Nonthyroid causes of extraocular muscle disease

Thyroid-Associated Orbitopathy and Biomarkers: Where We Are and What We Can Hope for the Future

Background

Thyroid-associated orbitopathy (TAO) is the most common autoimmune disease of the orbit. It occurs more often in patients presenting with hyperthyroidism, characteristic of Graves' disease, but may be associated with hypothyroidism or euthyroidism. The diagnosis of TAO is based on clinical orbital features, radiological criteria, and the potential association with thyroid disease. To date, there is no specific marker of the orbital disease, making the early diagnosis difficult, especially if the orbital involvement precedes the thyroid dysfunction.

Summary

The goal of this review is to present the disease and combine the available data in the literature concerning investigation of TAO biomarkers.

Conclusions

Despite the progress done in the understanding of TAO disease, some important pieces are still missing. Typically, for the future, major efforts have to be done in the discovery of new biomarkers, validation of the suspected candidates on multicenter cohorts with standardized methodologies, and establishment of their clinical performances on the specific clinical application fields in order to improve not only the management of the TAO patients but also the therapeutic options and follow-up.

Review of extraocular muscle biopsies and utility of biopsy in extraocular muscle enlargement

Aims

To review the distribution of pathology in extraocular muscle (EOM) biopsies performed at a tertiary orbital centre, identify clinical and imaging features which are associated with benign or malignant diseases and indicate when biopsy is necessary for EOM enlargement.

Methods

Retrospective case series including 93 patients with EOM enlargement who underwent an EOM biopsy. Clinical, radiological and histopathological information was recorded from the medical records. Statistical analysis was used to compare variables between patients with malignant and benign biopsies.

Results

The median age of subjects was 61.1 years. Forty-eight cases (52%) were benign and 45 (48%) were malignant. Those with malignant pathology were significantly older (P<0.0001). Males were more likely affected by a benign disease and females by a malignancy (P=0.029). A history of malignancy (P<0.0001) and diplopia (P=0.029) were significant factors in predicting a malignancy. Pain (P=0.005) and eyelid erythema (P=0.001) were more likely in benign conditions. Idiopathic orbital inflammation was the most common benign diagnosis and lymphoma the most common malignancy.

Conclusions

Biopsy is warranted in those with an atypical presentation of EOM enlargement or suspected of having a malignancy. Some features such as age, gender, pain, diplopia, history of malignancy and eyelid erythema may help indicate a particular diagnosis; however, clinical features and imaging findings are often not pathognomonic of each disease.

Orbital ultrasonography in the diagnosis of neoplastic extraocular muscle enlargement

Neoplastic infiltration of the extraocular muscle (EOM) is a rare condition which can pose a diagnostic dilemma due to its rarity and overlapping ultrasonographic features with orbital myositis. The ultrasonographic features of neoplastic enlargement of EOM have not been systematically studied and previously have been described in only a few case reports. Orbital ultrasonography, in conjunction with the pattern of ocular misalignment, was assessed for its potential role in identifying patients with neoplastic EOM enlargement. Retrospective chart review of patients with neoplasm and myositis. The clinical features of 8 patients with neoplastic infiltration of the EOM were compared to 15 patients with myositis. In the neoplastic group the width of the EOM was (10.5 mm) almost twice the normal width of the muscle with myositis (p < 0.001). All the muscles in the neoplastic category were low to medium reflective. Paretic deviation was seen in 4/8(50%), purely restrictive in 2/8 (25%) and combined pattern in 2/8 (25%) were noted. In the myositis group the average EOM enlargement was 5.8 mm and all muscles showed low reflectivity. Although ultrasonographic features overlapped between the 2 groups paretic deviations were more common in the neoplastic group versus the myositis group (50% versus 7%). Neoplastic muscle enlargement tends to be larger with paretic deviations of ocular motility seen clinically. These findings in a patient with EOM enlargement should raise the suspicion of neoplasm as the etiology and further work up should be considered.

Systemic Amyloidosis and Extraocular Muscle Deposition

Isolated amyloid deposition in an extraocular muscle is a rare event but can be a presenting feature of systemic amyloidosis. A 67-year-old woman with an acquired exotropia and hypertropia was found to have unilateral diffuse extraocular muscle enlargement on magnetic resonance imaging. Owing to the progressive nature of her strabismus and the negative laboratory testing for thyroid disease, she underwent an extraocular muscle biopsy that revealed amyloid deposition. Further workup demonstrated a monoclonal gammopathy consistent with systemic amyloidosis. This case demonstrates the need to consider amyloidosis in the differential diagnosis of patients presenting with an atypical acquired strabismus. We review other reports of isolated amyloid deposition in extraocular muscles and its association with systemic amyloidosis, emphasizing the importance of the ophthalmologist in the early recognition of this disease to prevent irreversible, life-threatening end organ damage.

Isolated primary amyloidosis of the inferior rectus muscle mimicking Graves' orbitopathy

The diagnosis of Graves’ orbitopathy is usually straightforward. However, orbital diseases that mimick some clinical signs of Graves’ orbitopathy may cause diagnostic confusion, particularly when associated to some form of thyroid dysfunction. This report describes the rare occurrence of localized inferior rectus muscle amyloidosis in a patient with autoimmune hypothyroidism, who was misdiagnosed as Graves’ orbitopathy. A 48-year-old man complained of painless progressive proptosis on the left side and intermittent vertical diplopia for 6 months. The diagnosis of Graves’ orbitopathy was entertained after magnetic resonance imaging revealing a markedly enlarged, tendon-sparing inferior rectus enlargement on the left side, and an autoimmune hypothyroidism was disclosed on systemic medical workup. After no clinical improvement with treatment, the patient was referred to an ophthalmologist and further investigation was performed. The presence of calcification in the inferior rectus muscle on computed tomography, associated with the clinical findings led to a diagnostic biopsy, which revealed amyloid deposition. This report emphasizes that a careful evaluation of atypical forms of Graves’ orbitopathy may be crucial and should include, yet with rare occurrence, amyloidosis in its differential diagnosis.

Orbital T-Cell Lymphoma with Discrete Enlargements of All Extraocular Muscles Bilaterally in Patient with Moon Face Countenance

Purpose. To report our findings in a case of orbital T-cell lymphoma in which all of the extraocular muscles (EOMs) were bilaterally and discretely enlarged and the patient had a moon face countenance. Case. A 59-year-old woman presented with visual disturbances in her left eye, hyperemia in both eyes, and a moon face countenance. Examinations showed limited upward gaze in the right eye, blepharoptosis, hypertropia, and limited downward and rightward gaze in the left eye. Slit-lamp examination showed only chemosis and hyperemia of both eyes. Magnetic resonance imaging with contrast revealed discrete enlargements of the muscle bellies in all EOMs without abnormalities of the orbital fat in both eyes. Blood examinations excluded thyroid- and IgG4-related ophthalmopathy, and EOM biopsy revealed peripheral T-cell lymphoma. After beginning aggressive chemotherapy, the enlarged EOMs, limited eye motility, and moon face countenance improved. Unfortunately, the patient died of sepsis during the chemotherapy. Conclusions. A lymphoma should be included in the differential diagnosis of eyes with enlarged EOMs. Because lymphomas can lead to death, it is important for clinicians to consider lymphomas in eyes with enlarged EOMs.

Imaging of orbital disorders

Diseases of the orbit can be categorized in many ways, but in this chapter we shall group them according to etiology. Inflammatory diseases of the orbits may be infectious or noninfectious. Of the infections, orbital cellulitis is the most common and typically arises as a complication of acute sinusitis. Of the noninfectious, inflammatory conditions, thyroid orbitopathy is the most common and results in enlargement of the extraocular muscles and proliferation of the orbital fat. Idiopathic orbital inflammatory syndrome is another cause of inflammation in the orbit, which may mimic thyroid orbitopathy or even neoplasm, but typically presents with pain. Masses in the orbit may be benign or malignant and the differential diagnosis primarily depends on the location of the mass lesion, and on the age of the patient. Lacrimal gland tumors may be lymphomas or epithelial lesions of salivary origin. Extraocular muscle tumors may represent lymphoma or metastases. Tumors of the intraconal fat are often benign, typically hemangiomas or schwannomas. Finally, globe tumors may be retinoblastomas (in children), or choroidal melanomas or metastases in adults.

Not All Orbitopathy Is Graves': Discussion of Cases and Review of Literature

INTRODUCTION

Graves' orbitopathy is the extra thyroidal manifestation of Graves' disease and the most common cause of exophthalmos. It is also known as thyroid-associated orbitopathy (TAO) as it occasionally occurs in euthyroid or hypothyroid patients with chronic thyroiditis. 5% of patients with Graves' orbitopathy can be euthyroid or hypothyroid as they have low titers of anti-thyrotropin-receptor antibodies, which are difficult to detect in some assays. Orbitopathy has also been seen in a small percentage of patients with Hashimotos thyroiditis. The eye involvement in Graves' is frequently bilateral and symmetric. These patients pose few diagnostic difficulties when the ocular findings occur concomitantly with the thyroid disease. However, when unilateral and asymmetric ocular findings occur with normal or mildly abnormal thyroid function tests, alternate etiologies should also be pursued. We aim to discuss some conditions like sarcoidosis, lymphoma, orbital pseudotumor, and orbital malignancy that mimic TAO.

CASES

Three patients were referred to us with concern for Graves' orbitopathy. After further work-up, we diagnosed the first patient with specific orbital myositis from sarcoidosis. Our second patient had CD10-positive B-cell lymphoma. Our third patient had orbitopathy likely secondary to Hashimotos or orbital pseudotumor.

CONCLUSION

Our cases and discussion describe some other conditions that clinically mimic TAO and the importance of pursuing further work-up for accurate diagnosis when presentation of orbitopathy is atypical.

The enlarged extraocular muscle: to relax, reflect or refer?

PurposeExtraocular muscle enlargement (EOME) is most commonly associated with thyroid eye disease, but there are other causes. We report our outcomes of investigating and managing non-thyroid-related EOME (NTR-EOME).MethodsRetrospective consecutive case series. Sixteen patients identified by clinical features and orbital imaging. Patient demographics, radiological features, and adjuvant tests including biopsy and final diagnosis were recorded.ResultsMean age at presentation 59.3 years (range 24-89 years). Mean follow-up 3.2 years (range 3 months to 5.5 years). Superior rectus (SR) was most commonly involved muscle (8/16 cases) followed by lateral rectus (4/16). Of the 16 cases, 14 were associated with underlying systemic neoplasia (5 lymphoma, 5 metastatic carcinoma, and 4 presumed paraneoplastic syndrome). All SR enlargement was associated with underlying neoplasia. All patients underwent orbital imaging followed by systemic imaging based on clinical index of suspicion (14/16 patients (13 full body CT (FBCT), 1 mammography)). Positive systemic radiological findings were detected in 12/14 cases. Of the remaining 2 patients, 1 underwent full body positron emission tomography-computed tomography (FBPET-CT), which detected thyroid carcinoma, and the second patient underwent FBCT for staging following orbital biopsy showing lymphoma. Four patients (25%) died within 3 years of follow-up due to disseminated systemic malignancy.ConclusionsAll cases of NTR-EOME should be viewed with a high level of clinical suspicion for systemic neoplasia, especially when the SR is involved. FBCT can help to identify a primary systemic cause. FBPET-CT is best reserved for cases negative on FBCT or for staging and monitoring systemic disease. NTR-EOME can be associated with significant mortality (25%), hence warrants prompt and thorough systemic investigation.

Orbital Myositis: Evaluating Five New Cases Regarding Clinical and Radiological Features

Orbital myositis (OM) is an inflammatory disorder of the extraocular muscles. The signs and symptoms of OM are periorbital pain, eyelid swelling and redness, restricted ocular motility, and strabismus. There are at least two major forms, described by Benedikt GH Schoser, a limited oligosymptomatic ocular myositis (LOOM), which is associated with conjunctival injection only, and severe exophthalmic ocular myositis (SEOM), which presents with additional ptosis, chemosis, and proptosis. We report the clinical and radiological features of five patients with OM who were recently followed in our clinic. Three patients, one man and two women, were placed in the LOOM group, and the other two patients, both women, were in the SEOM group. In both groups, the initial complaints were pain worsening with eye movements and double vision, with only one patient in the SEOM group having pain worsening secondary to Crohn's disease. The most affected muscles were the medial and lateral recti. All the patients were treated with corticosteroids, resulting in rapid improvement. Only one patient in the SEOM group experienced a relapse. Orbital magnetic resonance imaging of all the patients revealed enlargement and contrast enhancement of the involved muscles. Although clinical and radiological features are quite consistent, delayed diagnosis in some patients demonstrates the importance of the awareness of OM.

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.

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.

Imaging anatomy and pathology of extraocular muscles in adults

The extraocular muscles (EOM) are involved in a variety of disease processes with characteristic findings on imaging. EOM anatomy is described, followed by a review of adult EOM pathology. The imaging characteristics are explained with examples. The pattern of EOM disease on imaging, in corroboration with clinical findings, can often lead the radiologist towards a specific diagnosis.

Systemic Lupus Erythematosus Presenting as Orbital Myositis

The authors present a case of diplopia and eye pain due to orbital myositis in a patient with a de novo diagnosis of systemic lupus erythematosus. Systemic lupus erythematosus is a rare cause of orbital myositis and should be considered when other, more common, conditions have been excluded.

Orbital amyloidosis masquerading as metastatic breast carcinoma

One of the most common causes of enophthalmos is previous orbital fracture. In a patient with a known history of breast carcinoma, enophthalmos is concerning for metastatic disease. This report presents a patient with a history of scirrhous breast carcinoma and enophthalmos who was found to have orbital amyloidosis. This is the first report of enophthalmos as the presenting sign of orbital amyloidosis.

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.

Adalimumab for orbital myositis in a patient with Crohn's disease who discontinued infliximab: a case report and review of the literature

Background

Orbital myositis is a rare extra-intestinal manifestation of inflammatory bowel disease. Seventeen cases of Crohn’s disease associated orbital myositis and 3 cases of ulcerative colitis associated orbital myositis have been reported in the published literature since 1970. We report the use of adalimumab (Abbott, Canada, Inc.) for orbital myositis in a patient with Crohn’s disease who discontinued infliximab (Janssen, Canada, Inc.) and review of the published literature.

Case presentation

A 35 year-old male with a 7-year history of Crohn’s disease was treated with an ileocolonic resection and re-anastomosis followed by infliximab which maintained full endoscopic and clinical remission for four years. After stopping the infliximab for infusion-related reactions he presented with 3-day history of severe right eye pain, pain with ocular movement, proptosis, and conjunctival injection. He had no intestinal symptoms and endoscopic assessment revealed no active luminal disease. CT of the orbit revealed an enlarged right medial rectus muscle with tendonous involvement and a diagnosis of orbital myositis was made. Treatment with 80 mg per day prednisone with tapering dose and adalimumab, induction and maintenance, resulted in rapid resolution of the orbital myositis and ocular symptoms with no recurrences on follow-up at 10 months.

Conclusions

The current case demonstrates a rare extraintestinal manifestation of Crohn’s disease, orbital myositis, and its temporal relationship to the discontinuance of infliximab therapy and its successful treatment, without recurrence with tapering prednisone and adalimumab.

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.

Metastatic tumor to the extraocular muscles: report of 5 cases

We report the findings in 5 patients with metastases to the extraocular muscles. Familiarity with this condition will aid ophthalmologists in differentiating it from thyroid ophthalmopathy, the most common form of muscle enlargement. Palliative treatment is effective in ameliorating visual symptoms.

Orbital paraganglioma presenting as lateral rectus enlargement and its novel management: a case report and review of literature

Paragangliomas of the orbit are extremely rare. We report on a case of paraganglioma manifesting as enlargement of the lateral rectus muscle. Magnetic resonance imaging (MRI) of the orbit showed typical salt and pepper appearance of the mass and pathologic examination was consistent with paraganglioma. The patient underwent surgery with total removal of lateral rectus muscle. Alignment was preserved by a half tendon transposition of the vertical rectus muscles to the insertion of the resected lateral rectus muscle. Isolated lateral rectus enlargement has not been previously reported as a manifestation of paraganglioma.

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.

Evaluation of orbital disorders and cranial nerve innervation of the extraocular muscles

A wide range of orbital disorders, including an orbital mass, infection, inflammation, systemic disease, or intracranial lesions, may be encountered with imaging. Evaluation of orbital disorders requires the combination of accurate and relevant clinical information with an understanding of anatomy and pathologic processes. An imaging approach to an orbital differential diagnosis includes assessment for alteration of a normal orbital structure, a lesion that does not belong in the orbit, or alteration of the orbit from bone or periorbital disorders. This approach, combined with key elements of clinical history, leads to a narrower differential diagnosis and improved patient care.

Restrictive extraocular myopathy: a presenting feature of acromegaly

A 45-year-old man presented with binocular diplopia in primary gaze for 1 year. Orthoptic evaluation showed 10-prism diopter right eye hypotropia and 6-prism diopter right eye esotropia. The elevation and abduction of the right eye were mechanically restricted. This was associated with systemic features suggestive of acromegaly. Magnetic resonance imaging (MRI) of the brain demonstrated a pituitary macroadenoma. An elevated serum insulin-like growth factor I level and the failure of growth hormone suppression after an oral glucose load biochemically confirmed the diagnosis of acromegaly. Computed tomography (CT) of the orbit demonstrated bilateral symmetrical enlargement of the medial rectus and inferior rectus muscle bellies. All tests regarding Graves-Basedow disease were negative. Although rare, diplopia due to a restrictive extraocular myopathy could be the presenting symptom of acromegaly.

Unilateral orbital pain and eyelid swelling in a 46-year-old woman: orbital metastasis of occult invasive lobular carcinoma of breast masquerading orbital pseudotumour

Orbital metastasis is very infrequent in breast cancer; more so as an initial and sole presenting feature. The authors report a case of orbital metastasis of occult breast carcinoma in a 46-year-old woman, who presented with unilateral orbital pain and eyelid swelling. This was initially diagnosed as orbital pseudotumour and treated with steroids. The development of breast symptoms and finding of breast nodule, 3 months later, led to the diagnosis of invasive lobular carcinoma of the breast with orbital metastases, confirmed on biopsy.

Bilateral symmetrical metastasis to all extraocular muscles from distant rhabdomyosarcoma

INTRODUCTION

Rhabdomyosarcoma arising in the inguinal region has high potential of metastasis. The common sites for spread from inguinal region include regional lymph nodes, lungs, bone marrow and bone cortex. Orbit is an uncommon site for such metastasis. This case report describes a patient with inguinal rhabdomyosarcoma, which metastasized to both orbits to all the extraocular muscles.

CASE REPORT

A 14-year-old male patient presented with inguinal mass involving the scrotum. The patient underwent high inguinal orchiectomy with hemiscrotectomy for the mass and histopathology revealed rhabdomyosarcoma. After 2 weeks of initial surgery the patient developed bilateral axial proptosis and radiological imaging revealed bilateral extraocular muscle thickening involving all the extraocular muscles. A biopsy of right superior rectus muscle confirmed rhabdomyosarcoma.

COMMENT

Although rhabdomyosarcoma is the commonest primary orbital malignant mass developing in young patients, it is an uncommon metastasis. Metastasis from inguinal rhabdomyosarcoma to extraocular muscles bilaterally involving all the muscles has not been reported in the literature. The present report describes one such patient with favorable initial response to chemotherapy and muscle thickness reverting to normal. Metastasis from a distant site should be considered in differential diagnosis when evaluating a patient with bilateral enlargement of all extraocular muscles.

Recurrent orbital myositis mimicking sixth nerve palsy: diagnosis with MR imaging

We present a case with recurrent orbital myositis sequentially affecting both lateral rectus muscles separately. In the first episode, the absence of the required symptoms for the diagnosis of orbital myositis led to the erroneous diagnosis of sixth nerve palsy. Eventually, the correct diagnosis was established with cerebral MR imaging. Orbital myositis should be included in the differential diagnosis of what appears clinically to be abducens palsy, and MR imaging with a focus on the orbita is mandatory in such patients.

Acute proptosis in a newborn infant: a presentation of infantile dural fistula

Rapidly increasing proptosis is rare in a newborn. The causes are diverse, and determining an exact etiology is difficult. We report a case of acute proptosis in a 26 day old infant due to dural fistula. To our knowledge, this is the youngest reported patient with a dural fistula. A multidisciplinary approach was essential to understanding the etiology of the proptosis in this child and providing adequate and successful treatment.

Topical cyclosporine A as a steroid-sparing agent in steroid-dependent idiopathic ocular myositis with scleritis: a case report and review of the literature

OBJECTIVE

To report on a case of idiopathic orbital myositis with scleritis that was effectively controlled with topical 0.05% cyclosporine A and to provide a review of the literature on the treatment of ocular myositis with scleritis.

METHODS

A case report.

RESULTS

A 35-year-old woman presented with a longstanding history of intractable periorbital pain, redness on her left eye, and diplopia during ocular movement. Her medical history revealed that she had the same symptoms for 5 years and had used numerous prescribed medications for migraine and ocular myositis. During this period, her symptoms and signs had been lessened on systemic steroid treatment, which recurred or worsened after discontinuing or tapering the therapy. Magnetic resonance imaging scans demonstrated an isolated enlargement of the left medial rectus muscle. Laboratory examination results showed no evidence of dysthyroid ophthalmopathy or another systemic disease. Because of adverse affects of systemic corticosteroid and cyclosporine treatments, topical cyclosporine A (0.05%) and dexamethasone were administered four times daily. The patient continued to use topical 0.05% cyclosporine A for 6 months. Using only topical cyclosporine A, she currently has no recurrences of disease on the last examination after 6 months of treatment. Moreover, magnetic resonance imaging revealed a completely normal extraocular muscle configuration.

CONCLUSIONS

Topical 0.05% cyclosporine A may be a safe and effective long-term treatment of ocular myositis and scleritis. It should be considered as a steroid-sparing agent, particularly in recurrent disease and in those patients who experience adverse effects of systemic medications.

Treatment of idiopathic sclerosing inflammation of the orbit (myositis) with infliximab

PURPOSE

We report the successful use of infliximab in a young patient with idiopathic sclerosing orbital inflammation (myositis).

METHODS

We describe the patient's medical records and review the literature.

RESULTS

Idiopathic myositis in this patient could not be satisfactorily treated with corticosteroids or chemotherapy. Biopsy showed sclerosing orbital inflammation. The patient had a prompt and sustained response with infliximab and methotrexate treatment.

CONCLUSIONS

Infliximab and methotrexate might be considered in patients with idiopathic sclerosing orbital inflammation (myositis).

Head and neck manifestations of distant carcinomas

Metastatic tumors to the head and neck from distant carcinomas are rare lesions that epitomize the "zebras." They represent a diagnostic and therapeutic challenge for clinicians and health providers. These lesions usually rank low in the differential diagnosis list, but a history of cancer should prompt clinicians about the possibility of a metastatic lesion from a distant carcinoma. The presence of these lesions usually represents a poor prognosis. The surgeon's role in treating these lesions is to improve or maintain the patient's quality of life, taking into consideration the overall prognosis.