagen vascular diseases were analyzed retrospectively for demography, subtypes of collagen vascular disease, and findings of complete ophthalmic examination. RESULTS Lupus erythematosus (LE) in 39(53.4%, (SLE 18, DLE 21), systemic sclerosis in 27(37%), dermatomyositis in 5(6.8%), and primary Sjögren's syndrome in 2(2.7%) patients, respectively, were observed. Only 35(47.9%) patients had ocular manifestations. In LE keratoconjunctivitis sicca (n = 6), keratitis (n = 5), severe blepharitis (n = 3), retinopathy (n = 2), and optic neuritis in one patient, respectively, were major ocular manifestations. Major abnormalities occurring in systemic sclerosis included restricted eyelid mobility of variable severity (n = 8), eyelid telangiectasia (n = 5), keratoconjunctivitis sicca (n = 6), cataract (n = 5), shallow fornices (n = 4), conjunctival surface disease (n = 4), and uveitis, keratitis, episcleritis in one patient each, respectively. One patient with dermatomyositis had heliotrope rash. Two patients with primary Sjögren's syndrome had keratoconjunctivitis sicca. CONCLUSIONS The study shows that LE frequently presented with keratoconjunctivitis sicca, retinopathy, and optic neuritis. Systemic sclerosis commonly develops eyelid immobility, blepharitis and telangiectasia, ocular surface disease and keratoconjunctivitis sicca, corneal abnormalities, and uveitis. A comprehensive ocular evaluation is imperative for early detection and management particularly of ocular surface disease, uveitis, and retinopathy to prevent potential sight-threatening complications. Limitations include retrospective study design and small number of patients for stratification.
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Chan AJ, Rai AS, Lake S. Orbital myositis in systemic lupus erythematosus: A case report and literature review. Eur J Rheumatol 2020; 7:135-137. [PMID: 32809933 DOI: 10.5152/eurjrheum.2020.19217] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 06/08/2020] [Indexed: 11/22/2022] Open
Abstract
Orbital myositis is a rare manifestation of systemic lupus erythematosus (SLE). Herein, we report a case of orbital myositis in a patient with SLE, along with a literature review. A 45-year-old female patient presented with pain in the right eye, chemosis, proptosis, and limited abduction. Computed tomography of her orbits revealed thickening of her right lateral rectus muscle. She had no other systemic symptoms. There was no elevation in the biomarkers of inflammation or disease activity. She was treated with high-dose steroids, and her symptoms resolved rapidly. It is important to maintain a high index of suspicion for orbital myositis in patients with SLE even when there are no systemic disease activities, such that early treatment can be initiated. It is also important to rule out other mimickers such as orbital cellulitis and thyroid eye disease.
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Affiliation(s)
- Alvita J Chan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amandeep S Rai
- Department of Ophthalmology & Vision Sciences, University of Toronto, Ontario, Canada
| | - Shirley Lake
- Sunnybrook Research Institute, Holland Musculoskeletal Program, Toronto, Ontario, Canada
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Colon M, El Khoury L. Orbital compartment syndrome as the first manifestation of SLE. Clin Rheumatol 2020; 39:2223-2226. [PMID: 32152917 DOI: 10.1007/s10067-020-05010-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 02/18/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022]
Abstract
The occurrence of orbital compartment syndrome is a rare and unusual complication of systemic lupus erythematosus (SLE). Patients will present with symptoms of ocular pain and diplopia and visible signs of proptosis. The condition is considered an ophthalmological emergency because the myositis involving the ocular muscles can cause irrevocable damage to the retina and optic disk, potentially leading to blindness. We report a case of a young African American male who developed orbital myositis with compartment syndrome as his initial manifestation of SLE. The patient underwent an emergent orbital decompression, followed by prompt initiation of immunosuppressant medications. To our knowledge, this is the first report of a case of myositis secondary to SLE complicated by compartment syndrome of the orbit.
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Affiliation(s)
- Maria Colon
- Department of Internal Medicine, Northwell Health, LIJ Forest Hills Hospital, Forest Hills, New York, NY, USA.
| | - Lara El Khoury
- Division of Rheumatology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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DeParis SW, Joseph SS. Bilateral Sequential Acute Proptosis in a Woman With No History of Trauma. JAMA Ophthalmol 2019; 137:216-217. [DOI: 10.1001/jamaophthalmol.2018.3741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sarah W. DeParis
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Shannon S. Joseph
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland
- Now with Department of Ophthalmology, Kellogg Eye Center, University of Michigan, Ann Arbor
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Peponis V, Kyttaris VC, Tyradellis C, Vergados I, Sitaras NM. Ocular manifestations of systemic lupus erythematosus: a clinical review. Lupus 2016; 15:3-12. [PMID: 16482739 DOI: 10.1191/0961203306lu2250rr] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although the eye itself is regarded an ‘immune-privileged’ organ, systemic lupus erythematosus (SLE) can affect every ocular structure, leading, if left untreated, to significant visual loss or even blindness. Since ocular inflammation in SLE can antedate the diagnosis of the systemic disease and cause significant morbidity, prompt diagnosis and treatment of the underlying systemic autoimmune disease is imperative.
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Affiliation(s)
- V Peponis
- Department of Ophthalmology, General Hospital of Piraeus Tzaneion, Greece
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Shoughy SS, Tabbara KF. Ocular findings in systemic lupus erythematosus. Saudi J Ophthalmol 2016; 30:117-21. [PMID: 27330388 PMCID: PMC4908056 DOI: 10.1016/j.sjopt.2016.02.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 01/05/2016] [Accepted: 02/09/2016] [Indexed: 12/17/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease. Ocular complications occur in up to one-third of patients with SLE. The ocular findings may represent the initial manifestation of the disease and may lead to severe ocular morbidity and loss of vision. Early diagnosis and prompt management of patients with SLE are mandatory and require collaboration between the ophthalmologist and the rheumatologist.
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Affiliation(s)
- Samir S Shoughy
- The Eye Center and The Eye Foundation for Research in Ophthalmology, Riyadh, Saudi Arabia
| | - Khalid F Tabbara
- The Eye Center and The Eye Foundation for Research in Ophthalmology, Riyadh, Saudi Arabia; Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia; The Wilmer Ophthalmological Institute of The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Silpa-archa S, Lee JJ, Foster CS. Ocular manifestations in systemic lupus erythematosus. Br J Ophthalmol 2015; 100:135-41. [PMID: 25904124 DOI: 10.1136/bjophthalmol-2015-306629] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/04/2015] [Indexed: 12/19/2022]
Abstract
Systemic lupus erythematosus (SLE) can involve many parts of the eye, including the eyelid, ocular adnexa, sclera, cornea, uvea, retina and optic nerve. Ocular manifestations of SLE are common and may lead to permanent blindness from the underlying disease or therapeutic side effects. Keratoconjunctivitis sicca is the most common manifestation. However, vision loss may result from involvement of the retina, choroid and optic nerve. Ocular symptoms are correlated to systemic disease activity and can present as an initial manifestation of SLE. The established treatment includes prompt systemic corticosteroids, steroid-sparing immunosuppressive drugs and biological agents. Local ocular therapies are options with promising efficacy. The early recognition of disease and treatment provides reduction of visual morbidity and mortality.
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Affiliation(s)
- Sukhum Silpa-archa
- Massachusetts Eye Research and Surgery Institution, Cambridge, Massachusetts, USA Ocular Immunology & Uveitis Foundation, Cambridge, Massachusetts, USA Faculty of Medicine, Department of Ophthalmology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Joan J Lee
- Massachusetts Eye Research and Surgery Institution, Cambridge, Massachusetts, USA Ocular Immunology & Uveitis Foundation, Cambridge, Massachusetts, USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Cambridge, Massachusetts, USA Ocular Immunology & Uveitis Foundation, Cambridge, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA
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11
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Denniston AK, Gayed M, Carruthers D, Gordon C, Murray PI. Rheumatic Disease. Retina 2013. [DOI: 10.1016/b978-1-4557-0737-9.00080-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Kim DH, Kim HS. Recurrent orbital myositis in undifferentiated connective tissue disease. Joint Bone Spine 2012; 80:110-1. [PMID: 22840478 DOI: 10.1016/j.jbspin.2012.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 06/15/2012] [Indexed: 11/29/2022]
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Ocular manifestations of systemic lupus erythematosus: a review of the literature. Autoimmune Dis 2012; 2012:290898. [PMID: 22811887 PMCID: PMC3395333 DOI: 10.1155/2012/290898] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 05/31/2012] [Indexed: 01/14/2023] Open
Abstract
About one-third of patients suffering from systemic lupus erythematosus have ocular manifestations. The most common manifestation is keratoconjunctivitis sicca. The most vision threatening are retinal vasculitis and optic neuritis/neuropathy. Prompt diagnosis and treatment of eye disease is paramount as they are often associated with high levels of systemic inflammation and end-organ damage. Initial management with high-dose oral or IV corticosteroids is often necessary. Multiple "steroid-sparing" treatment options exist with the most recently studied being biologic agents.
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Abstract
Non-infectious vasculitides comprise a large number of diseases. Many of these diseases can cause inflammation within the orbit and a clinical presentation, which mimics numerous other processes. Orbital disease can often be the initial presentation of a systemic process and early diagnosis can help prevent long-term, potentially fatal consequences. The evaluation and treatment of non-infectious orbital vasculitides are often complicated and require a thorough understanding of the disease and underlying systemic associations. The long-term prognosis visually and systemically must be weighed against the risks and benefits of the treatment regimen. A large variety of corticosteroid formulations currently exist and are the mainstay of initial treatment. Traditional steroid-sparing immunosuppressive agents are also an important arsenal against these vasculitides. Recently, a new class of drugs called biologics, which target the various mediators of the inflammation cascade, may potentially provide more effective and less toxic treatment. This review aims to synthesize the current literature on non-infectious orbital vasculitides.
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Abstract
Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease, the exact etiology of which is unknown. It is characterized by the production of pathological autoantibodies which adhere to cellular surfaces or form immune complexes which deposit in tissue, leading to end-organ damage via inflammatory mechanisms including complement activation. SLE may manifest itself in any organ system. In the eye, keratoconjunctivitis sicca is the most common finding. Other ophthalmic sites of involvement include the cornea, conjunctiva, episclera, sclera, uveal tract, retina, vasculature, optic nerve, and orbit. Therapy varies based on the disease manifestation and severity.
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Affiliation(s)
- Russell W Read
- Department of Ophthalmology and Pathology, University of Alabama at Birmingham, AL 35233, USA.
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Lutt JR, Lim LL, Phal PM, Rosenbaum JT. Orbital Inflammatory Disease. Semin Arthritis Rheum 2008; 37:207-22. [PMID: 17765951 DOI: 10.1016/j.semarthrit.2007.06.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Revised: 06/05/2007] [Accepted: 06/17/2007] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To familiarize rheumatologists and internists with the signs, symptoms, and management of orbital inflammatory disease (OID). METHODS A comprehensive literature review related to OID was performed and reported from the perspectives of rheumatology, ophthalmology, and radiology. RESULTS OID is a general term encompassing inflammatory diseases that affect some or all of the structures contained within the orbit external to the globe. Orbital involvement as a part of the initial symptom complex is not uncommon for systemic diseases such as Graves' disease, Wegener's granulomatosis, and sarcoidosis. The management of these and other causes of OID, such as idiopathic orbital inflammation (formerly known as "orbital pseudotumor"), orbital myositis, and Tolosa-Hunt syndrome frequently involves systemic immunosuppression. Before immunosuppression is considered, however, infectious and malignant causes of inflammation must be ruled out. DISCUSSION Rheumatologists should be familiar with the differential diagnosis of OID and often need to assist colleagues in ophthalmology and internal medicine with the management of this group of diseases.
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Affiliation(s)
- Joseph R Lutt
- Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA.
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Abstract
The spectrum of orbital inflammatory disease (OID) ranges broadly from specific disease diagnoses, for example, Wegener's granulomatosis or sarcoidosis, to nonspecific inflammation which may involve one or multiple structures of the orbit. Mimics of idiopathic OID must be considered in a comprehensive differential diagnosis and include malignancies, congenital mass lesions, infectious diseases, and occult or distant trauma. Idiopathic OID may be secondary to an underlying systemic inflammatory disease, which must be diagnosed in order to develop a comprehensive therapeutic plan, or may represent localized pathologic processes without systemic involvement. Evaluation of the patient with suspected OID must include a careful history, physical examination, directed laboratory, and radiologic studies, and may sometimes require tissue for diagnostic studies. Therapeutic options for inflammatory diseases are expanding as biologically targeted agents become available that act on specific segments of the inflammatory cascades. The purpose of this paper is to provide a framework for the evaluation and management of patients with the spectrum of diseases known as OID and to discuss some of the new advances in immunologic monitoring and targeted immune therapies that will likely play an increasingly important role in the care of these patients.
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Affiliation(s)
- L K Gordon
- Jules Stein Eye Institute, University of California at Los Angeles and Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA.
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Abstract
Systemic vasculitis can affect practically any structure in or around the eye. Although the ocular presentations of vasculitic disease are highly variable and may be quite subtle, it is important for physicians to understand some of the basic concepts, critical findings, and potential significance of ocular signs and symptoms. In addition to preserving sight, awareness of specific ocular syndromes may afford a critical clue to undiagnosed or newly active systemic vasculitis. A brief discussion of the most common ocular syndromes seen in systemic vascular disease is presented, with special attention given to the signs that may be appreciated by non-ophthalmologists. Recent concepts of ocular immunologic therapy are also reviewed, especially as they relate to the use of systemic immunomodulating drugs, because care of these patients often requires close cooperation between ophthalmologists, primary care physicians, and rheumatologists.
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Affiliation(s)
- J Banks Shepherd
- Department of Ophthalmology, Washington University in St. Louis School of Medicine, MO 63130, USA.
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Abstract
Orbital inflammatory disease (OID) broadly describes a variety of pathologic processes and clinical presentations. OID may be idiopathic or may be secondary to a systemic inflammatory disease, retained foreign body, or infectious disease. OID includes the spectrum of bacterial or fungal infections, diffuse inflammation of multiple tissues (e.g., sclerosing orbititis or diffuse anterior OID), and preferential involvement of specific orbital structures (e.g., orbital myositis or optic perineuritis). Mimics of OID include congenital orbital mass lesions or orbital neoplastic disease such as lymphoma or rhabdomyosarcoma. The ultimate diagnosis and treatment plan relies on a careful history and detailed clinical examination followed by the judicious use of ancillary diagnostic testing and a comprehensive treatment plan. The purpose of this review is to provide an overview of the spectrum of diseases known as OID, with emphasis on specific diagnostic challenges in the evaluation and management of patients with idiopathic OID.
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Affiliation(s)
- Lynn K Gordon
- Jules Stein Eye Institute, University of California - Los Angeles and Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA.
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