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Nistal D, Lee A, Ruzevick J. Pediatric Orbital and Skull Base Pathology. Oral Maxillofac Surg Clin North Am 2024; 36:333-342. [PMID: 38522979 DOI: 10.1016/j.coms.2024.02.003] [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] [Indexed: 03/26/2024]
Abstract
Pediatric orbital and skull base pathologies encompass a spectrum of inflammatory, sporadic, syndromic, and neoplastic processes that require a broad and complex clinical approach for both medical and surgical treatment. Given their complexity and often multicompartment involvement, a multidisciplinary approach for diagnosis, patient and family counseling, and ultimately treatment provides the best patient satisfaction and clinical outcomes. Advances in minimally invasive surgical approaches, including endoscopic endonasal and transorbital approaches allows for more targeted surgical approaches through smaller corridors beyond more classic transcranial or transracial approaches.
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Affiliation(s)
- Dominic Nistal
- Department of Neurological Surgery, University of Washington, 1959 Northeast Pacific Street, Box 356470, Seattle, WA 98195, USA
| | - Amy Lee
- Department of Neurological Surgery, University of Washington, 1959 Northeast Pacific Street, Box 356470, Seattle, WA 98195, USA; Seattle Children's Hospital, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Jacob Ruzevick
- Department of Neurological Surgery, University of Washington, 1959 Northeast Pacific Street, Box 356470, Seattle, WA 98195, USA; Seattle Children's Hospital, 4800 Sandpoint Way NE, Seattle, WA 98105, USA.
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Wu KY, Kulbay M, Daigle P, Nguyen BH, Tran SD. Nonspecific Orbital Inflammation (NSOI): Unraveling the Molecular Pathogenesis, Diagnostic Modalities, and Therapeutic Interventions. Int J Mol Sci 2024; 25:1553. [PMID: 38338832 PMCID: PMC10855920 DOI: 10.3390/ijms25031553] [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: 12/31/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Nonspecific orbital inflammation (NSOI), colloquially known as orbital pseudotumor, sometimes presents a diagnostic and therapeutic challenge in ophthalmology. This review aims to dissect NSOI through a molecular lens, offering a comprehensive overview of its pathogenesis, clinical presentation, diagnostic methods, and management strategies. The article delves into the underpinnings of NSOI, examining immunological and environmental factors alongside intricate molecular mechanisms involving signaling pathways, cytokines, and mediators. Special emphasis is placed on emerging molecular discoveries and approaches, highlighting the significance of understanding molecular mechanisms in NSOI for the development of novel diagnostic and therapeutic tools. Various diagnostic modalities are scrutinized for their utility and limitations. Therapeutic interventions encompass medical treatments with corticosteroids and immunomodulatory agents, all discussed in light of current molecular understanding. More importantly, this review offers a novel molecular perspective on NSOI, dissecting its pathogenesis and management with an emphasis on the latest molecular discoveries. It introduces an integrated approach combining advanced molecular diagnostics with current clinical assessments and explores emerging targeted therapies. By synthesizing these facets, the review aims to inform clinicians and researchers alike, paving the way for molecularly informed, precision-based strategies for managing NSOI.
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Affiliation(s)
- Kevin Y. Wu
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.)
| | - Merve Kulbay
- Department of Ophthalmology & Visual Sciences, McGill University, Montreal, QC H4A 0A4, Canada
| | - Patrick Daigle
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.)
| | - Bich H. Nguyen
- CHU Sainte Justine Hospital, Montreal, QC H3T 1C5, Canada
| | - Simon D. Tran
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada
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Demirci H, Ciftci S, Teo HMT, Demirci FY, Shinder R, Elner VM. Intralesional or intraorbital rituximab injection for the management of biopsy-proven idiopathic orbital inflammation involving the lacrimal gland. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023:S0008-4182(23)00339-3. [PMID: 37995759 DOI: 10.1016/j.jcjo.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/26/2023] [Accepted: 10/28/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE To evaluate the efficacy of intralesional rituximab injection for the management of idiopathic orbital inflammation (IOI) involving the lacrimal gland, which is the most common subtype. METHOD Eighteen consecutive patients with biopsy-proven IOI involving the lacrimal gland were included. Rituximab (50 mg/5 mL) was injected intralesionally at monthly intervals. RESULTS Clinically, all patients presented with upper eyelid swelling and ptosis. Most patients (56%) had periocular pain and a palpable superotemporal mass. Biopsies showed chronic inflammation without fibrosis in 14 patients (78%) and chronic inflammation and fibrosis in 4 patients (22%). Intralesional rituximab was injected once in 1 patient (6%) because of complete response after the first injection, twice in 11 patients (61%), and 3 times in 6 patients (33%) because of partial response after 2 injections. After a mean follow-up of 33 months (median, 33 months; range, 11-59 months), 16 patients (89%) showed a clinical response, including 14 patients (78%) a complete response (i.e., disappearance of all lesions) and 2 patients (11%) with a partial response (i.e., ≤30% decrease in lesion diameter). Two patients (11%) did not respond after 3 injections and were placed on systemic corticosteroid and methotrexate therapies. Two patients (11%) with a complete response developed subsequent recurrence 12 and 49 months after their last injections. Both were treated with 2 additional rituximab injections, 1 month apart, and showed complete response when examined 27 and 11 months after treatment, respectively. CONCLUSION Intralesional rituximab injection may be an effective treatment for IOI involving the lacrimal gland, achieving a 78% complete response rate in this series. Local treatment with rituximab has the potential to avoid the ocular and systemic side effects of corticosteroid and systemic immunosuppressive treatment.
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Affiliation(s)
- Hakan Demirci
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI.
| | - Suleyman Ciftci
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI
| | - Honeylen M Tiu Teo
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI
| | - F Yesim Demirci
- School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Roman Shinder
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY
| | - Victor M Elner
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI
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Fang Y, Shen B, Dai Q, Xie Q, Wu W, Wang M. Orbital inflammatory pseudotumor: new advances in diagnosis, pathogenesis, and treatment. Eur J Med Res 2023; 28:395. [PMID: 37794419 PMCID: PMC10548690 DOI: 10.1186/s40001-023-01330-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 08/29/2023] [Indexed: 10/06/2023] Open
Abstract
Orbital inflammatory pseudotumor (OIP) is a benign, non-specific inflammatory disorder that commonly occurs in middle-aged adults and is usually unilateral but can occur bilaterally. Its clinical manifestations have tremendous clinical heterogeneity and vary according to the site of infiltration and the degree of lesions, including orbital pain, swelling, diplopia, proptosis, restricted eye movement, and decreased visual acuity. Clinical features, Image characteristics and pathological examinations often need to be evaluated to confirm the diagnosis. Currently, there is no systematic research on the pathogenesis of OIP, which may be related to immunity or infection. The first-line treatment is glucocorticoids. Radiotherapy, immunosuppressants, and biologics can be considered for treatment-resistant, hormone-dependent, or intolerant patients. In this review, we aim to summarize and focus on new insights into OIP, including new diagnostic criteria, pathogenesis, and discoveries in new drugs and treatment strategies. In particular, we highlight the literature and find that T cell-mediated immune responses are closely related to the pathogenesis of OIP. Further exploration of the mechanism and signaling pathway of T cells in the immune process will help to identify their therapeutic targets and carry out targeted therapy to treat refractory OIP and reduce the side effects of traditional treatments.
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Affiliation(s)
- Yenan Fang
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Bingyan Shen
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Qin Dai
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Qiqi Xie
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Wencan Wu
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China.
- State Key Laboratory of Ophthalmology, Optometry and Vision Science, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China.
| | - Min Wang
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China.
- State Key Laboratory of Ophthalmology, Optometry and Vision Science, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China.
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Identification of Hub Genes Associated with Nonspecific Orbital Inflammation by Weighted Gene Coexpression Network Analysis. DISEASE MARKERS 2022; 2022:7588084. [PMID: 35669499 PMCID: PMC9166965 DOI: 10.1155/2022/7588084] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/03/2022] [Indexed: 11/17/2022]
Abstract
Background Nonspecific orbital inflammation is a common ophthalmopathy with a high prevalence among adult females. Yet, its molecular mechanisms behind are poorly understood. Regulation of gene expression probably plays an important role in this disease. Thus, we utilized gene coexpression networks to identify key modules and hub genes involved in nonspecific orbital inflammation. Methods Data of gene expression in nonspecific orbital inflammation samples (n = 61) and healthy samples (n = 28) were obtained from the public Gene Expression Omnibus database. Afterward, differentially expressed genes were performed. Then, weighted correlation network analysis was done to define the key modules. Next, functional enrichment analysis was conducted by Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway in key modules. Finally, a protein-protein interaction network and Cytohubba plugin were used to screen hub genes. Results Differential expression of 716 genes was identified, among which 169 genes were upregulated and 547 genes were downregulated in the nonspecific orbital inflammation group. In weighted correlation network analysis, we clarified 2 key modules (MEturquoise and MEblue) that are likely to play key roles in nonspecific orbital inflammation. Functional enrichment analysis indicated that these genes are predominately involved in immune response and matrix homeostasis. In addition, among 2 key modules, there are 20 hub genes identified. Conclusion With this new approach, we identified several genes that could be critical to pathologies of nonspecific orbital inflammation. These findings may contribute to further therapeutic target development.
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Otsuka M, Yunoki T, Ozaki H, Hayashi A. Clinical Characteristics of Idiopathic Orbital Inflammation Syndrome in Relation to Intraocular Pressure. Clin Ophthalmol 2022; 16:1467-1473. [PMID: 35592671 PMCID: PMC9112790 DOI: 10.2147/opth.s361645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose To investigate the clinical characteristics of idiopathic orbital inflammation and changes in intraocular pressure (IOP) before and after its treatment. Patients and Methods We retrospectively studied 20 eyes from the medical records of 19 patients who were diagnosed with idiopathic orbital inflammation between April 1, 2004, and April 30, 2019, at Toyama University Hospital. The inflammation site (type of disease), treatment provided, IOP before and after treatment, and the symptoms (proptosis, decreased ocular movements or diplopia, periorbital edema, and ocular pain) were analyzed. Results The types of idiopathic orbital inflammation were dacryoadenitis in 14, myositis in 7, diffuse-type in 3, and posterior periscleritis in 1 case. The mean IOP after treatment was 15.4±3.9 mm Hg, which was significantly lower than the mean pretreatment IOP of 19.0±5.3 mm Hg (p = 0.009). Before treatment, all cases with the diffuse-type had high IOPs of 21 mm Hg or more. Ocular pain and eye movement disorders were present in 86% and 100% of subjects in the group with an IOP of 21 mm Hg or higher, but 38% and 31% in the group with an IOP of 20 mm Hg or lower, respectively. Conclusion Diffuse-type of idiopathic orbital inflammation is prone to develop high IOP. Patients with idiopathic orbital inflammation and high IOP exhibit many symptoms such as decreased ocular movements, diplopia, and ocular pain.
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Affiliation(s)
- Mitsuya Otsuka
- Department of Ophthalmology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Tatsuya Yunoki
- Department of Ophthalmology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Hironori Ozaki
- Department of Ophthalmology, Kurobe City Hospital, Toyama, Japan
| | - Atsushi Hayashi
- Department of Ophthalmology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
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Mimura M, Matsuura T, Takagi M, Taki K, Sato Y, Fujita Y, Oku H, Ikeda T. A randomized clinical trial of triamcinolone acetonide injection for suppression of inflammation after blepharoptosis surgery. J Plast Reconstr Aesthet Surg 2021; 75:1744-1749. [PMID: 34961699 DOI: 10.1016/j.bjps.2021.11.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 11/14/2021] [Indexed: 11/16/2022]
Abstract
This study aimed to determine the effectiveness of triamcinolone acetonide in suppressing inflammation after blepharoptosis surgery. The study was designed as prospective, randomized, two medical centers' clinical trial. Thirty-two patients with involutional blepharoptosis of the same degree in both eyelids underwent bilateral transcutaneous levator advancement. At the end of the surgery, 4 mg/0.1 ml of triamcinolone acetonide was injected into a randomly selected upper eyelid. The fellow eyelid was not injected and was used as control. Facial photographs were taken on day 1, week 1, month 1, and month 3, and the degree of inflammation, the margin reflex distance 1 (MRD-1), and levator function (LF) between the two eyelids of each patient were compared. The primary outcome was the selection of the less inflamed eyelid decided by the majority of three individuals unrelated to the study. MRD-1 and LF were analyzed for secondary outcomes. As a result, the injected eyelid was judged to be the less inflamed eyelid in all cases. The MRD-1 in the postoperative period less than 1 month was significantly larger in the injected eyelids than the control eyelids (P<0.03). The postsurgical MRD-1 at month 3, the postsurgical LF at all postsurgical examination times were not statistically different. Adverse complications by the injection, including ptosis, levator dysfunction, increase of the intraocular pressure, and visual disturbance were not observed. In conclusion, a triamcinolone acetonide injection after ptosis surgery is both safe and effective in reducing the early postsurgical inflammation and helpful in an earlier return to a daily routine for the patients.
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Affiliation(s)
- Masashi Mimura
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan; Department of Ophthalmology, Osaka Kaisei Hospital, Osaka, Japan.
| | | | - Mai Takagi
- Department of Ophthalmology, Osaka Kaisei Hospital, Osaka, Japan
| | - Koichiro Taki
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan
| | - Yohei Sato
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan
| | - Yasushi Fujita
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan
| | - Hidehiro Oku
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan
| | - Tsunehiko Ikeda
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan
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Lee MJ, Planck SR, Choi D, Harrington CA, Wilson DJ, Dailey RA, Ng JD, Steele EA, Hamilton BE, Khwarg SI, Rosenbaum JT. Non-specific orbital inflammation: Current understanding and unmet needs. Prog Retin Eye Res 2020; 81:100885. [PMID: 32717379 DOI: 10.1016/j.preteyeres.2020.100885] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/11/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
Non-specific orbital inflammation (NSOI) is a noninfectious inflammatory condition of the orbit. Although it is generally considered the most common diagnosis derived from an orbital biopsy, it is a diagnosis of exclusion, meaning that the diagnosis requires exclusion of a systemic process or another identifiable etiology of orbital inflammation. The clinical diagnosis of NSOI is ill-defined, but it is typically characterized by acute orbital signs and symptoms, including pain, proptosis, periorbital edema, chemosis, diplopia, and less commonly visual disturbance. NSOI poses a diagnostic and therapeutic challenge: The clinical presentations and histological findings are heterogeneous, and there are no specific diagnostic criteria or treatment guidelines. The etiology and pathogenesis of NSOI are poorly understood. Here we recapitulate our current clinical understanding of NSOI, with an emphasis on the most recent findings on clinical characteristics, imaging findings, and treatment outcomes. Furthermore, gene expression profiling of NSOI and its implications are presented and discussed.
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Affiliation(s)
- Min Joung Lee
- Department of Ophthalmology, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang, Gyeonggi-do, 14068, Republic of Korea; Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR, 97239, USA
| | - Stephen R Planck
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR, 97239, USA
| | - Dongseok Choi
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR, 97239, USA; OHSU-PSU School of Public Health, Oregon Health & Science University, 3181 SWSam Jackson Park Road, Portland, OR, 97239, USA; Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA; Graduate School of Dentistry, Kyung Hee University, Seoul, 02447, Republic of Korea
| | - Christina A Harrington
- Integrated Genomics Laboratory, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - David J Wilson
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR, 97239, USA
| | - Roger A Dailey
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR, 97239, USA
| | - John D Ng
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR, 97239, USA
| | - Eric A Steele
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR, 97239, USA
| | - Bronwyn E Hamilton
- Department of Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Sang In Khwarg
- Department of Ophthalmology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - James T Rosenbaum
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR, 97239, USA; Department of Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA; Devers Eye Institute, Legacy Health Systems, 1040 NW 22nd Avenue, Portland, OR, 97210, USA.
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Abstract
A 14-year-old female with juvenile idiopathic arthritis presented with left-sided recurrent painful periorbital swelling of 5 months duration. MRI revealed enlargement of the left lacrimal gland with extensive inflammatory change involving the orbital and periorbital soft tissues. Lacrimal gland biopsy showed evidence of chronic inflammation, and she had intralesional steroid injection at the time of biopsy. She remained asymptomatic at 6-month follow-up visit. Although juvenile idiopathic arthritis is usually related to intraocular inflammation, it may rarely be associated with dacryoadenitis.
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Yeşiltaş YS, Gündüz AK. Idiopathic Orbital Inflammation: Review of Literature and New Advances. Middle East Afr J Ophthalmol 2018; 25:71-80. [PMID: 30122852 PMCID: PMC6071347 DOI: 10.4103/meajo.meajo_44_18] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Idiopathic orbital inflammation (IOI) is a benign inflammatory condition usually confined to the orbit but extraorbital extension can also occur. IOI has been classified into categories including anterior, diffuse, posterior or apical, myositis, and dacryoadenitis. Other rare types of IOI include periscleritis, perineuritis, and focal mass. Diagnosis is based on careful history, clinical findings, computed tomography, and magnetic resonance imaging findings. An orbital biopsy is usually done for accessible orbital lesions such as dacryoadenitis. For other types such as myositis and apical IOI where surgery is difficult or dangerous, orbital biopsy is not initially considered. The mainstay of therapy consists of systemic corticosteroids, but other options including external beam radiotherapy, antimetabolites, alkylating agents, T-cell/calcineurin inhibitors, lymphocyte inhibitors, tumor necrosis factor-α inhibitors, and surgical debulking have also been used.
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Affiliation(s)
- Yağmur Seda Yeşiltaş
- Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ahmet Kaan Gündüz
- Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey
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