Etiology and management of idiopathic orbital inflammation

Systemic inflammatory markers differentiate between orbital cellulitis and non-specific orbital inflammation

PURPOSE

Bacterial orbital cellulitis (OC) and diffuse non-specific orbital inflammation (DNSOI) may be challenging to differentiate clinically. This study investigates the utility of systemic inflammatory markers, namely white cell count (WCC) and C-reactive protein (CRP), in differentiating between OC and DNSOI.

METHODS

A single-centre retrospective study of patients diagnosed with OC or DNSOI, between 2003 to 2021, who had WCC and/or CRP obtained at presentation. The mean levels of these factors and the proportion of positivity were compared between OC and DNSOI. A receiver operating characteristic (ROC) analysis was conducted to calculate the specificity and sensitivity of WCC or CRP in each group.

RESULTS

49 patients were included in this study. The mean age was 56 ± 20 years, and 21 patients were females. 26 (53.1%) patients had OC, and 23 (46.9%) patients had DNSOI. Mean WCC for OC and DNSOI were 14.5 × 10³/μL and 9.27 × 10³/μL, respectively (P = 0.001). Mean CRP for OC and DNSOI were 104.4 mg/L and 10.0 mg/L, respectively (P < 0.001). The optimal CRP cut-off value of 20.2 mg/L demonstrated 90.9% sensitivity and 90.5% specificity (AUC = 0.946, P < 0.001) for differentiating between OC and DNSOI. CRP was more predictive of OC than WCC (P = 0.017). 7/26 (26.9%) OC patients with fever also had an elevated CRP, while 1/23 (4.3%) of DNSOI with fever had a normal CRP.

CONCLUSIONS

An elevated WCC is suggestive of OC. However, a normal WCC can neither exclude nor differentiate between OC and DNSOI. CRP may be a more accurate predictor of OC compared to WCC.

A deep learning model combining multimodal radiomics, clinical and imaging features for differentiating ocular adnexal lymphoma from idiopathic orbital inflammation

OBJECTIVES

To evaluate the value of deep learning (DL) combining multimodal radiomics and clinical and imaging features for differentiating ocular adnexal lymphoma (OAL) from idiopathic orbital inflammation (IOI).

METHODS

Eighty-nine patients with histopathologically confirmed OAL (n = 39) and IOI (n = 50) were divided into training and validation groups. Convolutional neural networks and multimodal fusion layers were used to extract multimodal radiomics features from the T1-weighted image (T1WI), T2-weighted image, and contrast-enhanced T1WI. These multimodal radiomics features were then combined with clinical and imaging features and used together to differentiate between OAL and IOI. The area under the curve (AUC) was used to evaluate DL models with different features under five-fold cross-validation. The Student t-test, chi-squared, or Fisher exact test was used for comparison of different groups.

RESULTS

In the validation group, the diagnostic AUC of the DL model using combined features was 0.953 (95% CI, 0.895-1.000), higher than that of the DL model using multimodal radiomics features (0.843, 95% CI, 0.786-0.898, p < 0.01) or clinical and imaging features only (0.882, 95% CI, 0.782-0.982, p = 0.13). The DL model built on multimodal radiomics features outperformed those built on most bimodalities and unimodalities (p < 0.05). In addition, the DL-based analysis with the orbital cone area (covering both the orbital mass and surrounding tissues) was superior to that with the region of interest (ROI) covering only the mass area, although the difference was not significant (p = 0.33).

CONCLUSIONS

DL-based analysis that combines multimodal radiomics features with clinical and imaging features may help to differentiate between OAL and IOI.

KEY POINTS

• It is difficult to differentiate OAL from IOI due to the overlap in clinical and imaging manifestations. • Radiomics has shown potential for noninvasive diagnosis of different orbital lymphoproliferative disorders. • DL-based analysis combining radiomics and imaging and clinical features may help the differentiation between OAL and IOI.

Clinical heterogeneity between two subgroups of patients with idiopathic orbital inflammation

Objective

Idiopathic orbital inflammation (IOI) is a group of orbital inflammatory diseases of unknown etiopathogenesis. We investigated whether patients with IOI have clinical heterogeneity based on the presence (typical group) or absence (atypical group) of a unique onset that periocular inflammatory symptoms emerge suddenly but progress slowly.

Methods and analysis

This retrospective cohort study included 195 patients diagnosed with IOI. We analysed the clinical data of patients, including the outcomes of corticosteroid treatment, in two subgroups stratified on the basis of the presence (130 patients) or absence (65 patients) of the unique onset.

Results

Patients in the typical group were significantly younger at disease onset than those in the atypical group (median age; 52 vs 65 years, p=0.002); had more ocular adnexa-specific lesions, namely, dacryoadenitis, myositis, scleritis and optic perineuritis (78% vs 45%, p=0.00001); and had significantly fewer associations with immune-mediated inflammatory diseases (4% vs 15%, p=0.004). Among 30/119 patients (25%) who were steroid refractory in the typical group, a long period of time from symptom onset to initiation of treatment was a significant steroid-refractory risk factor (OR: 16.7), whereas, among the 18/40 patients (45%) who were steroid refractory in the atypical group, intraconal diffuse lesions were a significant steroid-refractory risk factor (OR: 8.8).

Conclusion

This cohort study suggests clinical heterogeneity between the two subgroups of patients with IOI.

Tolosa-Hunt Syndrome with Multiple Orbital Myositis in a Patient with Crohn’s Disease

Purpose: We report a case of Tolosa-Hunt syndrome with multiple orbital myositis identified via orbital magnetic resonance imaging in a patient with Crohn's disease who developed right eye pain and binocular horizontal diplopia.Case summary: A 46-year-old woman visited our clinic with a 2-month history of right eye pain and migraine, as well as a 3-day history of acute horizontal diplopia. She had previously been diagnosed with Crohn's disease and was taking immunosuppressive drugs. In the eye movement test, esotropia and an abduction limitation of -3.0 in the right eye were observed on the Krimsky test. There were no specific findings in anterior segment and fundus examinations. Orbital magnetic resonance imaging showed multiple extraocular muscle enhancement in the right eye and multiple extraocular muscle hypertrophy in the left eye. The patient was diagnosed with binocular multiple orbital myositis and right Tolosa-Hunt syndrome; she was treated with high-dose steroids for 3 days followed by lower dose oral medications. During the first week of treatment, the right eye pain disappeared and the right eye abduction limitation showed slight improvement. After 3 months of treatment, the right eye abduction limitation and esotropia completely disappeared.Conclusions: Orbital myositis and Tolosa-Hunt syndrome are idiopathic, nonspecific chronic granulomatous diseases with painful ophthalmoplegia. We describe a rare case in which the two diseases appear together.

Autoimmune markers in screening for orbital inflammatory disease

PURPOSE

Immunogenic causes of inflammation may be difficult to differentiate in the work-up of orbital inflammatory disease. The study aims to investigate the utility of autoimmune markers in the screening for orbital inflammation. Markers studied included angiotensin-converting enzyme (ACE), antinuclear antibody (ANA), anti-neutrophilic cytoplasmic autoantibodies (ANCA), extractable nuclear antigen (ENA), anti-cyclic citrullinated peptide (Anti-CCP) and anti-double stranded DNA antibody (Anti-dsDNA antibody).

METHODS

A retrospective single-centre study of consecutive patients with non-infective orbital inflammation screened for autoimmune markers at presentation. Serology was interpreted alongside clinical course and other investigations (e.g. radiographic features and histopathology). Tabulated data and Pearson's Chi-square allowed analysis of trends between serology, diagnosis and the decision to biopsy.

RESULTS

79 patients, between 1999 and 2021, were included (50 females, mean age was 50.4 ± 17.4 years). 28 (34.6%) patients had specific orbital inflammation and 53 (65.4%) patients had non-specific orbital inflammation (NSOI). Of the 12 patients with positive serology and a specific diagnosis, only 5 (41.7%) patients had concordant serological results. There was no association between serology results and the patient undergoing biopsy (P = 0.651). Serology was unable to exclude nor differentiate NSOI from other specific conditions and ANA had limited discriminatory value between specific conditions and NSOI.

CONCLUSION

Serological testing alone may not provide a clear direction for further investigation of orbital inflammation and a biopsy may occur independently of the serological results. The value of autoimmune markers may lie in subsequent follow-up as patients may develop suggestive symptoms after an indeterminate positive result or initially seronegative disease.

[Idiopathic orbital inflammation]

BACKGROUND

Orbital inflammatory disease encompasses a spectrum of disorders. Idiopathic orbital inflammation (IOI) is often a diagnosis of exclusion, which needs to be differentiated from infections, systemic inflammatory disease, and neoplasms. IOI includes anterior inflammation with dacryoadenitis, myositis, perineuritis of the optic nerve, periscleritis, diffuse sclerosing inflammation, and orbital apex inflammation.

OBJECTIVE

A differential diagnostic overview of IOI is presented, including its subcategories, diagnosis, and treatment.

CONCLUSION

The diagnosis of IOI is often made by exclusion with typical clinical findings, CT and MRI scans, and pathology. Treatment includes corticosteroids, immunomodulators, immunosuppressants, and radiotherapy.

Improving diagnostic performance of differentiating ocular adnexal lymphoma and idiopathic orbital inflammation using intravoxel incoherent motion diffusion-weighted MRI

PURPOSE

To investigate the utility of intravoxel incoherent motion diffusion-weighted MRI (IVIM-DWI) derived diffusion and perfusion parameters in differentiating ocular adnexal lymphoma (OAL) from idiopathic orbital inflammation (IOI), and to assess whether IVIM-DWI provides improved diagnostic performance for the distinction.

METHOD

Twenty-one patients with OAL and 24 patients with IOI underwent IVIM-DWI. Apparent diffusion coefficient (ADC) and IVIM-DWI parameters including true diffusion coefficient (D), pseudo-diffusion coefficient (D*), and perfusion fraction (f) were measured in lesions by two independent radiologists. The MRI parameter differences between OAL and IOI were tested using two-sample t-test. The receiver operating characteristic (ROC) analysis curves were used to determine the diagnostic performance of significant parameters for differentiation between OAL and IOI.

RESULTS

The ADC, D, and f were lower in OAL than those in IOI (ADC = 0.78 ± 0.12 vs. 0.99 ± 0.16 × 10^-3 mm²/s, P < 0.001; D = 0.34 ± 0.15 vs. 0.76 ± 0.25 × 10^-3 mm²/s, P < 0.001; f = 0.31 ± 0.06 vs. 0.41 ± 0.08 × 100 %, P < 0.001). There was no significant difference in D* between OAL and IOI (P = 0.235). The optimal cut-off values of ADC, D, and f in differentiating OAL from IOI were 0.83 × 10^-3 mm²/s, 0.56 × 10^-3 mm²/s, and 0.36 × 100 %, respectively. No significant differences were found in areas under the curve (AUCs) among ADC, D and f (all P > 0.05). The combination of D and f provided significantly higher AUC than ADC (AUC = 0.984 vs. 0.838, Z = 2.128, P = 0.033), and had higher sensitivity of 95.24 %, specificity of 95.83 %, and accuracy of 95.56 %.

CONCLUSIONS

IVIM-DWI is valuable in differentiating OAL from IOI, and D combined f can improve the performance of differential diagnosis.

Bag-of-features-based radiomics for differentiation of ocular adnexal lymphoma and idiopathic orbital inflammation from contrast-enhanced MRI

OBJECTIVES

To evaluate the effectiveness of bag-of-features (BOF)-based radiomics for differentiating ocular adnexal lymphoma (OAL) and idiopathic orbital inflammation (IOI) from contrast-enhanced MRI (CE-MRI).

METHODS

Fifty-six patients with pathologically confirmed IOI (28 patients) and OAL (28 patients) were randomly divided into training (n = 42) and testing (n = 14) groups. One hundred sixty texture features extracted from the CE-MR image were encoded into the BOF representation with fewer features. The support vector machine (SVM) with a linear kernel was used as the classifier. Data augmented was performed by cropping orbital lesions in different directions to alleviate the over-fitting problem. Student's t test and the Holm-Bonferroni method were employed to compare the performance of different analysis methods. The chi-square test was used to compare the analysis with MRI and human radiological diagnosis.

RESULTS

In the independent testing group, the differentiation by the BOF features with augmentation achieved an area under the curve (AUC) of 0.803 (95% CI: 0.725-0.880), which was significantly higher than that of the BOF features without augmentation and that of the texture features (p < 0.05). In addition, the same radiomic analysis with pre-contrast MRI obtained an AUC of 0.618 (95% CI: 0.560-0.677), which was significantly lower than that with CE-MRI. The diagnostic performance of the analysis with CE-MRI was significantly better than the radiology resident (p < 0.05) but had no significant difference with the experienced radiologist, even though there was less consistency between the radiomic analysis and the human visual diagnosis.

CONCLUSIONS

The BOF-based radiomics may be helpful for the differentiation between OAL and IOI.

KEY POINTS

• It is challenging to differentiate OAL from IOI due to the similar clinical and image features. • Radiomics has great potential for the noninvasive diagnosis of orbital diseases. • The BOF representation from patch to image may help the differentiation of OAL and IOI.

Treatment of recalcitrant orbital inflammatory syndrome with plasmapheresis therapy

Refractory idiopathic orbital inflammation (IOI) represents a management challenge due to its significant proportion of treatment failures. Currently, there are no established guidelines for recalcitrant IOI and majority of immunosuppressive agents have resulted in variable outcomes. Advancements of plasmapheresis therapy can play a significant role in ophthalmological diseases. This treatment has shown to produce a satisfactory therapeutic response in immune-mediated neurological conditions. In this case report, we share our successful experience with the use of plasmapheresis therapy in a patient with recalcitrant IOI.

MR-based radiomics signature in differentiating ocular adnexal lymphoma from idiopathic orbital inflammation

OBJECTIVES

To assess the value of the MR-based radiomics signature in differentiating ocular adnexal lymphoma (OAL) and idiopathic orbital inflammation (IOI).

METHODS

One hundred fifty-seven patients with pathology-proven OAL (84 patients) and IOI (73 patients) were divided into primary and validation cohorts. Eight hundred six radiomics features were extracted from morphological MR images. The least absolute shrinkage and selection operator (LASSO) procedure and linear combination were used to select features and build radiomics signature for discriminating OAL from IOI. Discriminating performance was assessed by the area under the receiver-operating characteristic curve (AUC). The predictive results were compared with the assessment of radiologists by chi-square test.

RESULTS

Five radiomics features were included in the radiomics signature, which differentiated OAL from IOI with an AUC of 0.74 and 0.73 in the primary and validation cohorts respectively. There was a significant difference between the classification results of the radiomics signature and those of a radiology resident (p < 0.05), although there was no significant difference between the results of the radiomics signature and those of a more experienced radiologist (p > 0.05).

CONCLUSIONS

Radiomics features have the potential to differentiate OAL from IOI.

KEY POINTS

• Clinical and imaging findings of OAL and IOI often overlap, which makes diagnosis difficult. • Radiomics features can potentially differentiate OAL from IOI non invasively. • The radiomics signature discriminates OAL from IOI at the same level as an experienced radiologist.

When an Orbital Infection Isn't Infectious at All: A Review of Orbital Inflammatory Syndrome

Orbital inflammatory syndrome (OIS) includes a wide range of clinical manifestations and may initially be misdiagnosed as orbital cellulitis due similar symptoms of fever, periorbital swelling, and pain with eye movements. A diagnosis of OIS requires evaluation for underlying systemic disorders including autoimmune disorders and thyroid disease. Symptoms typically improve rapidly after initiation of steroid therapy, although recurrence can occur. This article presents an illustrative case of a 13-year-old girl with OIS. [Pediatr Ann. 2017;46(11):e433-e436.].

Idiopathic sclerosing orbital inflammation mimicking a malignant spindle cell tumor in a dog

A dog presented with a retrobulbar mass, diagnosed histopathologically as malignant spindle cell neoplasia. Emergence of analogous findings in the contralateral orbit prompted extended immunohistochemistry of the original mass and reassignment to idiopathic sclerosing orbital inflammation. Early incisional biopsy with extended immunohistochemical analysis should be considered for canine orbital tumors.

Medical and Surgical Treatment in Pediatric Orbital Myositis Associated with Coxsackie Virus

Purpose. To report a case of orbital myositis associated with Coxsackie virus and its medical and surgical approach. Methods. Complete ophthalmological examination and imaging and analytical investigation were performed. Results. A 6-year-old male presented with subacute painless binocular horizontal diplopia. Examination revealed bilateral best-corrected visual acuity (BCVA) of 20/20 and right eye 45-prism-dioptre (PD) esotropia in near and distance fixations, with no motility restrictions. Serologic screening was positive for Coxsackie virus acute infection and computerized tomography (CT) suggested right eye medial rectus orbital myositis. An oral corticosteroid 1.0 mg/kg/day regimen was started. A new CT after two months showed symmetrical lesions in both medial rectus muscles. Corticosteroids were increased to 1.5 mg/kg/day. After imagiological resolution on the 4th month, alternating 45 PD esotropia persisted. Bilateral 7 mm medial rectus recession was performed after 1 year without spontaneous recovery. At 1-year follow-up, the patient is orthophoric with 200′′ stereopsis and bilateral 20/20 BCVA. Conclusions. To our knowledge, this is the first reported case of orbital myositis associated with Coxsackie virus. This is also the first reported case of isolated strabismus surgery after orbital myositis in pediatric age, highlighting the favourable aesthetic and functional outcomes even in cases of late ocular motility disorders.

Orbital pseudotumor can be a localized form of granulomatosis with polyangiitis as revealed by gene expression profiling

Biopsies and ANCA testing for limited forms of granulomatosis with polyangiitis (GPA) are frequently non-diagnostic. We characterized gene expression in GPA and other causes of orbital inflammation. We tested the hypothesis that a sub-set of patients with non-specific orbital inflammation (NSOI, also known as pseudotumor) mimics a limited form of GPA. Formalin-fixed, paraffin-embedded orbital biopsies were obtained from controls (n=20) and patients with GPA (n=6), NSOI (n=25), sarcoidosis (n=7), or thyroid eye disease (TED) (n=20) and were divided into discovery and validation sets. Transcripts in the tissues were quantified using Affymetrix U133 Plus 2.0 microarrays. Distinct gene expression profiles for controls and subjects with GPA, TED, or sarcoidosis were evident by principal coordinate analyses. Compared with healthy controls, 285 probe sets had elevated signals in subjects with GPA and 1472 were decreased (>1.5-fold difference, false discovery rate adjusted p<0.05). The immunoglobulin family of genes had the most dramatic increase in expression. Although gene expression in GPA could be readily distinguished from gene expression in TED, sarcoidosis, or controls, a comparison of gene expression in GPA versus NSOI found no statistically significant differences. Thus, forms of orbital inflammation can be distinguished based on gene expression. NSOI/pseudotumor is heterogeneous but often may be an unrecognized, localized form of GPA.

[Orbital inflammation]

Orbital inflammation is a generic term encompassing inflammatory pathologies affecting all structures within the orbit : anterior (involvement up to the posterior aspect of the globe), diffuse (involvement of intra- and/or extraconal fat), apical (involvement of the posterior orbit), myositis (involvement of only the extraocular muscles), dacryoadenitis (involvement of the lacrimal gland). We distinguish between specific inflammation and non-specific inflammation, commonly referred to as idiopathic inflammation. Specific orbital inflammation corresponds to a secondary localization of a "generalized" disease (systemic or auto-immune). Idiopathic orbital inflammation corresponds to uniquely orbital inflammation without generalized disease, and thus an unknown etiology. At the top of the differential diagnosis for specific or idiopathic orbital inflammation are malignant tumors, represented most commonly in the adult by lympho-proliferative syndromes and metastases. Treatment of specific orbital inflammation begins with treatment of the underlying disease. For idiopathic orbital inflammation, treatment (most often corticosteroids) is indicated above all in cases of visual loss due to optic neuropathy, in the presence of pain or oculomotor palsy.

Increased CD40+ Fibrocytes in Patients With Idiopathic Orbital Inflammation

OBJECTIVE

To investigate the phenotypic and functional characteristics of peripheral and tissue-infiltrating stem cells called fibrocytes in patients with idiopathic orbital inflammation (IOI).

METHODS

Seven patients with IOI were studied. In the 3 patients requiring orbital biopsy, fibrocytes were identified in orbital tissue from patients with IOI compared with healthy controls using immunohistochemistry. Fibrocytes from the peripheral blood of all 7 patients and controls were quantified and phenotyped by flow cytometry and immunofluorescence for expression of CD34, alpha smooth muscle actin, CD40, and collagen 1. Quantitation of CD40-mediated interleukin-6 (IL-6) production was measured using enzyme-linked immunosorbent assay.

RESULTS

Orbital biopsy specimens from patients with IOI demonstrate tissue infiltration by fibrocytes (n = 3). Fibrocytes are present in the peripheral blood of IOI patients (n = 7) but are scarce in healthy donors (n = 19). Fibrocytes from IOI patients express substantial levels of CD40, and ligation of CD40 increases IL-6 expression.

CONCLUSIONS

Fibrocytes are present in the peripheral blood and orbital tissues of patients with IOI and constitutively express CD40 and express IL-6 in response to ligation. This site-specific predilection of CD34(+) fibrocytes to sites of orbital inflammation and fibrosis may suggest a role in IOI. Moreover, CD40-mediated activation cytokine production may contribute to the proinflammatory and profibrotic features of IOI and may provide a mechanism for future targeted therapy.

Rituximab therapy for refractory orbital inflammation: results of a phase 1/2, dose-ranging, randomized clinical trial

IMPORTANCE

Orbital inflammation is a potentially blinding and disfiguring disease process that is often treated with systemic corticosteroids and immunosuppression; better treatments are needed.

OBJECTIVE

To determine whether rituximab, a monoclonal antibody against the B-lymphocyte antigen CD20, is effective in the treatment of refractory orbital inflammation.

DESIGN, SETTING, AND PARTICIPANTS

A dose-ranging, randomized, double-masked phase 1/2 clinical trial was conducted at a tertiary referral ophthalmology clinic. Ten individuals with orbital inflammation refractory to systemic corticosteroids and at least 1 other immunosuppressive agent were enrolled from January 2007 to March 2010.

INTERVENTIONS

Rituximab infusions were administered on study days 1 and 15 at doses of either 500 mg or 1000 mg. Initial responders with recurrent inflammation after week 24 were permitted reinfusion with an additional cycle of 2 open-label 1000-mg rituximab infusions.

MAIN OUTCOMES AND MEASURES

The primary outcomes were reduction of inflammation measured with a validated orbital disease grading scale and corticosteroid dose reduction by at least 50%. The secondary outcomes were visual acuity, reduction in pain, and participant- and physician-reported global health assessment.

RESULTS

Of 10 enrolled patients, 7 demonstrated improvement on the orbital disease grading scale at the 24-week end point with rituximab therapy. Of these 7 individuals, 4 were receiving corticosteroids at study inception and all achieved successful dose reduction. For the secondary outcome measures in the 10 participants, 7 patients and 8 patients improved in self-rated and physician global health scores, respectively, and 7 patients had reduction in pain by 25% or more at 24 weeks. Four patients who were positive responders at the week 24 end point experienced breakthrough inflammation after week 24 and received reinfusions between 24 and 48 weeks. Vision remained stable in all participants. Three of 10 patients had short-term objective or subjective worsening 2 to 8 weeks after receiving rituximab infusions, which was averted in subsequent patients with oral corticosteroids administered during the infusion and did not affect the eventual positive treatment outcome. No significant differences with regard to efficacy, toxicity, or likelihood of retreatment were noted between the dosing arms.

CONCLUSIONS AND RELEVANCE

Rituximab was safe and effective in 7 of 10 patients with noninfectious orbital disease, although 4 required reinfusion with rituximab to maintain control of orbital inflammation. Substantial toxicity was not noted. Rituximab should be considered in the treatment of refractory orbital inflammation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00415506.

[Clinical features and management of acute myositis in idiopathic orbital inflammation]

Acute myositis is the second most common component of non-specific orbital inflammation. We will describe its clinical features and natural history. This is a retrospective study of 10 cases. The diagnosis of acute myositis was based on clinical and imaging criteria. Our study includes five men and five women. The average age was 35.8 years (17-59 years). Clinical symptoms were: pain increased on eye movement (10/10), diplopia (4/10), proptosis (6/10), visual loss (3/10), lid edema (6/10), conjunctival hyperemia (7/10), anterior scleritis (2/10), episcleritis (2/10), chemosis (4/10), upper lid retraction (1/10), limitation of eye movement (3/10), fundus abnormalities (2/10). Imaging showed thickening of one or more extraocular muscles (10/10). Recovery was complete with anti-inflammatory therapy in six patients. Three patients experienced recurrence, and one patient had a clinical rebound upon tapering the treatment. Acute myositis can be defined by pain on eye movement, signs of inflammation, and extraocular muscle thickening on imaging. If the clinical presentation is typical, histopathological analysis can be deferred but remains necessary in cases of poor response to treatment, chronic duration or suspicion of tumor infiltration. The diagnosis of acute myositis may be suspected in the presence of consistent, well-defined clinical signs. Contiguous inflammation is often associated. Treatment is based on steroids or non-steroidal treatment anti-inflammatory therapy, administered alone or consecutively. Recurrences are frequent but do not alter the final prognosis.

Unilateral superior ophthalmic vein thrombosis in a neonate

A 10-month-old boy was referred for drooping and intermittent swelling in his right upper eyelid. Careful evaluation of his MRI findings along with the clinical presentation established the diagnosis of superior ophthalmic vein (SOV) thrombosis. History, old photographs, and imaging studies showed that the symptoms and signs were already present possibly since birth; however, further workup failed to reveal an underlying hematologic disorder or a congenital causative pathology. The patient was put on low-dose aspirin while waiting for the coagulation panel and genetic testing, which was stopped after 1 month of use with respect to normal test results. The symptoms except for ptosis resolved and did not recur during 6 months of follow up. To the authors' knowledge, this is the first reported case of unilateral isolated SOV thrombosis in the neonatal period.

Role of antimetabolites in recalcitrant idiopathic orbital inflammatory syndrome

Background:

High-dose systemic steroids are the primary modality of treatment for idiopathic orbital inflammatory syndrome (IOIS). Occasionally patients experience a relapse of symptoms on tapering steroids or require large doses of steroid, predisposing them to the adverse effects of steroids.

Aim:

We present our experience with the management of three patients with recalcitrant IOIS, with immunosuppressive therapy, using antimetabolites.

Materials and Methods:

A retrospective review of the medical records of the patients being reported. Results: Two patients were treated with Methotrexate and one with Azathioprine for a duration of 6-24 months. Two patients were symptom-free three years after stopping the medication. One was doing well clinically with methotrexate therapy alone, when he was lost to follow-up after six months. No adverse effects of immunosuppressive therapy were encountered.

Conclusion:

High-dose systemic steroid therapy is the first-line treatment for IOIS, but in refractory or steroid-dependent cases, immunosuppressive therapy with antimetabolites is a safe and effective treatment alternative to steroids. However, treatment with antimetabolites warrants close monitoring for complications like bone marrow suppression and liver dysfunction, especially because long-term treatment is required.

Recurrent bilateral orbital myositis: case report and review of the literature

Orbital myositis in children is uncommon. Recurrence is a major challenge in management. An 11-year-old Malay girl who presented with bilateral orbital myositis with recurrent attacks of diplopia is reported.

Inflammatory disorders of the orbit in childhood: a case series

PURPOSE

To describe a series of cases of orbital inflammatory disorders in children.

DESIGN

Retrospective case series.

METHODS

The medical records of pediatric patients diagnosed with orbital inflammation between September 1, 2002, and December 31, 2008, at Texas Children's Hospital were reviewed. Data collected included age at presentation, final diagnosis, treatment, workup and evaluation, need for biopsy and biopsy results, and involvement of lacrimal gland and muscles.

RESULTS

Twelve cases were identified. Six cases were males and 6 were females with age at presentation ranging from 1.3 to 16.2 years (mean, 11.9 years). The most common presentation was lacrimal gland enlargement, which was bilateral in 3 cases. Other common presenting signs were proptosis, extraocular motility limitation, and pain on eye movement. Half of our patients had systemic complaints at presentation, the most common of which was fever. Four patients were diagnosed as having a systemic cause and 2 of these patients had systemic symptoms.

CONCLUSIONS

Idiopathic orbital inflammatory conditions in children are uncommon, but can be associated with systemic conditions. Patients typically have lacrimal gland involvement, pain with eye movement, proptosis, and motility deficits at presentation. Bilateral cases may have a higher incidence of systemic disease.

Idiopathic orbital inflammatory syndrome without pain: a case report

BACKGROUND

Idiopathic orbital inflammatory syndrome (IOIS) is a collection of primary orbital inflammatory expressions manifested in a variety of clinical presentations. Because the process is idiopathic, it lacks association with neoplastic, infectious, or systemic immunologic and inflammatory diseases. Therefore, an extensive analysis is required to exclude secondary etiologies of orbital inflammation.

CASE REPORT

Exhibited is a case of a 68-year-old white man presenting with a recent history of viral conjunctivitis and acute complaints of monocular vision loss, epiphora, photophobia, and generalized irritation without pain. On examination, he was found to have chemosis, a serous retinal detachment, and choroidal detachments. Magnetic resonance imaging found evidence of dacryoadenitis, posterior scleritis, and mild diffuse orbital inflammation. Extensive history and physical examination found no evidence of systemic inflammatory disease. IOIS was diagnosed and treated successfully with prednisone, without recurrence.

CONCLUSIONS

Pain is historically considered a cardinal sign of acute inflammation and a predominant symptom of IOIS. The authors present a case of acute IOIS, atypical because of its presentation in the absence of pain. In addition, a review of the literature is conducted to identify predominant clinical and radiologic characteristics of IOIS along with current accepted and proposed treatment options. Differentials are discussed to distinguish this disease from systemic immunologic and inflammatory conditions such as syphilis, sarcoidosis, and Wegener's granulomatosis as well as potentially fatal neoplastic conditions.

Adenocarcinoma metastasis causing discrete extraocular muscle enlargement

BACKGROUND

Discrete extraocular muscle (EOM) metastasis is rarely reported. Clinical signs and symptoms of EOM metastasis can often be indistinguishable from primary idiopathic orbital myositis, posing a significant clinical challenge.

CASE REPORT

A case of a 61-year-old man with acute-onset unilateral periorbital pain and diplopia is presented. Magnetic resonance imaging showed an isolated edematous superior rectus/levator muscle complex with an isointense T2-weighted signal, supporting a diagnosis of orbital myositis. He was started on corticosteroids, with resolution of pain and improved motilities. Subsequently, his condition worsened. Repeat imaging results suggested the possibility of neoplastic infiltration of the muscle because of the newly demonstrated hyperintensity of the T2-weighted signal and perineural extension along the trigeminal nerve. Fine-needle aspiration biopsy showed adenocarcinoma cytology in the muscle.

CONCLUSIONS

This case illustrates discrete adenocarcinoma metastasis of an EOM, initially displaying characteristics predominantly consistent with orbital myositis. There is a paucity of epidemiologic data on EOM cancer, and clinical characteristics are derived only from a selection of case reports in the literature. Thus, the predominant features of global orbital metastatic cancer versus primary inflammation are highlighted in this presentation. This case shows that the variable characteristics of each process prohibit identification of any clinical feature that would prove pathognomonic for either disorder. The varied practice philosophies and standard of care regarding the proper time to biopsy are reviewed. This case shows the importance of early referral for orbital biopsy, even in the presentation of isolated, discretely edematous, and painful EOM enlargement.

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.

Orbital inflammatory disease and pseudotumor in dogs and cats

Orbital disease is common in dogs and cats. Clinical signs include exophthalmos, protrusion of the third eyelid, and resistance to retropulsion of the globe. This article discusses diagnostic work-up for dogs and cats with signs suggestive of orbital disease. Diagnosis and treatment of nonneoplastic orbital diseases follows. Congenital diseases are discussed first, followed by inflammatory diseases of the orbit including orbital pseudotumor. Lastly, other less common orbital conditions are addressed.

W(h)ither Orbital Pseudotumor?

Orbital pseudotumor is a nonspecific, idiopathic benign inflammatory process characterized by a polymorphous lymphoid infiltrate with varying degrees of fibrosis. We retrospectively reviewed the clinical presentation, management, and progress of six consecutive patients referred to our service with an initial diagnosis of orbital pseudotumor to underscore the challenge and pitfalls in managing this group of patients. Three male and three female patients, aged 27 to 74 years, presented with a variety of ophthalmologic problems, including orbital swelling, chemosis, proptosis, blepharoptosis, restricted eye motion, diplopia, and visual loss. The initial diagnosis of orbital pseudotumor was based on clinical findings, results of routine laboratory screening tests, computed tomographic and/or magnetic resonance imaging scans, and the response to corticosteroid treatment in three patients. In these three patients, the final diagnosis of orbital pseudotumor was confidently made only in one patient who remained in remission after corticosteroid therapy. The remaining two patients had Miller-Fisher syndrome and thyroid ophthalmopathy. Three other patients initially diagnosed with orbital pseudotumor underwent biopsy through an orbitotomy with comprehensive histopathologic evaluation. Two of these patients were subsequently diagnosed with non-Hodgkin lymphoma. Orbital pseudotumor belongs to a spectrum of lymphocytic infiltrative orbital conditions. It is a diagnosis of exclusion. The initial diagnosis must be regarded as provisional, and failure of complete resolution with corticosteroid therapy should heighten the index of suspicion and a biopsy should be considered. However, diagnosis may be difficult even with comprehensive histopathologic studies.

Receptor expression in orbital inflammatory syndromes and implications for targeted therapy

To investigate the expression of multiple therapeutic targets in tissue specimens from patients with orbital inflammatory syndromes, the clinical records of 16 patients treated for orbital inflammation between January 2003 and November 2005 for whom tissue blocks were available were reviewed retrospectively. Immunohistochemical staining was performed on archived specimens using commercially available monoclonal antibodies against CD3, CD20, CD22, CD23, CD25, and CD52 antigens. The histologic diagnoses were confirmed, and the immunohistochemical staining patterns were agreed upon by both collaborating pathologists (JLJ and PC-B). The study included 13 women and 3 men who ranged in age from 4 to 79 years (mean, 46 years). The histologic diagnoses were as follows: orbital pseudotumor in six patients; sarcoidosis, three; eosinophilic granuloma, one; necrobiotic xanthogranuloma, one; nonspecified granulomatous inflammation, one; Graves' ophthalmopathy, one; Wegener's granulomatosis, one; and reactive lymphoid hyperplasia, two. One orbital lymphoma specimen and one foreign body reaction specimen were used as controls. CD20 was strongly expressed in all specimens except three (Wegener's granulomatosis, eosinophilic granuloma, and nonspecified granulomatous inflammation specimens), and CD25 was strongly expressed in all specimens except the Wegener's granulomatosis specimen, in which this antigen was only moderately expressed. CD20 and CD25 were strongly or moderately expressed in most of the tested specimens of orbital inflammation. If our findings are confirmed in a larger study, rituximab, which targets CD20, and denileukin diftitox (ONTAK), which targets CD25, should be considered for future clinical trials for orbital inflammatory syndromes.

Postoperative myositis in reoperated extraocular muscles

PURPOSE

To report on a series of patients who developed orbital myositis following routine strabismus surgery.

METHODS

A retrospective medical record review of patients who developed myositis following routine strabismus surgery. Surgery was performed on all patients between 1998 and 2003 by a single pediatric ophthalmologist (SMA).

RESULTS

Four patients developed orbital myositis following routine strabismus surgery. All four cases were reoperations. Symptoms of myositis developed at a mean of 21 days after surgery (range, 4-34). In the initial patient, the diagnosis of myositis was based on clinical and computed tomography findings. The clinical course of the three subsequent patients was similar to that of the radiologically confirmed case. In all cases, the diagnosis was supported by rapid resolution after treatment with systemic corticosteroids.

CONCLUSIONS

Orbital myositis is a previously unreported complication of strabismus surgery. Reoperation appears to be a predisposing factor.

Orbital inflammatory disease: a diagnostic and therapeutic challenge

The spectrum of orbital inflammatory disease (OID) ranges broadly from specific disease diagnoses, for example, Wegener's granulomatosis or sarcoidosis, to nonspecific inflammation which may involve one or multiple structures of the orbit. Mimics of idiopathic OID must be considered in a comprehensive differential diagnosis and include malignancies, congenital mass lesions, infectious diseases, and occult or distant trauma. Idiopathic OID may be secondary to an underlying systemic inflammatory disease, which must be diagnosed in order to develop a comprehensive therapeutic plan, or may represent localized pathologic processes without systemic involvement. Evaluation of the patient with suspected OID must include a careful history, physical examination, directed laboratory, and radiologic studies, and may sometimes require tissue for diagnostic studies. Therapeutic options for inflammatory diseases are expanding as biologically targeted agents become available that act on specific segments of the inflammatory cascades. The purpose of this paper is to provide a framework for the evaluation and management of patients with the spectrum of diseases known as OID and to discuss some of the new advances in immunologic monitoring and targeted immune therapies that will likely play an increasingly important role in the care of these patients.

Successful treatment of idiopathic orbital inflammation with mycophenolate mofetil

PURPOSE

To report our experience with the use of mycophenolate mofetil for treatment of idiopathic orbital inflammation (IOI).

DESIGN

Noncomparative interventional case series.

METHODS

We reviewed the records of five patients with IOI who were treated with mycophenolate mofetil. The indications for use included recurrent inflammation after other therapies (four patients) and to avoid corticosteroid-induced blood sugar elevation in poorly controlled diabetes mellitus (one patient). Treated patients were followed for a median of 8.5 months (range, 4-30 months) after mycophenolate mofetil therapy was begun. Main outcome measures were response to treatment, treatment-related side effects, drug dosage, previous and final treatment regimens, and discontinuation of systemic corticosteroids.

RESULTS

Mycophenolate mofetil therapy was discontinued in one patient because of nausea. Each of the remaining four patients experienced complete resolution of orbital inflammation. Of these, only one patient remains on prednisone, but at a significantly reduced dose (1 mg/d).

CONCLUSION

Mycophenolate mofetil therapy resulted in the resolution of inflammation in patients with refractory or corticosteroid-dependent IOI and was used successfully for a first episode of IOI in a patient for whom corticosteroids were contraindicated.