Computed tomography of sarcoidosis of the optic nerve

Ophthalmic and neuro-ophthalmic manifestations of sarcoidosis

PURPOSE OF REVIEW

Sarcoidosis is a multisystemic inflammatory disease that commonly affects the eye and less often the neuro-ophthalmic pathways. The manifestations can be quite variable but can have characteristic signs and clinical features. This review provides a comprehensive overview of the various ocular and neuro-ophthalmic manifestations of sarcoidosis, emerging diagnostic measures and approach to treatment. Particular focus is given to recent advances in diagnostic approach and available treatment options.

RECENT FINDINGS

Laboratory investigations, chest and nuclear medicine imaging remain important techniques for helping to diagnose sarcoidosis. Recent evidence suggests a role for aqueous humor analysis in the diagnosis of ocular sarcoidosis. Characteristic neuroimaging may help differentiate neurosarcoidosis from other causes. The role of blind conjunctival biopsy for suspected neurosarcoidosis is discussed. The emerging role and use of biologics is delineated for the treatment of both ocular and neuro-ophthalmic sarcoidosis.

SUMMARY

Sarcoidosis can affect any part of the visual system: the most common ocular manifestation is uveitis and the most common neuro-ophthalmic manifestation is optic neuropathy. Although diagnosis remains challenging, recent advancements in diagnosis are promising. Emerging biologics with particular efficacy for ocular and neuro-ophthalmic disease provide expanding treatment options for sight-threatening disease.

Enlargement of the optic disk in childhood optic nerve tumors

Two children, a 9-year-old girl and an 8-month-old girl, were first examined because of unilateral proptosis. Both children were found to have unilateral optic nerve glioma, accompanied in the second case by neurofibromatosis. Two years after Patient 1 was first examined, the initial findings of thin vertical retinal striae and a gray opacification of the peripapillary retina had resolved. The enlarged left optic disk had an average diameter of 2 mm while that of the normal right optic disk was 1.6 mm. The disk-arteriolar ratio was R.E.:16:1 and L.E.: 20:1. Four years later, the patient's visual acuity was still 20/20 in both eyes and the only visual field abnormality was an enlarged blind spot corresponding to the enlarged left optic nerve head. Fundus photographs, orbital echography, and computed tomography showed no change in the size or location of the optic nerve glioma during the six-year follow-up period. In Case 2, the initial intraocular pressure was higher in the proptotic right eye than in the left eye (25 vs 19 mm Hg), but subsequent intraocular pressures were within normal limits and approximately equal in the two eyes. The disk-arteriolar ratio was R.E.:21:1 and L.E.: 18:1 and the cup-disk ratio was R.E.: 0.7 and L.E.: 0.3. Computed tomography disclosed an enlarged right retrobulbar optic nerve, a superior orbital fissure that was much larger on the right than on the left, and a larger cavernous sinus on the right. The right sphenoid bone was partially absent. Despite mild developmental delay, the patient's visual acuity apparently remained normal and the ophthalmologic findings did not change significantly during the 18-month follow-up period.

Eleven cases of sarcoidosis of the optic nerve

Of 11 patients (eight women and three men, ranging in age from 16 to 48 years) who had sarcoidosis of the optic nerve that caused decreased visual acuity and visual field abnormalities, only two were known to have sarcoidosis at the time the visual impairment developed. Four patients had granulomas involving the optic nerve head, four had granulomatous inflammation of the orbital or intracranial optic nerve or chiasm, and three had retrobulbar neuritis. All 11 patients had histologically confirmed idiopathic noncaseating granulomatous inflammation and eight of the 11 had abnormalities compatible with sarcoidosis in chest roentgenograms. In the three patients in whom the serum level of angiotensin-converting enzyme was determined, it was increased in one and normal in the other two. Computed tomography of the anterior visual pathways was the single most useful neurodiagnostic study. Treatment with corticosteroids was beneficial in six of the 11 cases. These cases demonstrated that sarcoidosis should be included in the differential diagnosis of any inflammatory or compressive lesion involving the anterior visual pathways.