Orbital lymphoma misdiagnosed as Graves' ophthalmopathy

Primary Orbital Lymphoma – A Challenging Diagnosis

Background and purpose: The occurrence of primary orbital lymphoma comprises approximately 1% of non-Hodgkin’s lymphoma and 8% of extranodal lymphoma. The vast majority of orbital lymphomas are of B-cell origin, of which extranodal marginal zone B-cell lymphoma is the most common subtype. The purpose of this paper was to present the diagnostic challenges in a case of orbital lymphoma. Case presentation: An 84-year -old woman with orbital tumour was operated on after a long period of inappropriate treatment. It was later diagnosed as B-cell lymphoma.

Conclusion: Orbital lymphoma can be easily mistaken for another ocular disease due to the slowly progressing non-specific complaints of the patients. We should be alert to the possibility of this ocular diagnosis when we are presented with an elderly patient with proptosis.

Asymmetric Graves' Orbitopathy

Graves' Orbitopathy (GO) is an autoimmune orbital disorder usually presenting as a sequala of autoimmune thyroid disease. The presence of GO is associated with increased psychological burden and, in severe cases may cause blindness. While most patients with GO present with bilateral disease, asymmetric or unilateral GO may affect a significant proportion of patients diagnosed with GO. Older age, male sex, active and severe disease correlate with asymmetric disease. However, the exact mechanisms causing asymmetry remain elusive. Herein, we review the literature on asymmetric GO and highlight its differences compared with bilateral GO.

Orbital lymphoma mimicking ophthalmopathy in a patient with Graves'

The objective of this case report is to present a rare association of a mucosa-associated lymphoid tissue lymphoma masquerading as Graves' orbitopathy in a patient with autoimmune hyperthyroidism, without evidence of Graves' ophthalmopathy. A 66-year-old male patient had pain and swelling of the right eye. Evaluation of serum thyroid hormone revealed low thyrotropin, elevated free thyroxin and antithyroperoxidase antibody levels, confirming the diagnosis of Graves' disease. Computed tomographic scan showed intraorbital muscle asymmetry. Biopsy demonstrated a low-grade, B-cell type non-Hodgkin's lymphoma of the mucosa-associated lymphoid tissue. Treatment included radiotherapy and chemotherapy, with regression of the orbital lesion and medical treatment with methimazole and (131)I. Detailed orbital evaluation should be considered in all patients who present any atypical signs and symptoms of the eyes, to prevent missing important and progressive diagnoses.

Bilateral metastatic melanoma to the extraocular-muscles simulating thyroid eye disease

We report a case of bilateral metastatic melanoma to the extraocular muscles that simulated thyroid eye disease. A 71-year-old man presented with bilateral painless axial proptosis, lid retraction and left gaze restriction. Orbital CT scan demonstrated enlargement of the extraocular muscles with tendon sparing, consistent with thyroid eye disease. However, thyroid function tests and antithyroid antibodies were normal. Systemic review including orbital MRI scan determined the correct diagnosis of metastatic melanoma to the orbit. Metastatic melanoma to the orbit can simulate thyroid eye disease.

Primary orbital liposarcoma misdiagnosed as thyroid associated orbitopathy

Orbital malignancy can mimic thyroid associated orbitopathy (TAO) due to overlap of clinical and radiographic findings, which include proptosis, extraocular muscle (EOM) enlargement on imaging, and EOM restriction with diplopia. We report a case of primary orbital liposarcoma masquerading as TAO which required exenteration.

CT and MRI findings with histopathologic correlation of a unique bilateral orbital mantle cell lymphoma in Graves' disease: a case report and brief review of literature

Bilateral orbital mantle cell lymphoma is rare. We present an unusual case report of a patient with Graves' disease and no previous history of lymphoma, who was found to have bilateral orbital mantle cell lymphoma on CT and MR imaging which was confirmed histopathologically. To our knowledge, there have been no previously described cases of bilateral mantle cell lymphoma in Graves' disease. Of particular radiologic interest, the left orbital mass presented in a bicompartmental fashion with a discreet intraconal component separated by a fat plane from an extraconal component that extended intraconally. In our review of radiologic literature, this presentation has not been described previously.

Prevalence of Asymmetric Exophthalmos in Graves Orbitopathy

PURPOSE

To report the prevalence and the degree of significant asymmetric orbital involvement secondary to thyroid-related (Graves) orbitopathy in a large patient population.

METHODS

The prevalence of exophthalmometric differences of > or =2 mm was determined in 391 consecutive patients diagnosed with Graves orbitopathy from the Jules Stein Eye Institute Division of Ophthalmic Plastic and Reconstructive Surgery patient registry.

RESULTS

Thirty-six of 391 patients (9%) in this cohort had asymmetric proptosis with a difference of > or =2 mm, based on single-observer Hertel measurements before orbital decompression surgery. This finding was similar among men (11/95, 12%) and women (25/296, 8%) but was not statistically significant (P= 0.358; 95% CI, 0.6% to 7.8%). Also, we found no racial variations in the incidence of unilateral disease.

CONCLUSIONS

Clinically, unilateral or asymmetric Graves orbitopathy is common and can lead to misdiagnosis or to unnecessary testing. Thyroid-related orbitopathy must be considered in the differential diagnosis for any case of asymmetric exophthalmos.