The differentiation of idiopathic inflammatory pseudotumor from lymphoid tumors of orbit: analysis of 319 cases

Orbital inflammatory pseudotumor: new advances in diagnosis, pathogenesis, and treatment

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.

Evaluation of Orbital Lymphoproliferative and Inflammatory Disorders by Gene Expression Analysis

Non-specific orbital inflammation (NSOI) and IgG4-related orbital disease (IgG4-ROD) are often challenging to differentiate. Furthermore, it is still uncertain how chronic inflammation, such as IgG4-ROD, can lead to mucosa-associated lymphoid tissue (MALT) lymphoma. Therefore, we aimed to evaluate the diagnostic value of gene expression analysis to differentiate orbital autoimmune diseases and elucidate genetic overlaps. First, we established a database of NSOI, relapsing NSOI, IgG4-ROD and MALT lymphoma patients of our orbital center (2000−2019). In a consensus process, three typical patients of the above mentioned three groups (mean age 56.4 ± 17 years) at similar locations were selected. Afterwards, RNA was isolated using the RNeasy FFPE kit (Qiagen) from archived paraffin-embedded tissues. The RNA of these 12 patients were then subjected to gene expression analysis (NanoString nCounter®), including a total of 1364 target genes. The most significantly upregulated and downregulated genes were used for a machine learning algorithm to distinguish entities. This was possible with a high probability (p < 0.0001). Interestingly, gene expression patterns showed a characteristic overlap of lymphoma with IgG4-ROD and NSOI. In contrast, IgG4-ROD shared only altered expression of one gene regarding NSOI. To validate our potential biomarker genes, we isolated the RNA of a further 48 patients (24 NSOI, 11 IgG4-ROD, 13 lymphoma patients). Then, gene expression pattern analysis of the 35 identified target genes was performed using a custom-designed CodeSet to assess the prediction accuracy of the multi-parameter scoring algorithms. They showed high accuracy and good performance (AUC ROC: IgG4-ROD 0.81, MALT 0.82, NSOI 0.67). To conclude, genetic expression analysis has the potential for faster and more secure differentiation between NSOI and IgG4-ROD. MALT-lymphoma and IgG4-ROD showed more genetic similarities, which points towards progression to lymphoma.

Role of Quantitative Spectral CT Analysis for Differentiation of Orbital Lymphoma and Other Orbital Lymphoproliferative Disease

PURPOSE

To investigate the value of quantitative parameters from spectral computed tomography for the differentiation of orbital lymphoma from other lymphoproliferative disease, including idiopathic orbital inflammatory disease (IOID) and IgG4-related disease (IgG4-RD).

METHODS

Patients with orbital masses who underwent pre-treatment contrast-enhanced spectral CT were enrolled in this retrospective study. The subjects were divided into lymphoma and other orbital lymphoproliferative disease groups. Qualitative imaging features (margin, location, enhancement pattern, cranial nerves, soft tissue, and bone involvement) were reviewed. Quantitative parameters (iodine density and spectral attenuation curve slope) derived from spectral CT were measured.

RESULTS

Eleven patients had orbital lymphoma and 11 had other orbital lymphoproliferative diseases (idiopathic orbital inflammatory disease (IOID), n = 5; IgG4-related disease (IgG4-RD), n = 6). Qualitative analysis showed no significant difference between the two groups. There was significantly higher iodine density in orbital lymphoma (1.24 ± 0.24 mg/ml) than in IOID/IgG4-RD (0.83 ± 0.23 mg/ml; P = 0.001). An iodine density threshold of 1.0 mg/ml gave sensitivity, specificity, and accuracy of 81.8%, with an area under the curve of 0.876 (P = 0.0003). Orbital lymphoma had a significantly higher iodine spectral attenuation curve slope (2.44 ± 0.51 HU/keV) than IOID/IgG4-RD (1.66 ± 0.47 HU/keV; P = 0.001). A threshold of 1.99 HU/keV for the spectral attenuation curve slope of 40-70 keV gave sensitivity, specificity, and accuracy of 81.8%, with an area under the curve of 0.884 (P = 0.0002).

CONCLUSIONS

Quantitative spectral CT parameters can help differentiate orbital lymphoma from other orbital lymphoproliferative disease, with lymphoma having a significantly higher iodine density value and spectral attenuation curve slope than IOID/IgG4-RD.

Non-specific orbital inflammation: Current understanding and unmet needs

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.

cDC2 and plasmacytoid dendritic cells diminish from tissues of patients with non-Hodgkin orbital lymphoma and idiopathic orbital inflammation

Non-Hodgkin orbital lymphoma (NHOL) and idiopathic orbital inflammation (IOI) are common orbital conditions with largely unknown pathophysiology. To investigate the immune cell composition of these diseases, we performed standardized 29 parameter flow cytometry phenotyping in peripheral blood mononuclear cells of 18 NHOL patients, 21 IOI patients, and 41 unaffected controls. Automatic gating by FlowSOM revealed decreased abundance of meta-clusters containing dendritic cells in patients, which we confirmed by manual gating. A decreased percentage of (HLA-DR⁺ CD303⁺ CD123⁺ ) plasmacytoid dendritic cells (pDC) in the circulation of IOI patients and decreased (HLA-DR⁺ CD11c⁺ CD1c⁺ ) conventional dendritic cells (cDC) type-2 for IOI patients were replicated in an independent cohort of patients and controls. Meta-analysis of both cohorts demonstrated that pDCs are also decreased in blood of NHOL patients and highlighted that the decrease in blood cDC type-2 was specific for IOI patients compared to NHOL or controls. Deconvolution-based estimation of immune cells in transcriptomic data of 48 orbital biopsies revealed a decrease in the abundance of pDC and cDC populations within the orbital microenvironment of IOI patients. Collectively, these data suggest a previously underappreciated role for dendritic cells in orbital disorders.

A pan-inflammatory microRNA-cluster is associated with orbital non-Hodgkin lymphoma and idiopathic orbital inflammation

Non-Hodgkin orbital lymphoma (NHOL) and idiopathic orbital inflammation (IOI) are common orbital conditions with largely unknown pathophysiology that can be difficult to diagnose. In this study we aim to identify serum miRNAs associated with NHOL and IOI. We performed OpenArray® miRNA profiling in 33 patients and controls. Differentially expressed miRNAs were technically validated across technology platforms and replicated in an additional cohort of 32 patients and controls. We identified and independently validated a serum miRNA profile of NHOL that was remarkably similar to IOI and characterized by an increased expression of a cluster of eight miRNAs. Pathway enrichment analysis indicated that the miRNA-cluster is associated with immune-mediated pathways, which we supported by demonstrating the elevated expression of this cluster in serum of patients with other inflammatory conditions. The cluster contained miR-148a, a key driver of B-cell tolerance, and miR-365 that correlated with serum IgG and IgM concentrations. In addition, miR-29a and miR-223 were associated with blood lymphocyte and neutrophil populations, respectively. NHOL and IOI are characterized by an abnormal serum miRNA-cluster associated with immune pathway activation and linked to B cell and neutrophil dysfunction.

Differentiation of orbital lymphoma and idiopathic orbital inflammatory pseudotumor: combined diagnostic value of conventional MRI and histogram analysis of ADC maps

Background

The overlap of morphological feature and mean ADC value restricted clinical application of MRI in the differential diagnosis of orbital lymphoma and idiopathic orbital inflammatory pseudotumor (IOIP). In this paper, we aimed to retrospectively evaluate the combined diagnostic value of conventional magnetic resonance imaging (MRI) and whole-tumor histogram analysis of apparent diffusion coefficient (ADC) maps in the differentiation of the two lesions.

Methods

In total, 18 patients with orbital lymphoma and 22 patients with IOIP were included, who underwent both conventional MRI and diffusion weighted imaging before treatment. Conventional MRI features and histogram parameters derived from ADC maps, including mean ADC (ADC_mean), median ADC (ADC_median), skewness, kurtosis, 10th, 25th, 75th and 90th percentiles of ADC (ADC₁₀, ADC₂₅, ADC₇₅, ADC₉₀) were evaluated and compared between orbital lymphoma and IOIP. Multivariate logistic regression analysis was used to identify the most valuable variables for discriminating. Differential model was built upon the selected variables and receiver operating characteristic (ROC) analysis was also performed to determine the differential ability of the model.

Results

Multivariate logistic regression showed ADC₁₀ (P = 0.023) and involvement of orbit preseptal space (P = 0.029) were the most promising indexes in the discrimination of orbital lymphoma and IOIP. The logistic model defined by ADC₁₀ and involvement of orbit preseptal space was built, which achieved an AUC of 0.939, with sensitivity of 77.30% and specificity of 94.40%.

Conclusions

Conventional MRI feature of involvement of orbit preseptal space and ADC histogram parameter of ADC₁₀ are valuable in differential diagnosis of orbital lymphoma and IOIP.

Characterization of diffuse orbital mass using Apparent diffusion coefficient in 3-tesla MRI

Purpose

To evaluate if the apparent diffusion coefficient (ADC) value in diffusion-weighted magnetic resonance imaging (DW-MRI) improves the diagnostic accuracy of diffuse orbital masses.

Materials and methods

ADC DW-MRI was used to evaluate cases of diffuse orbital masses at our institution from 2000 to 2015. Lesions were grouped according to histopathologic diagnosis as, benign, pre-malignant and malignant. Lymphoproliferative lesions were further subgrouped as lymphoma or other lymphoproliferative lesions. The validity of the ADC value for the diffuse orbital mass was compared between groups. The area under curve (AUC) was also calculated.

Results

Thirty-nine cases of diffuse orbital masses were evaluated. The median ADC was 0.58 (25% quartile 0.48; minimum: 0.45; maximum: 1.72 × 10⁽⁻³⁾) for the malignant tumors and 1.19 (25% quartile 0.7; minimum: 0.5; maximum: 1.95 × 10⁽⁻³⁾ mm⁽²⁾ s⁽⁻¹⁾) for benign lesions. This difference in ADC between lesions was statistically significant (Mann Whitney U test P < 0.001). The median ADC was 0.51 (25% quartile 0.48) for lymphomas and 0.9 (25% quartile 0.7) for other lymphoproliferative lesions. This difference in ADC was statistically significant (Mann Whitney U test P = 0.02). An ADC value of 0.8 × 10⁽⁻³⁾ mm⁽²⁾ s⁽⁻¹⁾ was noted as the ideal threshold value for differentiating malignant from benign diffuse orbital masses. The validity of ADC in predicting a malignant or benign diffuse orbital mass had a sensitivity of 87%, specificity of 67% and accuracy of 88%.

Conclusion

ADC is a promising imaging metric to characterize malignant and benign diffuse orbital masses and to distinguish lymphomas from other non−lymphoproliferative lesions.

Unilateral optic perineuritis due to nonspecific orbital inflammation: A case report

Nonspecific orbital inflammation is an idiopathic chronic tumor-like inflammation process that usually affects the orbital tissues of both eyes. Isolated optic nerve involvement by an idiopathic inflammatory process is a rare finding. Here, we report a patient with unilateral sudden onset severe orbital pain and headache with visual loss to no light perception that could only be attributed to perineuritis. Radiological findings enabled making the correct diagnosis. Various relevant diagnoses are also discussed.

Case report of subcutaneous panniculitis-like T-cell lymphoma complicated by eyelid swelling

BACKGROUND

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare, highly malignant, extranodal lymphoma that preferentially infiltrates into subcutaneous adipose tissue. No case of SPTCL with the earliest symptoms occurring in the eye region has been reported. We report a case of SPTCL complicated by eyelid swelling.

CASE PRESENTATION

A 19-year-old Japanese man presented with worsening left eyelid swelling. The patient's best-corrected visual acuity (BCVA) was 0.8, left intraocular pressure was 36 mm Hg, and he had prominent mucosal hyperemia and edema. His left eye had light reflex attenuation and a positive relative afferent pupillary defect, but no abnormality in the visual field or central flicker value. Magnetic resonance imaging showed left orbital adipose tissue inflammation. The blood examination was normal. He was hospitalized for an intensive examination and treatment for possible cellulitis, orbital panniculitis, and inflammatory pseudotumor. Systemic antibiotics were initiated. The following day, he underwent a sub-Tenon's injection of triamcinolone. Left eyelid swelling gradually improved. He was discharged on the ninth day and followed up with oral prednisolone. Two months later, he visited our department because of a high fever and slight right eyelid swelling. Ocular hypertension was detected. A blood examination revealed pancytopenia. Computed tomography showed fluid retention, hydrothorax, and abdominal dropsy. Magnetic resonance imaging revealed right orbital panniculitis. Because of suspected hemodyscrasia, he was referred to the hematology department of another hospital where he was diagnosed with SPTCL.

CONCLUSIONS

The possibility of SPTCL, with attention to recurrence and systemic symptoms, should be considered in young patients with sudden eyelid swelling.

Concomitant Idiopathic Orbital Inflammatory Pseudotumor and Thyroid-Associated Ophthalmopathy

PURPOSE

Coexistence of idiopathic orbital inflammatory pseudotumor (IOIP) and thyroid-associated ophthalmopathy (TAO) is extremely rare. The purpose of this article is to analyze the clinical features, image findings, and therapeutic outcomes of concomitant IOIP and TAO in China.

MATERIALS AND METHODS

Detailed clinical records of 3 Chinese patients with concomitant IOIP and TAO were reviewed, including their clinical history, symptoms and signs, ultrasonography, computed tomography (CT), and steroid therapy.

RESULTS

Among the 3 patients, were 2 men and 1 woman, aged 42, 49, and 48 years, respectively. The right orbit was involved in 1 patient and both orbits in 2 patients. In addition to showing the typical features of TAO, such as hyperthyroidism, upper eyelid retraction, and enlarged extraocular muscles with tendon sparing, all 3 patients showed ambiguous soft tissue masses in one or both orbits. Pathologic examination after biopsy of the mass in 1 patient confirmed the diagnosis of lymphatic IOIP. All the patients responded extremely well to steroid treatment.

CONCLUSIONS

Although rare, a simultaneous coexistence of IOIP and TAO can occur. Therefore, it is important for clinicians to be aware of the potential for concomitant IOIP and TAO.

Modern techniques of magnetic resonance in the evaluation of primary central nervous system lymphoma: contributions to the diagnosis and differential diagnosis

In addition to findings from conventional magnetic resonance imaging, modern magnetic resonance imaging techniques have provided important information about tumor metabolism, in vivo metabolite formation, water molecule diffusion, microvascular density, and blood-brain barrier permeability, all of which have improved the in vivo diagnostic accuracy of this method in the evaluation of primary central nervous system lymphoma. These nonconventional magnetic resonance techniques are useful in the clinical practice because they enhance conventional magnetic resonance imaging by reinforcing the possibility of a diagnosis and by allowing the early detection of disease recurrence.

This report is a review of the most relevant contributions of nonconventional magnetic resonance techniques to the imaging diagnosis of primary central nervous system lymphoma, the differential diagnosis of this disease, and the prognosis of patients. This paper aims to describe a wide range of presentations of primary central nervous system lymphoma, their appearance in imaging, and the differential diagnoses of this disease.

Idiopathic orbital myositis

PURPOSE

There is a paucity of reliable data and limited experience on the clinical features and therapeutic outcomes of orbital myositis. The purpose of this study was to collate data on the clinical features, imaging, diagnosis, and therapeutic effects of case reports from patients with myositis of idiopathic orbital inflammation pseudotumor in a tertiary eye hospital in China.

METHODS

A retrospective study was performed on the records of 44 Chinese patients with orbital myositis. Data were obtained from the period of January 1, 2000, to August 31, 2010, from patients treated at the Eye Hospital of the Zhongshan Ophthalmic Center at Sun Yat-sen University, Guangzhou, China.

RESULTS

Twenty-five patients were women and 19 men. The mean age was 39.1 years (range, 11-77 years). Right eyes were involved in 18 cases, left in 17 cases, and both eyes in 9 cases. Dysfunctions of the affected muscles included pure paretic (20.5%), pure restrictive (45.5%), or mixed paretic-restrictive (34.1%). The ratio of acute to subacute stage was 1:3. The rank order of affected muscles was as follows: superior rectus (29.1%), lateral rectus (25.6%), medial rectus (24.4%), inferior rectus (19.8%), and superior oblique (1.16%). The proportion of single muscle involvement was 37.5%, and tendon involvement was seen in 40.9% of the muscles. All patients were treated with systemic corticosteroids (prednisone or dexamethasone). Full recovery was achieved in 38.6% of patients, whereas 59.1% achieved partial recovery with an average of 6.4 recurrences (range, 2.0-8.0 recurrences). Recurrences occurred in 81.8% of the patients.

CONCLUSIONS

Orbital myositis occurs in multiple clinical manifestations and may be recurrent. Imaging is an important technique for use in diagnosis. Systemic corticosteroid represents an effective approach for treatment.

Orbital inflammatory disease: Pictorial review and differential diagnosis

Orbital inflammatory disease (OID) represents a collection of inflammatory conditions affecting the orbit. OID is a diagnosis of exclusion, with the differential diagnosis including infection, systemic inflammatory conditions, and neoplasms, among other conditions. Inflammatory conditions in OID include dacryoadenitis, myositis, cellulitis, optic perineuritis, periscleritis, orbital apicitis, and a focal mass. Sclerosing orbital inflammation is a rare condition with a chronic, indolent course involving dense fibrosis and lymphocytic infiltrate. Previously thought to be along the spectrum of OID, it is now considered a distinct pathologic entity. Imaging plays an important role in elucidating any underlying etiology behind orbital inflammation and is critical for ruling out other conditions prior to a definitive diagnosis of OID. In this review, we will explore the common sites of involvement by OID and discuss differential diagnosis by site and key imaging findings for each condition.

Orbital and optic nerve complications of inflammatory bowel disease

BACKGROUND AND AIMS

Extraintestinal manifestations of inflammatory bowel disease (IBD) can involve the orbit and the optic nerve. Although these manifestations are rare, they can be particularly serious as they can lead to permanent loss of vision. The aim of the review is to present the existing literature on IBD-related optic nerve and orbital complications.

METHODS

A literature search identified the publications reporting on incidence, clinical features and management of IBD patients with optic nerve and orbital manifestations.

RESULTS

Posterior scleritis and orbital inflammatory disease (orbital pseudotumor) are the most commonly encountered entities affecting the structures of the orbit. On the other hand, the optic nerve of IBD patients can be affected by conditions such as optic (demyelinating) neuritis ("retrobulbar" neuritis), or ischaemic optic neuropathy. Other neuro-ophthalmic manifestations that can be encountered in patients with IBD are related to increased intracranial pressure or toxicity secondary to anti tumour necrosis factor (anti-TNF) agents.

CONCLUSIONS

IBD-related optic nerve and orbital complications are rare but potentially vision-threatening. Heightened awareness and close cooperation between gastroenterologists and ophthalmologists are warranted.

Unilateral optic neuritis, scleritis and exudative retinal detachment due to recurrent orbital pseudotumor

Idiopathic orbital inflammation, also known as orbital pseudotumor, describes a spectrum of idiopathic, non-neoplastic, non-infectious, space-occupying orbital lesions without identifiable local or systemic cause. The condition occurs mainly in young adults who may present with acute pain, proptosis, chemosis and limitations of extraocular movements. Decreased vision due to optic nerve infiltration and macular edema as a result of scleritis is less common sequel of orbital pseudotumor. Herein, we present a case of unilateral orbital pseudotumor in a young male who presented with chief complaints of painful decreased vision which was attributed to optic neuritis and macular edema as a result of scleritis. Imaging studies were helpful in the establishment of the correct diagnosis and patient's complaints improved with administration of systemic corticosteroids.

Orbital masses: CT and MRI of common vascular lesions, benign tumors, and malignancies

A wide variety of space occupying lesions may be encountered in the orbit. CT and MR imaging frequently help confirm the presence of a mass and define its extent. Characteristic imaging features may help distinguish among lesions that have overlapping clinical presentations. This review focuses on some of the common orbital masses. Common vascular lesions that are reviewed include: capillary (infantile) hemangioma, cavernous hemangioma (solitary encapsulated venous-lymphatic malformation), and lymphangioma (venous-lymphatic malformation). Benign tumors that are reviewed include: optic nerve sheath meningioma, schwannoma, and neurofibroma. Malignancies that are reviewed include: lymphoma, metastasis, rhabdomyosarcoma, and optic glioma. Key imaging features that guide radiological diagnosis are discussed and illustrated.

Bilateral multiple extraocular muscle metastasis from hepatocellular carcinoma

Hepatocellular carcinoma (HCC) rarely metastasizes to the extra ocular muscles (EOMs). We present a case of bilateral metastasis of HCC to the EOMs and focus on the magnetic resonance imaging (MRI) features. Orbital MRI revealed nodular enlargement of bilateral multiple EOMs, with isointensity on T1-weighted images and heterogeneous, intermediate-to-high signal intensity on T2-weighted images, and showed mild-to-significant heterogeneous contrast enhancement with gadolinium. Physicians should be aware of this rare cause of EOM enlargement, understand the radiologic characteristics of EOM metastasis, and thus make appropriate treatment strategy.

Nonsimultaneous bilateral nonrhegmatogenous retinal detachments presenting as a complication of panuveitis in the setting of idiopathic orbital inflammatory syndrome

BACKGROUND

Idiopathic orbital inflammatory syndrome (IOIS), also known as orbital pseudotumor, consists of a spectrum of idiopathic, nonneoplastic, noninfectious, space-occupying lesions, without identifiable local or systemic cause. This case demonstrates a unique presentation of IOIS associated with panuveitis and nonsimultaneous bilateral serous nonrhegmatogenous retinal detachments (NRRD).

METHODS

A 38-year-old man initially presented with a unilateral uveitis that progressed quite rapidly to a bilateral presentation. A diagnosis of IOIS was made after comprehensive blood work and imaging studies.

RESULTS

The patient had nonsimultaneous bilateral serous NRRD in the setting of panuveitis and IOIS. Retinal detachment is a rare complication of IOIS that has been reported only twice before. There are no prior reports in the literature of this unique triad of NRRD, panuveitis, and IOIS. The patient responded promptly to aggressive treatment with oral corticosteroids.

CONCLUSIONS

IOIS should be considered in the evaluation and management of patients with NRRD and panuveitis. Prompt diagnosis and treatment of IOIS with corticosteroids is important to yield good clinical response and significant visual recovery, as demonstrated by this case.

[Resistant orbital pseudotumor treated with rituximab in a patient with systemic lupus erythematosus. A case presentation]

Ocular manifestations in Systemic Lupus Erythematosus (SLE) are relatively frequent, with a major prevalence of the Keratoconjunctivitis sicca. Nevertheless, the appearance of unilateral exophthalmos secondary to orbital pseudotumor in patients with SLE is extremely rare(1-7), and on occasion it can be refractory to conventional pharmacological treatment (glucocorticoids and immunosuppressants). We present the case of a patient with SLE and orbital pseudotumor refractory to treatment with Cyclophosphamide (CF) and an excellent clinical response, with disappearance of the ophthalmological condition after the beginning of therapy with Rituximab (1g×2), continuing after the infusion of two complete cycles without incidents.

Idiopathic orbital pseudotumour

Idiopathic orbital pseudotumour (IOP) is a benign inflammatory condition usually confined to the orbit. This may involve single or multiple intraorbital structures. Extraorbital extension can also occur. The imaging appearances often mimic other orbital diseases. Both computed tomography (CT) and magnetic resonance imaging (MRI) are frequently used to investigate orbital diseases, and it is important for radiologists to be aware of the variety of imaging appearances that occur in IOP. We present the imaging appearances in histopathologically confirmed cases of IOP and discuss the clinical features, natural history, and differential diagnosis of this condition.

Differentiation between benign and malignant orbital tumors at 3-T diffusion MR-imaging

INTRODUCTION

To differentiate between malignant and benign orbital tumors at 3-T diffusion MR imaging.

METHODS

A retrospective study was conducted on 47 patients (34 males and 13 females aged 4-74 years) with orbital masses. They underwent echo-planar diffusion-weighted MR imaging of the orbit with b-factor of 0, 500, and 1,000 s/mm(2) at 3-T MR unit. Apparent diffusion coefficient (ADC) maps were reconstructed, and the ADC value of the orbital mass was calculated.

RESULTS

The mean ADC value of the malignant orbital tumors (0.84 ± 0.34 × 10(-3) mm(2)/s) was significantly lower (P = 0.001) than that of the benign orbital tumors (1.57 ± 0.33 × 10(-3) mm(2)/s). The selection of an ADC value of 1.15 × 10(-3) mm(2)/s as a threshold value for differentiating malignant orbital tumors from benign lesions has a sensitivity of 95%, a specificity of 91%, and an accuracy of 93%. There was a significant difference in the ADC value between well- and poorly differentiated malignancies (P = 0.005).

CONCLUSION

Apparent diffusion coefficient value at 3 T is an additional noninvasive imaging parameter that can be used for the differentiation of malignant orbital tumors from benign lesions, the characterization of some orbital tumors, as well as the grading of orbital malignancy.

Visual field deficit: a rare initial symptom of autoimmune pancreatitis

An autoimmune pancreatitis (AIP) patient with metachronous and multiple extrapancreatic lesions is reported. Initial symptoms were proptosis, oculomotor deficits, and a visual field deficit of the left eye, and swelling of bilateral lacrimal glands. Swelling of the right salivary gland and elevated serum levels of hepatobiliary enzymes were detected. AIP associated with IgG4-related orbital pseudotumor, IgG4-related sclerosing dacryoadenitis and sialadenitis, and IgG4-related sclerosing cholangitis was diagnosed. All symptoms and lesions improved with steroid therapy. Although an orbital pseudotumor is a rare extrapancreatic lesion of AIP, we should know that AIP patients may describe unusual symptoms such as abnormal visual field.

Orbital pseudotumor

Orbital pseudotumor is a benign condition that accounts for approximately 10% of all orbital mass lesions. Any part of the orbit may be involved. The etiology is unknown. The presentation may be either acute or subacute. Patients may present with a palpable mass, a swollen eyelid, congestion, pain, diminished ocular motility, and/or decreased visual acuity. Approximately, 25% of patients present with bilateral disease. A modest proportion of patients experience resolution of their symptoms without treatment. Biopsy is indicated for those who do not respond to, or relapse after, first-line therapy. Oral corticosteroids are the initial treatment and approximately 80% of patients respond. Roughly half of those who respond to corticosteroids relapse. Second-line therapy consists of either low-dose radiotherapy (20-30 Gy at 2 Gy per fraction), cytotoxic chemotherapy, or immunosuppressive agents. Radiotherapy results in long-term local control rates of 50% or higher. Limited lesions may be successfully resected. A small subset of patients may experience inexorable progression to a fixed, painful, sightless eye and require orbital exenteration.

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.

MR imaging of orbital inflammatory syndrome, orbital cellulitis, and orbital lymphoid lesions: the role of diffusion-weighted imaging

BACKGROUND AND PURPOSE

Orbital inflammatory syndrome (OIS) has clinical features that overlap with orbital lymphoid lesions and orbital cellulitis. Prompt diagnosis is needed in all 3 conditions because the management of each one differs greatly. CT and MR imaging, though useful, do not always distinguish among these conditions. The aim of this study was to identify the role of diffusion-weighted imaging (DWI) in differentiating these 3 diagnoses.

MATERIALS AND METHODS

A retrospective analysis of orbital MR imaging was conducted. T1- and T2-weighted and postcontrast images were analyzed. Region-of-interest analysis was performed by using measurements in areas of abnormality seen on conventional MR imaging sequences and measurements of the ipsilateral thalamus for each patient. The DWI signal intensity of the lesion was expressed as a percentage of average thalamic intensity in each patient. Similarly, lesion apparent diffusion coefficients (ADCs) and lesion-thalamus ADC ratios were calculated. Statistical significance was determined by the Kruskal-Wallis test, and post hoc pairwise comparisons, by the Mann-Whitney U test for DWI-intensity ratio, ADC, and ADC ratio.

RESULTS

A significant difference was noted in DWI intensities, ADC, and ADC ratio between OIS, orbital lymphoid lesions, and orbital cellulitis (P < .05). Lymphoid lesions were significantly brighter than OIS, and OIS lesions were significantly brighter than cellulitis. Lymphoid lesions showed lower ADC than OIS and cellulitis. A trend was seen toward lower ADC in OIS than in cellulitis (P = .17).

CONCLUSIONS

DWI may help differentiate OIS from lymphoid lesions and cellulitis and may allow more rapid management.

Orbital Inflammatory Disease

OBJECTIVES

To familiarize rheumatologists and internists with the signs, symptoms, and management of orbital inflammatory disease (OID).

METHODS

A comprehensive literature review related to OID was performed and reported from the perspectives of rheumatology, ophthalmology, and radiology.

RESULTS

OID is a general term encompassing inflammatory diseases that affect some or all of the structures contained within the orbit external to the globe. Orbital involvement as a part of the initial symptom complex is not uncommon for systemic diseases such as Graves' disease, Wegener's granulomatosis, and sarcoidosis. The management of these and other causes of OID, such as idiopathic orbital inflammation (formerly known as "orbital pseudotumor"), orbital myositis, and Tolosa-Hunt syndrome frequently involves systemic immunosuppression. Before immunosuppression is considered, however, infectious and malignant causes of inflammation must be ruled out.

DISCUSSION

Rheumatologists should be familiar with the differential diagnosis of OID and often need to assist colleagues in ophthalmology and internal medicine with the management of this group of diseases.

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.

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.

The role of radiation therapy in benign diseases

Although adequate prospective data are lacking, radiation therapy seems to be effective for many benign diseases and remains one of the treatment modalities in the armamentarium of medical professionals. Just as medication has potential adverse effects, and surgery has attendant morbidity, irradiation sometimes can be associated with acute and chronic sequelae. In selecting the mode of treatment, most radiation oncologists consider the particular problem to be addressed and the goal of therapy in the individual patient. It is the careful and judicial use of any therapy that identifies the professional. With an understanding of the current clinical data, treatment techniques, cost, and potential detriment, the goal is to provide long-term control of the disease while minimizing unnecessary treatment and potential risks of side effects. The art lies in balancing benefits against risks.

Idiopathic orbital inflammatory pseudotumor in Chinese children

PURPOSE

To study the clinical features of idiopathic orbital inflammatory pseudotumor (IOIP) in Chinese children.

METHODS

Pediatric patients with IOIP seen between Jan. 1, 1978 and Dec. 31, 1999 in the Eye Hospital, Zhongshan Ophthalmic Center, Sun Yat-sen University were evaluated retrospectively. Their clinical features were compared with those of adult cases of IOIP.

RESULTS

Of the 209 cases, 24 (11.5%) were equal to or less than 20 years old; 14 were female and 10 were male. There were 11 in the right eye, 9 in the left eye and 4 in both eyes. Palpable mass (58%), ocular motility restriction (46%), swollen eyelid (42%), proptosis (42%) and high orbital pressure (42%) were the five most common presenting signs in children with IOIP. Ptosis occurred more often in pediatric IOIP cases (38%) than in adult IOIP cases (9%) (P < 0.0003). However, compared with adult IOIP cases, pediatric patients showed less proptosis (69% vs. 42%, P = 0.0074). According to radiological and surgical findings, a local mass within the orbit was the most frequent subtype (50%), followed by dacryoadenitis (29%), myositis (8%), perineuritis (4%), eyelid pseudotumor (4%), and diffuse orbital inflammation (4%). The frequency of clinical subtypes in children was similar to that in adults. After systemic corticosteroids, surgical management and local radiotherapy the full recovery response rate was 29% and the total effective rate was 92%.

CONCLUSIONS

Pediatric IOIP accounted for 11.5% of all IOIP patients. Pediatric cases had more sign of ptosis and less sign of proptosis than in adult IOIP. The full recovery response rate was low in children with IOIP.