Diverse clinical presentations of orbital sarcoid

A Case of Orbital Sarcoidosis with Caseating Granulomatous Inflammation

The authors report a rare case of orbital sarcoidosis with caseating granulomatous inflammation. A 55-year-old man presented with a 2-month history of progressively worsening diplopia and proptosis of the OS. Orbital CT demonstrated a diffuse orbital mass. Diagnostic anterior orbitotomy demonstrated caseating granulomas. Infectious testing, including special stains, cultures, and polymerase chain reaction testing, were negative for infectious causes. Chest CT demonstrated the presence of hilar lymphadenopathy with bronchoscopic biopsy showing noncaseating granulomas, supporting a diagnosis of sarcoidosis. The patient achieved clinical and symptomatic improvement at 8-month follow-up on methotrexate. While sarcoidosis is typically characterized by non-necrotizing granulomatous inflammation, sarcoid granulomas with necrosis have been previously described in pulmonary histopathology. This case emphasizes the importance of a comprehensive systemic workup, keeping systemic sarcoidosis on the differential, for necrotizing granulomatous inflammation of the orbit.

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.

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.

Lacrimal and salivary gland ultrasound - how and when to use in patients with primary Sjögren's syndrome

This paper addresses how to perform an ultrasound assessment of the salivary and lacrimal glands, how to identify pathological changes, and how to score disease activity, focusing on the use for primary Sjögren's syndrome (pSS). It addresses the role of salivary gland ultrasound for diagnosing and management of patients with pSS and touches upon the use for differential diagnosis, including how and when to perform ultrasound-guided biopsies and injections.

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.

Autoimmune markers in screening for orbital inflammatory disease

PURPOSE

Immunogenic causes of inflammation may be difficult to differentiate in the work-up of orbital inflammatory disease. The study aims to investigate the utility of autoimmune markers in the screening for orbital inflammation. Markers studied included angiotensin-converting enzyme (ACE), antinuclear antibody (ANA), anti-neutrophilic cytoplasmic autoantibodies (ANCA), extractable nuclear antigen (ENA), anti-cyclic citrullinated peptide (Anti-CCP) and anti-double stranded DNA antibody (Anti-dsDNA antibody).

METHODS

A retrospective single-centre study of consecutive patients with non-infective orbital inflammation screened for autoimmune markers at presentation. Serology was interpreted alongside clinical course and other investigations (e.g. radiographic features and histopathology). Tabulated data and Pearson's Chi-square allowed analysis of trends between serology, diagnosis and the decision to biopsy.

RESULTS

79 patients, between 1999 and 2021, were included (50 females, mean age was 50.4 ± 17.4 years). 28 (34.6%) patients had specific orbital inflammation and 53 (65.4%) patients had non-specific orbital inflammation (NSOI). Of the 12 patients with positive serology and a specific diagnosis, only 5 (41.7%) patients had concordant serological results. There was no association between serology results and the patient undergoing biopsy (P = 0.651). Serology was unable to exclude nor differentiate NSOI from other specific conditions and ANA had limited discriminatory value between specific conditions and NSOI.

CONCLUSION

Serological testing alone may not provide a clear direction for further investigation of orbital inflammation and a biopsy may occur independently of the serological results. The value of autoimmune markers may lie in subsequent follow-up as patients may develop suggestive symptoms after an indeterminate positive result or initially seronegative disease.

Optic Neuropathy Caused by a Perineural Sarcoid Lesion

A 74-year-old woman had a six-month history of decreased vision in the left eye. On the first examination, her left best-corrected visual acuity was 0.02, and Goldmann visual field test revealed a central scotoma in the left eye. Magnetic resonance imaging demonstrated lesions around the optic nerve on both sides and enlargement of the lacrimal gland and superior rectus/levator palpebrae superioris muscles on both sides and the medial and inferior recti muscles on the left side. Systemic computed tomography revealed bilaterally enlarged mediastinal and supraclavicular lymph nodes. The blood test results included an elevated soluble interleukin-2 receptor. Pathological examination of the specimens harvested from the lacrimal gland on both sides, left levator palpebrae superioris muscle, and the lesion around the optic nerve on the left side showed lymphocytic infiltration with noncaseating epithelioid granuloma. After the biopsy, the patient underwent two cycles of steroid pulse therapy, followed by oral prednisolone. Although the lesions were reduced after steroid treatment, the left vision did not recover.

Rapid visual field progression in a patient with glaucoma as the presenting manifestation of sarcoidosis

PURPOSE

To report a case of accelerated visual field progression secondary to a new orbital apex lesion in a patient with a longstanding history of fatigue and cough.

OBSERVATIONS

A 73-year-old myopic female with known open angle glaucoma presented with accelerated unilateral visual field progression. Maximally tolerated medical therapy was instituted over a period of 1-2 years with imminent discussions of surgical intervention. Around this time the patient reported worsening cough and fatigue, which were initially attributed to glaucoma medication side effects. Consideration of the patient's remote history of melanoma and the current asymmetry of the visual field progression triggered a computerized tomography (CT) scan of the orbits as part of the management. An orbital apex lesion was discovered, raising suspicion for metastatic melanoma, and restaging CT imaging uncovered renal, hepatic, and mediastinal masses. Unexpectedly, biopsies revealed non-necrotizing granulomatous inflammatory processes consistent with a diagnosis of sarcoidosis. It is perhaps noteworthy that the patient had received interferon therapy for management of her melanoma; previous reports have associated interferon exposure with subsequent sarcoid disease, regardless of duration of therapy or elapsed time since exposure.

CONCLUSIONS AND IMPORTANCE

Although rare, sarcoidosis can occur virtually anywhere in the body, including the orbital apex. Its common early symptoms, fatigue and cough, are insidious and seen frequently in this patient's age group and medication side effect profile. It is important to maintain an appropriate index of suspicion when monitoring atypical visual field progression in a patient with glaucoma. In this case, imaging, subsequent biopsy, and a multi-specialty team were integral to this patient's diagnosis and management.

Sarcoidosis presenting as bilateral lacrimal gland swelling: a pediatric case report

BACKGROUND

To describe a case of pediatric sarcoidosis which initially presented as papillary conjunctivitis before manifesting as bilateral lacrimal gland swelling without other known systemic involvement.

CASE PRESENTATION

A 10-year-old female presented to the pediatric ophthalmology clinic with complaints of bilateral eyelid swelling, tearing and itching for approximately 1 month. Her history and exam were most consistent with allergic conjunctivitis, for which she was started on a standard topical regimen. Despite initial improvement, she re-presented with significantly worsened eyelid swelling and minimal allergic symptoms. Enlargement of the lacrimal glands were palpable at this time. Lacrimal gland biopsy was obtained which demonstrated noncaseating granulomas. Systemic workup did not reveal evidence of disease involvement elsewhere.

CONCLUSIONS

Sarcoidosis in the pediatric population may present in a myriad of ways and is well-known to mimic other disease entities. We present a case of pediatric sarcoidosis which presented initially as papillary conjunctivitis before manifesting as bilateral lacrimal gland swelling without systemic involvement.

Optic Perineuritis as a Presenting Sign of Sarcoidosis

Purpose: To report a rare case of optic perineuritis as the presenting sign of sarcoidosis. Case summary: A 57-year-old man presented with decreased visual acuity and pain with extraocular movement in his left eye starting 2 weeks earlier. He had a history of asymptomatic optic perineuritis in that eye 18 months previously, which had improved after 1 month on oral prednisolone. His best corrected visual acuity had decreased to 20/50 and he also had relative afferent pupillary defect and color vision defects in the left eye. Slit lamp examination results were normal. There were no inflammatory reactions in the anterior chamber or vitreous. Fundoscopy showed optic disc edema. Orbital magnetic resonance imaging showed diffuse enhancement surrounding the left optic nerve. The serum levels of eosinophil cationic protein and angiotensin- converting enzyme were markedly increased. A chest radiograph showed bilateral hilar lymph node enlargement. A biopsy via endobronchial ultrasound-guided transbronchial needle aspiration revealed multifocal non-caseating granulomas. Acid fast bacilli stain showed no evidence of tuberculosis. Based on these findings, he was diagnosed with sarcoidosis. After treatment with high-dose intravenous methylprednisolone and subsequent tapering with oral prednisolone for 6 months, the visual acuity improved. Conclusions: Optic perineuritis can be the initial sign of sarcoidosis. Therefore, sarcoidosis should be considered in the differential diagnosis of optic perineuritis.

Extrapulmonary sarcoidosis with a focus on cardiac, nervous system, and ocular involvement

Sarcoidosis is a poorly understood granulomatous disease that involves the lungs and/or intrathoracic lymph nodes in more than 90% of cases. Although pulmonary sarcoidosis is the leading cause of mortality in this disease, this review focuses on three sites of extrapulmonary involvement (heart, nervous system, and eyes), since involvement of any of these sites can be catastrophic, leading to death, debilitation, or blindness. Patients with cardiac, ocular and neurosarcoidosis necessitate a multidisciplinary approach with careful and long-term follow-up. Prompt diagnosis with imaging and/or biopsy and treatment is required to avoid irreversible damage. Corticosteroids are the mainstay of therapy and are often associated with rapid and durable remissions. Immunosuppressive or biologic agents are reserved for patients failing or experiencing side effects from steroids. Managing sarcoidosis requires vigilance, judgement, and awareness of the vagaries of this fascinating disease.

Orbital inflammatory disorders: new knowledge, future challenges

PURPOSE OF REVIEW

This review aims to bring together recent advances in basic, translational and clinical research on the pathogenesis and treatment of orbital inflammatory conditions.

RECENT FINDINGS

Basic science studies provide mechanistic insights into why the orbit is targeted for inflammation by autoimmune inflammatory disorders. Using Graves' disease as a test case reveals that endocrine pathways, such as the TSH and IGF1 receptor pathways play important roles in stimulating orbital inflammation. Furthermore, orbital tissues contain high concentrations of retinoids - byproducts of the visual pathway that diffuse across the sclera and can activate de novo transcription of inflammatory cytokines. Such cytokine expression places the orbit in a hyper-inflammatory 'resting' state, prone to respond to any additional systemic or local pro-inflammatory signals. The HIF2A--LOX pathway appears important for orbital tissue fibrosis. Lastly, bench-to-bedside studies of the IGF1R pathway have led to an FDA-approved drug, teprotumumab that represents a novel treatment approach for Graves' orbitopathy. Unfortunately, high drug costs and misplaced insurance company 'step-therapy' policies may block patients from receiving therapy that can protect vision and improve quality of life.

SUMMARY

Improved understanding of orbital inflammatory conditions has led to a new drug and promises additional breakthroughs. Translational research is successful, but requires time, resources, and patience.

Rare Diseases of the Orbit

This article provides an overview of rare orbital diseases. Congenital malformations, inflammatory diseases, benign and malignant neoplasias are described. Although it represents a relatively small area of the body the orbit contains multiple different tissues. Therefore, a great variety of diseases can be found within the orbital space. That is the reason, why both the completeness and the level of detail in the description of particular diseases must be somewhat limited. Nevertheless, clinical manifestations, important aspects of diagnosis, treatment strategies, and, when specific data are available, the prognosis are described. The authors tried to highlight the most characteristic aspects of the different diseases to describe their relevant aspects in spite of the brevity of the subsections.

Dry eye and Meibomian gland dysfunction evaluation in sarcoidosis patients

PURPOSE

To analyze the relation between Meibomian gland dysfunction, dry eye, and sarcoidosis.

MATERIALS AND METHODS

Twenty eyes of 10 sarcoidosis patients (Group 1) and 20 left eyes of 20 age-sex matched healthy volunteers (Group 2) were included. Presence of dry eye was evaluated with Schirmer 1 test, tear film break-up time (T-BUT), Oxford scale scoring, Ocular Surface Disease Index (OSDI) score assessments. A slit-lamp biomicroscope infrared filter (Topcon, SL-D701, IJssel, The Netherlands) was used to evaluate Meibomian glands. The drop-out ratio according to meibography was scored for each eyelid from grade 0 (no loss) through grade 3 (lost area >2/3 of the total Meibomian gland area).

RESULTS

Among dry eye tests mean Schirmer 1 and T-BUT values were lower and OSDI score was higher in Group 1 compared to Group 2 and the differences were statistically significant (p = 0.017, p = 0.039, p = 0.003, respectively). In addition, the upper, lower and total meiboscores were statistically significantly higher in Group 1 (p = 0.047, p = 0.003, p = 0.005, respectively).

CONCLUSION

A significantly higher presence of dry eye and Meibomian gland drop out ratios was detected in sarcoidosis patients. It is important to monitor sarcoidosis patients for dry eye and Meibomian gland dysfunction and when detected, to treat adequately to prevent ocular surface damage.

Orbitopalpebral and ocular sarcoidosis: what does the ophthalmologist need to know

Sarcoidosis is a chronic multisystemic disease of unknown aetiology, characterised by non-caseating granulomas. Ocular involvement rate ranges from 30% to 60% among individuals with sarcoidosis, and can vary widely, making the diagnosis a challenge to the ophthalmologist. Cutaneous manifestations occur in about 22% of sarcoidosis cases, but eyelid involvement is rare. Eyelid swelling and nodules are the most frequent forms of eyelid involvement, but other findings have been reported. The joint analysis of clinical history, ancillary exams and compatible biopsy is needed for the diagnosis, as well as the exclusion of other possible conditions. This review aims to describe the different forms of presentations, the clinical reasoning and treatment options for ocular, eyelid and orbital sarcoidosis.

[Secondary eyelid pockets: Pitfalls in blepharoplasty surgery]

INTRODUCTION

Requests for cosmetic eyelid surgery are frequent. The surgeon must carry out a complete clinical examination in order to rule out any orbital pathologies responsible for eyelid pockets.

METHODS

Study of ten patients who have consulted in the oculopalpebral surgery department of La Fondation Ophtalmologique de Rothschild for cosmetic surgery of the eyelid pockets and in whom an underlying pathology was diagnosed.

RESULTS

The clinical examination allows to look for signs of alarms, such as medical history, unilateral involvement, pain and the presence of exophthalmos. These should lead to perform orbital imaging and surgical biopsy if an orbital mass has been identified for histological analysis which will make the diagnosis. We identified four cases of orbital lymphoma, one foreign body granuloma, chronic bilateral dacryoadenitis, sarcoidosis involvement, AAPOX syndrom, cavernous hemangioma, and simple fatty hernia.

CONCLUSION

These cases shows the importance of not ignoring an underlying orbital pathology before proposing cosmetic surgery for eyelid pockets.

Imaging of Lacrimal Gland Pathologies: A Radiological Pattern-Based Approach

Despite their unassuming size, lacrimal glands can have a variety of pathologies affecting them which often poses a diagnostic challenge clinically in view of their nonspecific presentation as palpable lump in the superolateral aspect of the orbit. There are a myriad of pathological entities ranging from inflammatory to neoplastic lesions that can affect the lacrimal glands. Cross-sectional imaging is must for the detection, characterization, and mapping of these lesions. In this pictorial review, we propose a radiological pattern-based approach for various lacrimal gland lesions that provides a working algorithm for radiologists in the evaluation of lacrimal gland pathologies.

[Management of orbital inflammatory disorders in internal medicine: New findings resulting from a retrospective study of 31 consecutive patients]

PURPOSE

To describe a case series of patients investigated in internal medicine for orbital inflammation (OI) since the individualization of the clinical entity of the IgG4-related orbital disease (IgG4 ROD).

PATIENTS AND METHODS

Thirty four patients were consecutively referred by a specialized center where orbital biopsy was performed when the lesion was surgically accessible. Fourteen patients were excluded in case of missing data or lymphoma, periocular xanthogranuloma or Graves' orbitopathy. Patients with systemic or auto-immune disease according to the international criteria, or presenting with idiopathic orbital inflammation syndrome (IOIS), were included. Knowing the histological similarities between IOIS and IgG4 ROD, immunohistochemical assessment of plasma cells for IgG4 positivity was performed for every patient with available biopsy. Clinical and biological characteristics, treatment and response to treatment of included patients are reported.

RESULTS

Among 22 included patients, 10 presented with orbital manifestation of a systemic or autoimmune disease including 2 sarcoidosis (9%) and 8 (36%) cases of non specific OI which were reclassified in IgG4 ROD. Finally, IOIS of various clinicopathological presentation was diagnosed for 12 patients including 10 with histological documentation. Whereas relapse and resistance were not found to be related to IgG4 positivity (50% in both IOIS and IgG4 ROD groups), another treatment in addition to corticosteroids was more often necessary in IgG4 ROD patients (50%) than in IOIS patients (25%).

CONCLUSION

After ruling out auto-immune orbital diseases, especially IgG4 ROD, IOIS should be discussed. Factors conditioning the corticosteroid response are yet to be determined.

Educational Case: Orbital B-Cell Lymphoma With Amyloid Deposition

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.¹

Sarcoid-like granulomatous orbitopathy-presentation, systemic involvement and clinical outcome

AIM

To describe patients with sarcoid-like granulomatous orbitopathy (SLGO), the rate of known and subsequent systemic sarcoidosis, and the treatment and outcome for the condition.

PATIENTS AND METHODS

Retrospective review of patients with SLGO presenting between 1990 and 2018, excluding solely lid or lacrimal drainage disease.

RESULTS

Sixty-one patients (45 female; 74%) were identified, 54 having biopsy-proven sarcoidosis (47 orbital, 24 prior extra-orbital), and half were Afro-Caribbean. The average age at presentation was 45.3 years (range 18-78 years), with the commonest symptoms being swelling, pain and diplopia; of clinical signs, most patients (87%) had eyelid swelling, reduced motility (25%), and disease-related visual impairment (10%). Localized dacryoadenitis was present in 49/61 (21/49 bilateral) patients, and more diffuse disease in 28/61 (8/28 bilateral). Systemic involvement was found in 23 (62%) of the 37 first presenting with orbital disease. Twenty-three (38%) patients were observed and two-thirds received oral corticosteroids, with 53/61 (87%) patients having subjective and objective clinical improvement. The average follow-up was 53.4 months (range 1-315 months) and clinical recurrence occurred in 12 (20%) patients at 26.5 months (range 1-115 months) after first diagnosis.

CONCLUSIONS

Systemic sarcoidosis may be discovered in about two-thirds of patients presenting with SLGO (that tends to present with inflammatory features), but the treatment response appears similar in patients with known sarcoidosis and those with newly-diagnosed systemic disease after orbital presentation. With long-term follow-up, a third of patients have spontaneous regression of orbital disease, but 20% have recurrence after reducing or stopping systemic immunosuppression.

Resolved heart tamponade and controlled exophthalmos, facial pain and diabetes insipidus due to Erdheim-Chester disease

A 69-year-old woman suffering from exophthalmos and facial pain came to us referred for aetiological diagnosis of exophthalmos. Orbital MRI showed thinned extrinsic ocular musculature, intraconal fat infiltration, retro-ocular compression and thickening of maxillary and sphenoid sinus walls. She had been suffering from diabetes insipidus for the last 7 years. During our diagnosis process, she presented signs of cardiac tamponade. Transthoracic heart ultrasound revealed large pericardial effusion and a heterogeneous mass that compressed the right ventricle. No osteosclerotic lesions on appendicular bones were present. Pericardiocentesis temporarily controlled tamponade and corticoid therapy temporarily abated exophthalmos. Pericardiectomy definitively resolved tamponade. Histological examination of pericardial tissue was conclusive of Erdheim-Chester disease. Exophthalmos responded to pegylated interferon-alpha-2a. Facial bone pain disappeared after zoledronic acid and interferon treatment. During interferon therapy, the patient suffered from a severe generalised desquamative exanthema that slowly resolved after discontinuing interferon. Diabetes insipidus remains controlled with desmopressin.

Diagnostic dilemmas of mechanical restriction of the medial rectus: A case report

Background

Due to the proximity of the maxillary sinus and ethmoid sinuses to the orbit, inflammatory processes that originate in the sinonasal region have the potential to extend into the orbit.

Objective

We presented a case of ptosis and restrictive strabismus of the medial rectus muscle.

Methods

A case report with a literature review of possible diagnoses.

Results

Biopsy, imaging, and laboratory evaluation by otolaryngology, ophthalmology, and rheumatology services were unable to identify the cause of the fibrosis after 22 months of follow-up. A response to oral steroids indicated an inflammatory process.

Conclusion

Unilateral mechanical restriction of the medial rectus muscle is a rare complication of nasal disease. Inflammatory processes and iatrogenic injury are known to cause fibrosis of surrounding tissue. We presented a unique case of medial rectus fibrosis that did not meet the diagnostic criteria of recognized etiologies.

[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.

An erosive lesion in the orbital apex as the presenting sign of sarcoidosis

Sarcoidosis is an autoimmune granulomatous disease that can affect any organ system in the body. Ocular and orbital manifestations are relatively common. Osseous involvement is rare and usually involves bones of the appendicular skeleton. We present an unusual case of an erosive sarcoid granuloma in a 48-year-old woman that involved the orbital apex. This case highlights diagnosis, treatment, and the importance of full systemic workup to determine the extent of the disease.

Osteolytic Sarcoidosis of the Orbital Roof Masquerading as a Malignant Orbital Lesion

A 51-year-old man without a significant past medical history presented with 4 weeks of progressive swelling and drooping of his left upper eyelid. A CT of the left orbit revealed an osteolytic mass lesion in the area of the lacrimal gland. A left orbitotomy with excisional biopsy was performed. The excised tissue was sent for infectious workup and histopathological examination, which revealed osteolytic sarcoidosis. The patient was treated with systemic and local injection corticosteroids, and followed over 10 months without evidence of recurrence. Systemic workup with CT of his chest, abdomen, and pelvis revealed no further evidence of sarcoidosis. To the best of the authors knowledge, this is the first report of an otherwise healthy patient presenting with isolated osteolytic sarcoidosis of the orbit and a negative systemic workup.

The role of biopsy in lacrimal gland inflammation: A clinicopathologic study

PURPOSE

To determine the causes of lacrimal gland inflammation based on histopathology and systemic evaluation.

METHODS

This is a retrospective case series study. From the University of British Columbia Orbit Clinic between January 1976 and December 2008, we reviewed the medical records of 60 patients who presented with inflammatory features of the lacrimal gland (i.e., erythema, edema, or tenderness) in which the diagnoses were not possible clinically and on imaging alone. As was our routine practice, all these patients underwent lacrimal gland biopsy before starting any treatment.

RESULTS

The histopathologic findings of the 60 patients showed that 37 (61.7%) had identifiable types of lacrimal inflammation including 10 with Sjogren's syndrome, seven with sarcoidal reaction, six with feature of granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis), five with lymphoma, two with sclerosing inflammation, two with IgG4-related dacryoadenitis, and one patient each with infectious dacryoadenitis, myoepithelial carcinoma, xanthogranuloma, eosinophilic angiocentric fibrosis, and eosinophilic allergic granulomatous nodule. The histopathologic findings of the remaining 23 (38.3%) patients showed nonspecific inflammation of the lacrimal gland. 23 patients (38.3%) had associated systemic diseases. 48 patients (80%) were treated successfully and 10 (16.7%) had recurrence of inflammation.

CONCLUSIONS

We recommend that in patients presenting with lacrimal gland inflammation (i.e., erythema, edema, tenderness) in which the specific diagnosis cannot be made clinically and on imaging, biopsy is warranted for accurate diagnosis and appropriate treatment. We found that the majority of these patients (61.7%) had specific histopathology, and 38% had systemic diseases.

Bilaterally Diffuse Lacrimal Gland Involvement: Initial Presentation of Systemic Sarcoidosis

Orbital involvement in systemic sarcoidosis is a rare condition. We report a case of orbital sarcoidosis with bilaterally huge lacrimal gland involvement as the initial manifestation of systemic sarcoidosis. A 20-year-old woman admitted the ophthalmology department with progressive bilateral upper eyelid swelling for 6 months. The only pathologic finding was the presence of bilateral, symmetrical, solid, lobular masses at the lateral upper eyelids at the location of lacrimal glands. On systemic examination, bilateral parotid and submandibular glands appeared swollen. Magnetic resonance imaging of the orbit revealed bilateral symmetrical diffuse enlargement of the lacrimal glands with maximum and minimum thickness of 11 mm and 7 mm, respectively. The biopsy findings were compatible with sarcoidosis. Although lacrimal gland involvement has been reported in different studies, we for the first time report an unusual case with bilateral diffuse huge lacrimal gland involvement. Normal lacrimal gland thickness is approximately 4-5 mm in magnetic resonance imaging, while our case had bilateral diffuse enlargement of lacrimal glands, which showed maximum and minimum thickness of 11 mm and 7 mm, respectively. Although orbital involvement is uncommon in sarcoidosis, it should be remembered in the differential diagnosis of orbital masses.

Laboratory Investigations for Diagnosis of Autoimmune and Inflammatory Periocular Disease: Part II

PURPOSE

To review the important laboratory serological investigations routinely performed for the diagnosis of autoimmune and inflammatory diseases of the orbit and ocular adnexa.

METHODS

Review of the literature as well as personal clinical experience of the authors. Due to the extensive nature of the topic, the review has been split into 2 parts. Part I covers thyroid eye disease, IgG4-related disease, and myasthenia gravis. In part II of the review, sarcoidosis, vasculitis, Sjögren syndrome, and giant cell arteritis will be discussed.

RESULTS

Several relatively specific serologic tests are available for the diagnosis of a variety of inflammatory and serologic diseases of the orbit.

CONCLUSION

In cases of limited orbital or sino-orbital disease, serologic testing may be negative in a significant number of patients. Specifically, the clinician should be wary of ruling out limited orbital sarcoid or sinoorbital granulomatosis with polyangiitis based on serologic testing alone. Part I of this review has covered serologic testing for thyroid eye disease, IgG4-related disease, and myasthenia gravis. In part II, the authors discuss serologic testing for sarcoidosis, vasculitis, Sjögren syndrome (SS), and giant cell arteritis (GCA).

Clinical-Radiologic Correlation of Extraocular Eye Movement Disorders: Seeing beneath the Surface

Extraocular eye movement disorders are relatively common and may be a significant source of discomfort and morbidity for patients. The presence of restricted eye movement can be detected clinically with quick, easily performed, noninvasive maneuvers that assess medial, lateral, upward, and downward gaze. However, detecting the presence of ocular dysmotility may not be sufficient to pinpoint the exact cause of eye restriction. Imaging plays an important role in excluding, in some cases, and detecting, in others, a specific cause responsible for the clinical presentation. However, the radiologist should be aware that the imaging findings in many of these conditions when taken in isolation from the clinical history and symptoms are often nonspecific. Normal eye movements are directly controlled by the ocular motor cranial nerves (CN III, IV, and VI) in coordination with indirect input or sensory stimuli derived from other cranial nerves. Specific causes of ocular dysmotility can be localized to the cranial nerve nuclei in the brainstem, the cranial nerve pathways in the peripheral nervous system, and the extraocular muscles in the orbit, with disease at any of these sites manifesting clinically as an eye movement disorder. A thorough understanding of central nervous system anatomy, cranial nerve pathways, and orbital anatomy, as well as familiarity with patterns of eye movement restriction, are necessary for accurate detection of radiologic abnormalities that support a diagnostic source of the suspected extraocular movement disorder. ^©RSNA, 2016.

Ocular Sarcoidosis

Sarcoidosis is one of the leading causes of inflammatory eye disease. Ocular sarcoidosis can involve any part of the eye and its adnexal tissues and may cause uveitis, episcleritis/scleritis, eyelid abnormalities, conjunctival granuloma, optic neuropathy, lacrimal gland enlargement, and orbital inflammation. Glaucoma and cataract can be complications from inflammation itself or adverse effects from therapy. Ophthalmic manifestations can be isolated or associated with other organ involvement. Patients with ocular sarcoidosis can present with a wide range of clinical presentations and severity. Multidisciplinary approaches are required to achieve the best treatment outcomes for both ocular and systemic manifestations.

Masquerading Orbital Sarcoidosis with Isolated Extraocular Muscle Involvement

Two patients, previously diagnosed and treated for euthyroid, autoantibody-negative thyroid eye disease, presented with active orbitopathy. An atypical disease course and presentation prompted orbital biopsy. Extraocular muscle histopathology demonstrated noncaseating granulomatous inflammation consistent with presumed orbital sarcoidosis involving multiple extraocular muscles, including the inferior oblique in one of the cases. These two cases emphasize the importance of a broad differential diagnosis and the utility of an orbital biopsy in the context of an unusual disease presentation or poor treatment response. The patients’ clinical course is discussed alongside important clinical signs, imaging findings, and biopsy results that support a diagnosis of isolated orbital sarcoidosis.

[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.

Granulomatous disease in the head and neck: developing a differential diagnosis

Granulomatous diseases have a varied etiology that includes autoimmune, infectious, idiopathic, and hereditary causes. The unifying factor in these diseases is the formation of granulomas, which histologically are mononuclear inflammatory cells or macrophages surrounded by lymphocytes. Granulomatous diseases often have systemic manifestations that affect organs throughout the body. Granulomatous diseases with head and neck manifestations include granulomatosis with polyangiitis, Churg-Strauss syndrome, Behçet disease, chronic granulomatous disease, and sarcoidosis. Infectious causes include tuberculosis, cat-scratch disease, syphilis, leprosy, actinomycosis, rhinoscleroma, and fungal infections. In the head and neck, granulomatous disease may affect the orbits, sinonasal cavities, salivary glands, aerodigestive tract, temporal bone, or skull base. Imaging findings include sinonasal opacification, ocular and other soft-tissue masses, osseous erosion, airway narrowing, lymphadenopathy, and salivary gland infiltration. Vascular involvement may also be evident, with displacement, narrowing, or occlusion of arteries and veins. Some radiologic findings of granulomatous processes have a considerable overlap with findings of malignancy, and a radiologic differential diagnosis inclusive of both is critical to avoid incorrect clinical treatment. Without the benefit of a prior clinical diagnosis, laboratory findings, or suggestive clinical signs and symptoms, granulomatous diseases may be difficult to differentiate radiologically. Although individual granulomatous diseases may have overlapping findings at imaging, certain radiologic findings should prompt the inclusion of granulomatous diseases in the differential diagnosis, thus facilitating appropriate clinical management.

"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.