Sarcoid optic neuropathy

Ocular Sarcoidosis

Sarcoidosis is one of the leading causes of inflammatory eye disease. Any part of the eye and its adnexal tissues can be involved. Uveitis and optic neuropathy are the main manifestations, which may require systemic treatment. Two groups of patients with sarcoid uveitis can be distinguished: one of either sex and any ethnicity in which ophthalmological findings are various and another group of elderly Caucasian women with mostly chronic posterior uveitis. Clinically isolated uveitis revealing sarcoidosis remains a strictly ocular condition in a large majority of cases. Although it can be a serious condition involving functional prognosis, early recognition in addition to a growing therapeutic arsenal (including intravitreal implant) has improved the visual prognosis of the disease in recent years. Systemic corticosteroids are indicated when uveitis does not respond to topical corticosteroids or when there is bilateral posterior involvement, especially macular edema. In up to 30% of the cases that require an unacceptable dosage of corticosteroids to maintain remission, additional immunosuppression is used, especially methotrexate. As with other forms of severe noninfectious uveitis, monoclonal antibodies against tumor necrosis factor-α have been used. However, only very rarely does sarcoid uveitis fail to respond to combined corticosteroids and methotrexate therapy, a situation that should suggest either poor adherence or another granulomatous disease. Optic neuropathy often affects women of African and Caribbean origins. Some authors recommend that patients should be treated with high-dose of corticosteroids and concurrent immunosuppression from the onset of this manifestation, which is associated with a poorer outcome.

Optic neuropathy associated with systemic sarcoidosis

Objective:

To identify and follow a series of 52 patients with optic neuropathy related to sarcoidosis.

Methods:

Prospective observational cohort study.

Results:

The disorder was more common in women and affected a wide age range. It was proportionately more common in African and Caribbean ethnic groups. Two clinical subtypes were identified: the more common was a subacute optic neuropathy resembling optic neuritis; a more slowly progressive optic neuropathy arose in the remaining 17%. Sixteen (31%) were bilateral. Concurrent intraocular inflammation was seen in 36%. Pain arose in only 27% of cases. An optic perineuritis was seen in 2 cases, and predominate involvement of the chiasm in one. MRI findings showed optic nerve involvement in 75% of cases, with adjacent and more widespread inflammation in 31%. Treatment with corticosteroids was helpful in those with an inflammatory optic neuropathy, but not those with mass lesions. Relapse of visual signs arose in 25% of cases, necessitating an increase or escalation of treatment, but relapse was not a poor prognostic factor.

Conclusions:

This is a large prospective study of the clinical characteristics and outcome of treatment in optic neuropathy associated with sarcoidosis. Patients who experience an inflammatory optic neuropathy respond to treatment but may relapse. Those with infiltrative or progressive optic neuropathies improve less well even though the inflammatory disorder responds to therapy.

Current options for the treatment of optic neuritis

Optic neuritis can be defined as typical (associated with multiple sclerosis, improving independent of steroid treatment), or atypical (not associated with multiple sclerosis, steroid-dependent improvement). Causes of atypical optic neuritis include connective tissue diseases (eg, lupus), vasculitis, sarcoidosis, or neuromyelitis optica. In this manuscript, updated treatment options for both typical and atypical optic neuritis are reviewed. Conventional treatments, such as corticosteroids, therapeutic plasma exchange, and intravenous immunoglobulin therapy are all discussed with commentary regarding evidence-based outcomes. Less commonly used treatments and novel purported therapies for optic neuritis are also reviewed. Special scenarios in the treatment of optic neuritis – pediatric optic neuritis, acute demyelinating encephalomyelitis, and optic neuritis occurring during pregnancy – are specifically examined.

Keep an eye on the lung

The case of a 42-year-old man, originally seen in the Ophthalmology clinic after his wife noticed his pupil sizes were different, is presented. He had been feeling tired with lack of energy for 6 months, during which time he had lost about 6.4 kg in weight. Then he started to have night sweats and a non-productive cough. His appetite was good. A chest x ray showed right midzone and some left lung opacities. Thoracic high-resolution CT showed patchy consolidation involving both midzones with widespread nodular shadowing. Transbronchial biopsies showed non-caseating epitheloid cell granulomata consistent with sarcoidosis.

Neurosarcoïdose : état des connaissances

The origins of neurosarcoidosis, a multisystemic granulomatous disease, remain unknown. Nervous system localizations remain rare, but severe. Lymphocytic meningitis, psychiatric disorders, diabetes insipidus and cranial nerve palsy are the most frequent signs. Cerebral fluid test and cervical medullar and cerebral MRI with gadolinium have to be performed first. In some cases, histological evidence of granuloma have to be obtained with neuromuscular, meningeal or cerebral biopsies. Functional impairment and life-threatening conditions require early corticosteroid therapy. In worsening cases or in the event of no therapeutic response or poor tolerance to corticosteroids, other immunosuppressive agents should be associated. Maintenance therapy and most often life long maintenance therapy allow a continuous success while avoiding relapse.

Neuro-ophthalmological findings in sarcoidosis

PURPOSE

This review emphasizes the importance of neuro-ophthalmological signs and symptoms in sarcoidosis. The presence of ophthalmological and neuro-ophthalmological findings may lead to diagnosis of the disease and the initiation of adequate treatment.

MATERIAL AND METHODS

Patients who had been diagnosed with neurosarcoidosis during the period 1990 - 2001 were identified from the departmental diagnostic index. The history, clinical, laboratory and imaging data of patients were analysed.

RESULTS

Fifteen patients were identified, four men and 11 women, with a mean age of 44.1 years (range 26-65 years). In six of the 15 (40%), neurological deficits were the initial symptoms. Nine (60%) had known sarcoidosis at the time of presentation. Ten patients (66%) had ophthalmological/neuro-ophthalmological symptoms and signs.

CONCLUSION

Neuro-ophthalmological symptoms may develop early in neurosarcoidosis. If neuro-ophthalmological symptoms arise in patients with established biopsy-proven sarcoidosis, the diagnosis is usually easy to make. However, a number of patients with neurosarcoidosis may present with neuro-ophthalmic symptoms before systemic involvement becomes obvious. In this situation the diagnosis is challenging, and the major goal is to establish the presence of systemic sarcoidosis.

Neurologic manifestations of sarcoidosis

Sarcoidosis is multisystem granulomatous disease of unknown etiology. Although the nervous system is involved in only 5% to 16% of patients, neurosarcoidosis is one of the more serious manifestations of the disease. Cranial neuropathies are common, but involvement of the mininges or the brain or spinal cord parenchyma causes more severe morbidity. MR imaging of affected portions of the neuraxis is a very sensitive diagnostic technique. Treatment with corticosteroids is the mainstay of therapy.

Diagnosis and management of neurosarcoidosis

Sarcoidosis is a multisystemic disorder characterised by the presence of multiple noncaseating granulomas. Clinically recognisable nervous system involvement occurs in 5-16% of patients with sarcoidosis. However, the incidence of subclinical neurosarcoidosis may be higher. The following article presents a review of the disease, including its pathophysiology, clinical and radiological characteristics and treatment. Neurosarcoidosis should be included in the differential diagnosis of infectious and noninfectious neurological syndromes.

Ocular sarcoidosis in Kuwait with a review of literature

OBJECTIVE

To study 18 cases of sarcoidosis, the hall mark of which was uveitis.

SETTING

Referrals from peripheral eye clinics.

PATIENTS

18 patients with bilateral almost symmetric uveitis, negative Mantoux test and positive gallium scan were enrolled in the study. Preliminary bronchoscopy and bronchial lavage were not done due to social habits.

RESULTS

Age ranged between 7-48 years with median 15 and mean 19 years. Although the patients were multinational, yet all of them were residents of Kuwait. A father and son were affected within 8 months period. 78% were strictly ocular, associated pulmonary and salivary gland affection 11% each. Sole anterior uveitis was found in 28%, associated with intermediate uveitis in 55% and with posterior in 16.6% of cases. Clinically detectable dry eyes associated 33% of cases. All our patients developed glaucoma which resolved with treatment of uveitis in 88% of them. Gallium uptake of the eye balls was found in 22%, of the lacrimal glands (panda sign) in 67%, and of the salivary glands or chest 11% each. Positive biopsy was found in 72%, 22% of which was conjunctival. Chest X-ray and SACE were positive in 11%. 61% had hypergammaglobulinaemia and all had negative ANA and RF.

CONCLUSIONS

(1) 61% of ocular sarcoidosis presented below sarcoid age. (2) Multinationality together with father's and son's affection indicate a climatic or environmental insult in an already predisposed person. (3) Routine chest X-ray and SACE may not be adequate for diagnosis of ocular sarcoidosis. Gallium should be done in suspected cases. (4) Follow-up for prospects is emphasized.

Cardiac and neurologic dysfunction in sarcoidosis

Clinically apparent involvement of the heart and nervous system occurs in a relatively small number of patients with sarcoidosis. The diagnosis of myocardial and neurological sarcoidosis is difficult because anatomic presence of granulomas without clinical dysfunction is an important feature of sarcoidosis. The chest radiography is abnormal in 8 of every 10 patients with myocardial or neurosarcoidosis. Serum angiotensin-converting enzyme and gallium uptake studies may provide some indication of the extent and severity of the granulomatous process. Corticosteriods are the mainstay of therapy but chloroquine or hydroxychloriquine, methotrexate, and azathioprine are also effective. Prognosis of myocardial and neurological sarcoidosis is poor.

Sarcoid masquerading as optic nerve sheath meningioma

Sarcoid manifesting as an optic nerve tumor without evidence of systemic disease is uncommon. Throughout a 2-year period, a 22-year-old white woman had progressive monocular loss of vision to the level of no light perception. Optic atrophy but no uveitis was noted in the affected eye. Magnetic resonance imaging revealed thickening and enhancement of the apical optic nerve, with "tram-tracking." The presumptive diagnosis was optic nerve sheath meningioma; however, a biopsy specimen from the optic nerve revealed sarcoid. Extensive postoperative investigations revealed no systemic sarcoidosis. To our knowledge, 17 cases similar to ours, with the diagnosis proved by optic nerve biopsy, have been previously reported in the English-language literature. Most of these were mistaken preoperatively for optic nerve sheath meningioma. None of the patients had evidence of systemic sarcoidosis on initial postoperative testing. Neuroimaging, serum level of angiotensin-converting enzyme, and clinical characteristics such as age, race, sex, and optochoroidal collaterals do not distinguish optic nerve sheath meningioma from sarcoid of the optic nerve. In the absence of uveitis or systemic involvement, optic nerve sarcoid manifesting as an orbital tumor is virtually impossible to diagnose without results of biopsy.

Optic nerve enlargement and chronic visual loss

We present four patients with sarcoidosis of the anterior visual pathways. The first patient presented with unilateral visual loss, a mass lesion at the optic nerve head, and an enlarged orbital optic nerve. The second patient presented with bilateral progressive painless visual loss, associated with optic nerve pallor and visual field loss. In these two patients, optic nerve biopsy was diagnostic of sarcoidosis. The third patient developed optic nerve and chiasmal involvement after sarcoidosis was established by lacrimal gland biopsy. The fourth patient had optic nerve, pulmonary, and lymph node involvement with sarcoidosis. A conjunctival and lung biopsy were diagnostic. Computed tomography and magnetic resonance imaging have greatly facilitated diagnosis of sarcoidosis of the anterior visual pathways. Sarcoidosis of the anterior visual pathways may occur alone or in association with other ocular or systemic manifestations. A conjunctival or lacrimal gland biopsy may be preferable as the initial diagnostic approach. Treatment of patients with this condition may require systemic immunosuppression, in addition to corticosteroids, to prevent permanent visual loss.

Fundus pathology in neurosarcoidosis

We describe the ocular symptomatology in 6 patients with neurosarcoidosis. All patients suffered from uveitis posterior or panuveitis. Ophthalmoscopy revealed multifocal chorioretinic lesions, periphlebitis, severe papilledema or an isolated chorioretinic process. The similarity with birdshot chorioretinopathy is described. Nuclear magnetic resonance imaging, computer assisted tomography and visual field examination can all contribute to the determination of neurological involvement in sarcoidosis.

Meningeal sarcoidosis, pseudo-meningioma, and pachymeningitis of the convexity

Two cases of meningeal sarcoidosis with unusual and misleading presentations are reported. In the first case, CT scan, angiographic, and MRI findings were indistinguishable from those of meningioma. CSF pleiocytosis may help in diagnosing sarcoid pseudo-meningioma. The second patient had transient focal deficits and pachymeningitis of the convexity. The transient deficits were probably of epileptic origin based on their response to antiepileptic treatment. The diagnosis of neurosarcoidosis was made only after meningeal biopsy, despite thorough investigations.

Disc edema, transient obscurations of vision, and a temporal fossa mass

A 56-year-old woman presented with a four-month history of transient obscurations of vision that progressed to constant visual loss. She had a nodular, lumpy-bumpy, cauliflower-like asymmetric edema of the nerve head, which suggested direct optic nerve head invasion with foreign tissue. Imaging of her intracranial contents revealed a well circumscribed gadolinium enhancing mass in the middle fossa. Histopathology of material obtained at craniotomy revealed noncaseating granulomata consistent with sarcoidosis. Central nervous system sarcoid may present either as an infiltrative granulomatous process, or one of discrete tumor mass, masquerading as a neoplasm. Neurologic symptoms and signs often herald the presence of systemic disease. Our illustrates that isolated sarcoid optic neuropathy may occur and be associated with neither intraocular inflammatory signs nor extensive disease elsewhere; indeed, it may be the first declaration of neurosarcoidosis.

Meningeal neurosarcoidosis mimicking convexity en-plaque meningioma

A 34-year old man presented with headaches. Computed tomography scanning revealed an enhancing subdural mass extending from the skull base to the convexity, thought to represent an en-plaque meningioma. Pathologic study revealed extraaxial subdural granulomatous inflammation consistent with neurosarcoidosis.

Optic neuropathy in sarcoidosis

Five patients with isolated optic neuropathy and sarcoidosis are discussed. The spectrum of clinical disease was variable but two groups could be identified: patients with chronic progressive visual loss which was associated with thickening of the optic nerve and was refractory to steroid treatment, and patients with acute or subacute optic neuropathy in which the visual loss responded rapidly to steroids. In the latter group steroid dependence developed in all three of the patients. In none did the clinical picture resemble that of the optic neuritis associated with multiple sclerosis.

Rare multiple orbital localizations of sarcoidosis. A case report

We report a case of bilateral orbital sarcoidosis without other systemic lesions. Steroid therapy did not improve the clinical status of the patient.

Eleven cases of sarcoidosis of the optic nerve

Of 11 patients (eight women and three men, ranging in age from 16 to 48 years) who had sarcoidosis of the optic nerve that caused decreased visual acuity and visual field abnormalities, only two were known to have sarcoidosis at the time the visual impairment developed. Four patients had granulomas involving the optic nerve head, four had granulomatous inflammation of the orbital or intracranial optic nerve or chiasm, and three had retrobulbar neuritis. All 11 patients had histologically confirmed idiopathic noncaseating granulomatous inflammation and eight of the 11 had abnormalities compatible with sarcoidosis in chest roentgenograms. In the three patients in whom the serum level of angiotensin-converting enzyme was determined, it was increased in one and normal in the other two. Computed tomography of the anterior visual pathways was the single most useful neurodiagnostic study. Treatment with corticosteroids was beneficial in six of the 11 cases. These cases demonstrated that sarcoidosis should be included in the differential diagnosis of any inflammatory or compressive lesion involving the anterior visual pathways.