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Cutler C, Azab MA, Lucke-Wold B, Khan M, Henson JC, Gill AS, Alt JA, Karsy M. Systematic Review of Treatment Options and Therapeutic Responses for Lesions of the Sella and Orbit: Evidence-Based Recommendations. World Neurosurg 2023; 173:136-145.e30. [PMID: 36639102 DOI: 10.1016/j.wneu.2022.12.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/26/2022] [Accepted: 12/26/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Inflammatory pathologies of the sella and orbit are rare but require prompt diagnosis to initiate effective treatment. Because uniform recommendations for treatment are currently lacking, we performed an evidence-based review to identify recommendations. METHODS We performed a literature search of the PubMed, Embase, and Web of Science databases to identify papers evaluating treatment of inflammatory pathologies of the sella and orbit. We used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to define recommendations, specifically examining aggregated sample sizes, disease-specific patient follow-up, and clinical trials focused on inflammatory diseases of the sella and orbit. RESULTS A total of 169 studies were included and organized by disease pathology. Treatments for various pathologies were recorded. Treatment options included surgery, radiation, steroids, targeted treatments, immunomodulators, intravenous immune globulin, and plasmapheresis. Steroids were the most often employed treatment, second-line management options and timing varied. Pathological diagnosis was highly associated with treatment used. Most evidence were level 3 without available control groups, except for 13 trials in neuromyelitis optica with level 1 or 2 evidence. CONCLUSIONS This is the first evidence-based review to provide recommendations on specific treatments for pathologies of the orbit and sella. The reported data may be useful to help guide randomized clinical trials and provide resource for clinical management decisions based on the available evidence.
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Affiliation(s)
- Christopher Cutler
- Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Mohammed A Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Majid Khan
- Reno School of Medicine, University of Nevada, Reno, Nevada, USA
| | - J Curran Henson
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Amarbir S Gill
- Division of Otolaryngology, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Jeremiah A Alt
- Division of Otolaryngology, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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Ng CC, Sy A, Cunningham ET. Rituximab for treatment of non-infectious and non-malignant orbital inflammatory disease. J Ophthalmic Inflamm Infect 2021; 11:24. [PMID: 34448063 PMCID: PMC8390731 DOI: 10.1186/s12348-021-00253-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 06/25/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To provide a comprehensive review of rituximab use for the treatment of non-infectious/non-malignant orbital inflammation. METHODS Review of literature through January 2021. RESULTS Individual data was available for 167 patients with refractory non-infectious/non-malignant orbital inflammation who received treatment with rituximab (RTX). Rituximab was generally utilized as third-line or later treatment (108/149, 72.5%) at a mean of 44.6 months following the diagnosis of orbital inflammation (range = 0 to 360 months; median = 13.7 months). Patients with non-infectious/non-malignant orbital inflammation either received prior treatment with corticosteroids only (27/122, 22.1%), or with one (31/122, 25.4%), two (25/122, 20.5%), or three or more (25/122, 20.5%) corticosteroid-sparing immunosuppressive agents with or without corticosteroids before initiation of RTX treatment. The rheumatologic protocol (two infusions of 1 gram of RTX separated by 14 days) was utilized most frequently (80/144, 55.6%), followed by the oncologic protocol (four weekly infusions of 375 mg/m2 RTX; 51/144, 35.4%). Various other off-label regimens were used infrequently (13/144, 9.0%). Rituximab treatments resulted in a positive therapeutic response for the majority of patients with orbital inflammation (146/166, 88.0%). Commonly treated diagnoses included granulomatosis with polyangiitis (99/167, 59.3%), IgG-4 related disease (36/167, 21.6%), and orbital inflammation of indeterminate cause (25/167, 15.0%). No side effects were reported in 83.3% (55/66) of cases. The most common RTX-induced adverse event was an infusion-related temporary exacerbation of orbital disease (4/66, 6.1%), which occurred prior to the routine use of systemic corticosteroids as pre-conditioning. CONCLUSIONS Overall, RTX appears to be both efficacious and well-tolerated as second- or third-line therapy for patients with non-infectious/non-malignant orbital inflammation.
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Affiliation(s)
- Caleb C Ng
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, USA.
- West Coast Retina Medical Group, 1445 Bush Street, San Francisco, CA, 94109, USA.
| | - Aileen Sy
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, USA
- Department of Ophthalmology, Kaiser Permanente Santa Clara, California, USA
| | - Emmett T Cunningham
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, USA
- West Coast Retina Medical Group, 1445 Bush Street, San Francisco, CA, 94109, USA
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA, USA
- Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, CA, USA
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Sorin SM, Răzvan-Marian M, Daniela MM, Dan-Alexandru T. Therapy of ocular complications in ANCA+ associated vasculitis. Rom J Ophthalmol 2021; 65:10-14. [PMID: 33817427 PMCID: PMC7995502 DOI: 10.22336/rjo.2021.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
ANCA+ associated vasculitis (AAV) is a group of rare diseases with potentially vision-threatening complications. Ocular and orbital complications of these diseases are caused by vasculitis of the small vessels of the eye or by granulomatous mass formation. ANCA (anti-neutrophil cytoplasmic antibodies) represent a key component of pathophysiological pathways as well as a diagnostic marker. Various manifestations are reported in literature, scleritis and episcleritis being the most common, followed by pseudotumor orbitae. In vision-threatening orbital or ocular disease, aggressive systemic treatment with a combination of high-dose glucocorticoids and either cyclophosphamide or rituximab is needed. Certain cases require locoregional surgical management to preserve ocular integrity or vision. Ocular involvement of AAV remains a challenge in clinical practice, requiring multi-specialty cooperation in order to ensure the best possible visual outcome. Abbreviations: AAV = ANCA+ associated vasculitis, ANCA = anti-neutrophil cytoplasmic antibodies, GPA = granulomatosis with polyangiitis, EGPA = eosinophilic granulomatosis with polyangiitis, MPA = microscopic polyangiitis
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Miłkowska-Dymanowska J, Laskowska P, Rzuczkowski M, Białas AJ, Piotrowski WJ, Górski P. Untypical Manifestations of Granulomatosis with Polyangiitis—A Review of the Literature. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s42399-019-00083-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Monmany J, Granell E, López L, Domingo P. Resolved heart tamponade and controlled exophthalmos, facial pain and diabetes insipidus due to Erdheim-Chester disease. BMJ Case Rep 2018; 2018:bcr-2018-225224. [PMID: 30337283 PMCID: PMC6254461 DOI: 10.1136/bcr-2018-225224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
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.
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Affiliation(s)
- Jaume Monmany
- Medicina Interna, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Esther Granell
- Diagnòstic per la Imatge, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Laura López
- Anatomia Patològica, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Pere Domingo
- Medicina Interna, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Grusha YO, Ismailova DS, Novikov PI, Kogan EA, Abramova YV, Bulanov NM, Sherstneva LV. [Combination therapy of refractory localized granulomatosis with polyangiitis and orbital involvement]. Vestn Oftalmol 2017; 133:86-91. [PMID: 28524146 DOI: 10.17116/oftalma2017133286-90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Granulomatous orbital cellulitis is one of the most common ocular manifestations of granulomatosis with polyangiitis (Wegener's). The process is often refractory to conventional immunosuppressive therapy and requires a more radical treatment approach. However, surgical experience with this type of patients is limited. There have been just a few reported cases of orbital decompression in such patients and many authors have doubted the appropriateness of the procedure, since it is associated with a high risk of potentially fatal complications. Our experience demonstrates the feasibility and effectiveness of orbital mass removal as to pain relief and exophthalmos reduction.
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Affiliation(s)
- Y O Grusha
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - D S Ismailova
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - P I Novikov
- UCH #3 of I.M. Sechenov First Moscow State Medical University, 11, str.5 Rossolimo St., Moscow, Russian Federation, 119021
| | - E A Kogan
- I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - Yu V Abramova
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021
| | - N M Bulanov
- I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - L V Sherstneva
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
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Lopes Caçola R, Morais SA, Carvalho R, Môço R. Bilateral dacryoadenitis as initial presentation of a locally aggressive and unresponsive limited form of orbital granulomatosis with polyangiitis. BMJ Case Rep 2016; 2016:bcr-2015-214099. [PMID: 27170605 DOI: 10.1136/bcr-2015-214099] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Limited orbital granulomatosis with polyangiitis (GPA) is uncommon and its diagnosis may be delayed, especially when isolated lacrimal involvement is the initial presentation, because clinical manifestations are non-specific and systemic diagnostic criteria are not applicable. Making an early diagnosis despite the absence of systemic progression is extremely important because in some cases the disease is locally destructive, with irreversible visual and functional loss, and it can be refractory to corticosteroids and conventional immunosuppressive drugs to induce remission. The authors report an unusual limited form of orbital GPA in a 35-year-old woman presenting with bilateral dacryoadenitis, evolving later to locally aggressive bilateral orbital pseudotumour leading to proptosis, extraocular myositis, diplopia and medial deviation of the nasal septum. She had never had systemic manifestations but her disease was persistently active and unresponsive to corticosteroids and immunosuppressors. The aim of this paper is to provide further evidence of aggressive and refractory limited forms of GPA.
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Affiliation(s)
- Rute Lopes Caçola
- Department of Internal Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Sandra Alves Morais
- Department of Internal Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Rui Carvalho
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Rui Môço
- Department of Internal Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
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