Nonthyroid causes of extraocular muscle disease

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.

Recurrent posterior scleritis and orbital myositis as extra-intestinal manifestations of Crohn's disease: Case report and systematic literature review

BACKGROUND

Ocular episcleritis and uveitis are well-recognised extra-intestinal manifestations of Crohn's disease. Orbital myositis is rare: to our knowledge it has been associated with Crohn's disease in thirteen cases. Posterior scleritis, orbital myositis and Crohn's disease have been reported as coexisting in only two cases.

METHODS AND RESULTS

We describe a third case, that of a 31-year old female with Crohn's colitis for 8 years, complicated by enteropathic arthritis and pyoderma gangrenosum. She presented with intense and intractable periorbital pain, particularly at night and worse on eye movements. B-scan ultrasonography confirmed posterior scleritis and treatment with high dose oral steroids (up to 60 mg prednisolone) was initially effective, but subsequently failed to control the inflammation. There was only a partial response to infliximab. Five months after presentation, diplopia developed, with failure of abduction of the left eye. MRI scan of the orbits confirmed orbital myositis involving the left lateral and medial rectus muscles. Pulsed intravenous methylprednisolone and six cycles of intravenous cyclophosphamide over a three month period resulted in complete resolution of inflammatory symptoms.

CONCLUSIONS

This case highlights a rare combination of ocular abnormality secondary to Crohn's disease and reports successful resolution with aggressive immunosuppressive therapy.

Rhabdomyosarcoma metastases to all extraocular muscles

A 24-year-old woman developed acute bilateral proptosis. She had a history of rhabdomyosarcoma of the left orbit treated 2 years previously with chemotherapy and radiation. Computed tomography demonstrated enlargement of each of the extraocular muscles in both orbits. Extraocular muscle biopsy confirmed rhabdomyosarcoma. She was treated with radiation but died 2 months after presentation.

Extraocular muscle involvement in marginal zone B-cell lymphomas of the orbit

INTRODUCTION

Marginal zone B-cell lymphoma is the most frequent ocular adnexal lymphoma. It may involve the conjunctiva, lacrimal gland, eyelid, extraocular muscle, and orbital connective tissue. Extraocular muscle infiltration is rare.

METHODS

We report here a series of 5 patients presenting with extraocular muscle infiltration due to marginal zone B-cell lymphoma, extracted from a retrospective study of 39 patients with primitive ocular adnexal marginal zone B-cell lymphoma presenting within a 15-year period, from 1993 to 2007, at two university hospitals.

RESULTS

Out of 39 patients, two females and three males presented with extraocular muscle involvement (one levator muscle, one medial rectus muscle, one lateral rectus muscle, one inferior rectus muscle, and one inferior oblique muscle). In 4 cases, the right eye was involved. The median age of presentation was 60 years. Proptosis and diplopia were the main clinical signs. A mean duration of symptoms was 12 months before diagnosis was given. Three patients were stage IE at the diagnosis, according to Ann Arbor classification, and one was at stage IV. Three patients received radiotherapy and two received chemotherapy. Three patients underwent local relapses at a median time of 40 months. The patients with relapses were treated with chemotherapy alone in one case, radiotherapy alone in one case, and immunotherapy and chemotherapy in one case. The mean follow-up period was 54 months.

DISCUSSION

When compared to other locations of marginal zone B-cell lymphomas of the orbit, extraocular involvement occurred in younger patients and had similar prognosis.

CONCLUSION

Extraocular muscle involvement is a rare location of marginal zone B-cell lymphoma that had to be known and can simulate thyroid orbitopathy.

External ophthalmoplegia as the presenting feature of systemic amyloidosis

INTRODUCTION

Amyloidosis is a multi-system disease characterised by the intracellular deposition of beta-pleated sheets of amyloid. It can involve the eye, orbit and ocular adnexae.

METHOD

We describe a case of a 58-year-old woman presenting to the eye department with external ophthalmoplegia, including the findings of various investigations. The spectrum of ocular amyloidosis is discussed.

CONCLUSION

Amyloidosis may be the underlying diagnosis in some cases of external ophthalmoplegia with findings atypical to other systemic disease.

Assessment of inflammation in idiopathic orbital myositis with fat-suppressed T2-weighted magnetic resonance imaging

PURPOSE

To evaluate the inflammation in idiopathic orbital myositis by fat-suppressed T2-weighted magnetic resonance imaging (MRI).

DESIGN

Observational case series.

METHODS

The inflammation in nine patients with orbital myositis was evaluated with fat-suppressed T2-weighted MRI within three weeks of onset. Patients were mainly treated with steroid pulse therapy and followed to the acute improvement or chronic ocular motility restriction phases.

RESULTS

Each patient was found to have localized inflammations in the extraocular muscles or associated fascial structures. Of the five patients with acute improvement, none had inflammation of the extraocular muscles, whereas the four patients with chronic ocular motility restriction had inflammation of the extraocular muscles.

CONCLUSION

These results suggest that acute or chronic pattern in orbital myositis is correlated with the localized inflammation. The inflammation in the extraocular muscles may be one of the factors that lead to the chronic ocular motility restriction.

Lymphoplasmacytic Lymphoma Isolated to an Extraocular Muscle

A 44-year-old woman presented with a 1-month history of right-sided tearing, redness, and chronic headache. Clinical examination was notable for 4-mm proptosis and decreased visual acuity OD. Orbital CT demonstrated isolated enlargement of the right lateral rectus. Surgical biopsy was undertaken after an unsuccessful trial of oral steroids. Histopathology and immunophenotyping demonstrated a lymphoplasmacytic lymphoma. External beam radiation induced regression of the lymphoma with decreased proptosis and improved visual acuity.

Extraocular mitochondrial myopathies and their differential diagnoses

The diagnosis of mitochondrial myopathy depends upon a constellation of findings, family history, type of muscle involvement, specific laboratory abnormalities, and the results of histological, pathobiochemical and genetic analysis. In the present paper, the authors describe the diagnostic approach to mitochondrial myopathies manifesting as extraocular muscle disease. The most common ocular manifestation of mitochondrial myopathy is progressive external ophthalmoplegia (PEO). To exclude myasthenia gravis, ocular myositis, thyroid associated orbitopathy, oculopharyngeal muscular dystrophy, and congenital fibrosis of the extraocular muscles in patients with an early onset or long-lasting very slowly progressive ptosis and external ophthalmoplegia, almost without any diplopia, and normal to mildly elevated serum creatine kinase and lactate, electromyography, nerve conduction studies and MRI of the orbits should be performed. A PEO phenotype forces one to look comprehensively for other multisystemic mitochondrial features (e.g., exercise induced weakness, encephalopathy, polyneuropathy, diabetes, heart disease). Thereafter, and presently even in familiar PEO, a diagnostic muscle biopsy should be taken. Histological and ultrastructural hallmarks are mitochondrial proliferations and structural abnormalities, lipid storage, ragged-red fibers, or cytochrome-C negative myofibers. In addition, Southern blotting may reveal the common deletion, or molecular analysis may verify specific mutations of distinct mitochondrial or nuclear genes.

Orbital Lymphoma Simulating Thyroid Orbitopathy

An 82-year-old man with hypothyroidism had vertical diplopia and swelling around his left eye. Visual acuity was 20/20 OD and 20/50 OS. There was moderate blepharoptosis and edema of the left eyelids and superior scleral show of the right eye. The left eye showed 4 mm of proptosis, motility restriction, afferent pupillary defect, and normal optic disc. Orbital MRI revealed enlargement of the left superior and medial rectus muscles without tendinous involvement. These findings were initially suggestive of thyroid orbitopathy. Thyroid function tests were normal. Coronal MRI showed additional superior oblique enlargement and involvement of the levator superioris palpebrae muscle, which are both suggestive of a non-thyroid pathology. Muscle biopsy revealed large B-cell lymphoma. The patient was treated with chemotherapy, immunotherapy, and radiotherapy, with complete tumor control. Orbital lymphoma can simulate thyroid orbitopathy, even in patients with classic "thyroid-like" symptoms and imaging.

Facial pain: clinical differential diagnosis

Differential diagnosis of pain in the face as the presenting complaint can be difficult. We propose an approach based on history and neurological examination, which allows a working diagnosis to be made at the bedside, including aetiological hypotheses, leading to a choice of investigations. Neuralgias are characterised by stabs of short lasting, lancinating pain, and, although neuralgias are often primary, imaging may be needed to exclude symptomatic forms. Facial pain with cranial nerve symptoms and signs is almost exclusively of secondary origin and requires urgent examination. Facial pain with focal autonomic signs is mostly primary and belongs to the group of the idiopathic trigeminal autonomic cephalalgias, but can occasionally be secondary. Pure facial pain is most often due to sinusitis and the chewing apparatus, but also a multitude of other causes. The pain can also be idiopathic. Imaging as well as non-neurological specialist assessment is often necessary in these cases.

Neuro-Ophthalmic Emergencies for the Neurologist

A variety of acute neurologic disorders present with visual signs and symptoms. In this review the authors focus on those disorders in which the clinical outcome is dependent on timely and accurate diagnosis. The first section deals with acute visual loss, specifically optic neuritis, ischemic optic neuropathy (ION), retinal artery occlusion, and homonymous hemianopia. The authors include a discussion of those clinical features that are helpful in distinguishing between inflammatory and ischemic optic nerve disease and between arteritic and nonarteritic ION. The second section concerns disc edema with an emphasis on the prevention of visual loss in patients with increased intracranial pressure. The third section deals with abnormal ocular motility, and includes orbital inflammatory disease, carotid-cavernous fistulas, painful ophthalmoplegia, conjugate gaze palsies, and neuromuscular junction disorders. The final section concerns pupillary abnormalities, with a particular emphasis on the dilated pupil and on carotid artery dissection. Throughout there are specific guidelines for the management of these disorders, and areas are highlighted in which there is ongoing controversy.

Clinical Case Notes. Orbital lymphoid tumour located within an extraocular muscle

A rare case of an orbital lymphoid tumour within an extraocular muscle is presented. The tumour displayed features of a progressive indolent systemic lymphoma. There was no response to a trial of chemotherapy and so local radiotherapy was instituted. At follow up 2 months later there was no evidence of disease.

Enlarged extraocular muscles as the presenting feature of acromegaly

: The authors report the case of a 32-year-old woman who presented with bilateral lower eyelid swelling and extraocular muscle enlargement as the initial manifestation of acromegaly. The acromegaly, however, was not diagnosed until 6 years after her symptoms began. Acromegaly should be entertained in the differential diagnosis of any patient who presents with bilateral, symmetrical extraocular muscle enlargement on computed tomographic scan, especially in the patient with normal thyroid hormone levels and no clinical findings associated with thyroid orbitopathy.

Bilateral orbital tumour as the presentation of mammographically occult breast cancer

We report a rare case of bilateral orbital metastases as the presentation in a 63-year-old woman. Biopsy of a diffusely infiltrated medial rectus muscle suggested metastatic adenocarcinoma. Investigation revealed a palpable mass of the right breast not shown on mammography or sonography. Invasive lobular carcinoma was found at core-needle biopsy with histological features identical to those of the orbital lesion. Metastases to the extraocular muscles are uncommon, particularly as the initial abnormality in the absence of disseminated disease.

Screening for ophthalmic involvement in asymptomatic patients with metastatic breast carcinoma

BACKGROUND

Breast carcinoma metastasises to the eye more frequently than is clinically recognised. The incidence is perhaps not appreciated, either because of the more common involvement and consequences of spread to major organs (such as lung, liver, or bone) or because a number of eye lesions are small and asymptomatic. Over a 6-month period, all patients with locally advanced or metastatic breast cancer were screened for ocular involvement and as a result management recommendations made.

MATERIALS AND METHODS

Between January 2001 and June 2001, 68 patients with known locally advanced or metastatic breast carcinoma were referred for a screening ophthalmic examination. The aim of the study was to assess the frequency of asymptomatic ocular metastases by breast carcinoma in visually asymptomatic patients. The recognition and early treatment of both ocular metastases and ocular manifestations of metastatic breast carcinoma are important in maximising the quality of life in this group of palliative patients. These patients were all referred and recruited from the Beatson Oncology Centre and Breast Unit at the Western Infirmary, Glasgow by the oncologist (ANH). Examination included visual acuity assessment, slit-lamp examination, tonometry, and indirect ophthalmoscopy.

RESULTS

The median time from diagnosis of breast carcinoma to ophthalmic screening was 5 years (range 6 months-23 years). No patient had any evidence of choroidal metastases on ophthalmic examination. Four patients (5.8%) had ophthalmic manifestations of metastatic breast carcinoma and a further two had ocular complications of treatment. One patient had a restrictive motility problem from a metastatic deposit to her lateral rectus muscle and another had corneal punctate epitheliopathy secondary to a seventh nerve palsy. A further patient had coarse nystagmus from cerebellar metastases and the final patient of the four had a Horner's syndrome from metastases in the neck. In addition, two patients had symptomatic dry eyes whose onset coincided with commencement of chemotherapy.

CONCLUSION

Ophthalmic manifestations of metastatic breast carcinoma occurred in 5.8% of asymptomatic patients. Orbital metastases were documented in one patient. No case of choroidal metastases was observed in this group with advanced or metastatic disease. Therefore, patients do not need to be routinely screened particularly for choroidal metastases.

Orbital myositis associated with Borrelia burgdorferi (Lyme disease) infection

OBJECTIVE

To report on the clinical findings in a patient with isolated left inferior rectus myositis associated with serologically confirmed Borrelia burgdorferi infection.

DESIGN

Interventional case report.

TESTING

Comprehensive clinical, laboratory, and imaging evaluation.

RESULTS

Contrast-enhanced computed tomography showed a swollen inferior rectus muscle with infraorbital soft tissue swelling in a patient with diplopia and prior symptoms consistent with manifestations of Lyme disease. Positive serum and cerebrospinal fluid antibodies to B. burgdorferi by enzyme-linked immunoassay were confirmed by Western blot, and the cerebrospinal fluid/serum antibody ratio was elevated. No alternative cause for orbital myositis was found, and treatment with antibiotics resulted in a complete recovery.

CONCLUSIONS

Orbital myositis should be added to the expanding list of ophthalmic manifestations of Lyme disease. Correct diagnosis and appropriate antibiotic therapy may reduce the likelihood of further neurologic or ophthalmologic sequelae.

Painful ophthalmologic disorders and eye pain for the neurologist

Neurologists should be aware of the following causes of eye pain: (1)ocular and orbital disorders with or without visible pathology of the eye (eg,redness, corneal opacity, or proptosis); (2) ophthalmologic syndromes associated with headache; and (3) headache syndromes associated with ophthalmologic findings.

Diagnostic dilemmas in orbital inflammatory disease

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.

Orbital myositis in scleritis

AIMS

To investigate the association between scleritis and myositis.

METHODS

Retrospective, non-comparative case series. Records and ultrasonograms were examined of 132 patients, with a diagnosis of episcleritis or scleritis, who attended the ophthalmology department at Leiden University Medical Center between 1997 and 2000. 103 were eligible for comprehensive examination. Medical records were evaluated. Ultrasonography was performed in all patients diagnosed with episcleritis or scleritis. Clinical features, precipitating factors, systemic associations, ocular complications, treatment, and outcome of each patient were assessed.

RESULTS

Of the 103 patients, 27 (26.2%) had episcleritis and 76 (73.8%) had scleritis. Myositis was found to be present in 11 patients. It was present in 14.5% of all patients with scleritis and 30.5% of those in whom the posterior sclera was affected. The presence of the associated myositis did not worsen the visual prognosis and the presence of myositis was not associated with other systemic diseases. There were no cases of unilateral scleritis with bilateral orbital myositis. During an attack ocular complications were more common in patients with scleritis and myositis (64%) than in patients with scleritis alone (30.4%), indicating a more diffuse and potentially dangerous inflammation. There was no evidence that the inflammatory changes in the orbit had spread to involve the sclera, so it is assumed that the muscle changes are an extension of a generalised response to intense inflammation of the episclera and sclera.

CONCLUSION

This study found a frequent association between myositis and scleritis. Prognosis for vision was not affected by coexistence of myositis.

Bilateral infraorbital nerve involvement in idiopathic orbital myositis

We describe a case of bilateral infraorbital nerve involvement in idiopathic orbital myositis. Computed tomographic scanning of the orbits showed enlargement of extraocular muscles consistent with orbital myositis and enlargement of the ipsilateral infraorbital nerve. With disease progression, infiltration of the contralateral infraorbital nerve also developed. Biopsies of the inferior oblique muscle and infraorbital nerve showed the same inflammatory infiltrate: a mixed population of lymphocytes (B and T) with B cells expressing kappa and lambda light chains. Although orbital myositis may be associated with several conditions, to the best of our knowledge, this is the first time a case of idiopathic orbital myositis with bilateral infraorbital nerve involvement has been described.

Orbital intramuscular haemangioma

PURPOSE

To present the clinical and histopathological characteristics of an intramuscular haemangioma in the extraocular muscles.

METHODS

In 1989, an otherwise healthy 21-year-old female developed proptosis of the left eye. Clinical examination revealed a painless, non-compressible, retrobulbar lesion. No discoloration of skin or conjunctiva could be observed. The patient had no history of head injury. She underwent surgery three times over a period of 9 years, without reaching a diagnosis. The tumour increased slowly in size despite the operations and MR imaging suggested a tumour of angiomatous origin. Finally, radical surgery was performed with enucleation of the left eye and excision of affected extraocular muscles.

RESULTS

Histopathological examination of the removed orbital tumour showed a mixed type intramuscular haemangioma involving four extraocular muscles.

CONCLUSION

We report the first case of an intramuscular haemangioma of the orbit.

Clinical review: the differential diagnosis of pain in the quiet eye

BACKGROUND

Eye pain, periorbital and retro-orbital pain, and headache or facial pain referred to the orbital region are common presenting complaints.

REVIEW SUMMARY

In this review, we discuss the etiologies of eye pain in the quiet eye, which is defined clinically as one with a clear cornea without redness or irritation of the conjunctiva or sclera.

CONCLUSIONS

The causes of eye pain may be divided into two groups: (1) those associated with abnormal localizing ophthalmologic and neuro-ophthalmologic findings (including trigeminal neuropathies);(2) those with a normal ophthalmologic and neurologic examinations. The latter group is further divided into the following subgroups: (1) specific short-lasting or long-lasting headache or eye pain syndromes; (2) pain referred to the eye from other pathologic processes (secondary eye pain) sometimes distant from structures concerned with vision; and (3) pain from orbital, superior orbital fissure, cavernous sinus, or intracranial infiltrative, neoplastic, or inflammatory disease processes with normal ophthalmologic and neuro-ophthalmologic exam. Unfortunately, in some patients, no etiology for the pain syndrome is discerned and one is left with a diagnosis of idiopathic eye pain, eye strain, or atypical facial pain.

Advances in imaging in oculoplastics

Color Doppler imaging, computed tomography (CT) and magnetic resonance (MR) imaging are the most precious imaging tools for the clinician in the field of oculoplastics. Orbital and facial vasculature, with its dynamic changes and flow velocities seen in orbital varices, carotid-cavernous fistulas, and dural cavernous arteriovenous malformations, is best detected by Color Doppler imaging. Computed tomography remains the dominant imaging modality in the evaluation of orbital trauma. Helical CT axial scanning with multiplanar reconstruction and three-dimensional CT imaging are most helpful in assessing iatrogenic, traumatogenic, and teratogenic orbital abnormalities. Despite its poor histologic specificity, MR imaging provides superior soft tissue contrast, and contrast-enhanced MR imaging has an established role regarding soft tissue tumor infiltration. The greatest value of MR studies in the evaluation of orbital and palpebral tumors is that it has the capacity to show the precise relation between lesions and adjacent structures before the clinician contemplates a surgical approach. Finally, contrast-enhanced MR imaging proved to be a valuable vascularization indicator based upon the extent of relative enhancement within porous orbital implant in anophthalmic socket.

Paralytic strabismus

In the last year, published works on paralytic strabismus have concerned many topics. New advances have been made in the knowledge of epidemiology of ocular nerve palsies in children, muscular causes of paralytic strabismus, and neuroimaging management of patients with third nerve palsy who are at risk of cerebral aneurysms. The author describes reports on rare associations of oculomotor imbalances and neurologic diseases as well as atypical orbital localizations of tumors. He also discuss new neuroimaging findings in congenital superior oblique muscle palsy and new acquisitions on cyclofusion deterioration in acquired trochlear palsy.

Pseudo-pseudotumor

The initial diagnostic impression in a patient with a "hot orbit" may evolve as more laboratory and radiographic information becomes available. We present a patient in whom nearly the entire differential diagnosis of painful orbitopathy was considered before the correct diagnosis was made, after the patient had improved and all paraclinical data, including magnetic resonance imaging, were available.

Orbital granulomatous giant cell myositis: a case report and review

To present a case of orbital granulomatous giant cell myositis and review the literature. We describe the case of a 51-year-old woman, with a past history of melanoma, who presented with an acutely painful orbital myositis. This evolved into a chronic relapsing process involving multiple muscles bilaterally; which demonstrated partial steroid responsiveness. Biopsy revealed a granulomatous giant cell myositis. Orbital granulomatous giant cell myositis is a rare histological entity which has an association with giant cell myocarditis and underlying malignancy.