Inferior rectus myositis: a rare cause of painful ophthalmoplegia and a therapeutic challenge

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.

Idiopathic inferior rectus myositis: A rare cause of diplopia and a therapeutic success

Orbital myositis is a rare inflammatory condition of a single or multiple extraocular muscles. It usually presents with unilateral or sequential bilateral sub-acute eye swelling, orbital pain, restricted eye movement, and redness of the eyelid. The swelling of extraocular muscles may lead to limited range of motion that produces blurred vision or diplopia. In this article, we report a male patient with idiopathic inferior rectus myositis presenting with diplopia who was managed successfully by medical and surgical intervention. Acute onset of diplopia with eye pain or limited extraocular movement is an ophthalmic emergency requiring urgent assessment and diagnostic imaging studies such as CT or MRI. The present case shows the crucial role of surgery as an adjunctive modality to achieve an improved clinical picture in patients not responding to immunosuppressive therapy. The secret to the success of management includes regular follow-up with frequent examination and comprehensive radiological and tissue investigations.

"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.