Orbital inflammatory disease: Pictorial review and differential diagnosis

Deep learning-based intratumoral and peritumoral features for differentiating ocular adnexal lymphoma and idiopathic orbital inflammation

OBJECTIVES

To evaluate the value of deep-learning-based intratumoral and peritumoral features for differentiating ocular adnexal lymphoma (OAL) and idiopathic orbital inflammation (IOI).

METHODS

Nighty-seven patients with histopathologically confirmed OAL (n = 43) and IOI (n = 54) were randomly divided into training (n = 79) and test (n = 18) groups. DL-based intratumoral and peritumoral features were extracted to characterize the differences in heterogeneity and tissue invasion between different lesions, respectively. Subsequently, an attention-based fusion model was employed to fuse the features extracted from intra- and peritumoral regions and multiple MR sequences. A comprehensive comparison was conducted among different methods for extracting intratumoral, peritumoral, and fused features. Area under the curve (AUC) was used to evaluate the performance under a 10-fold cross-validation and independent test. Chi-square and student's t-test were used to compare discrete and continuous variables, respectively.

RESULTS

Fused intra-peritumoral features achieved AUC values of 0.870-0.930 and 0.849-0.924 on individual MR sequences in the validation and test sets, respectively. This was significantly higher than those using intratumoral features (p < 0.05), but not significantly different than those using peritumoral features (p > 0.05). By combining multiple MR sequences, AUC values of the intra-peritumoral features were boosted to 0.943 and 0.940, higher than those obtained from each sequence alone. Moreover, intra-peritumoral features yielded higher AUC values compared to entire orbital cone features extracted by either the intra- or the peritumoral DL model, although no significant difference was found from the latter (p > 0.05).

CONCLUSION

DL-based intratumoral, peritumoral, and especially fused intra-peritumoral features may help differentiate between OAL and IOI.

KEY POINTS

Question What is the diagnostic value of the peritumoral region and its combination with the intratumoral region for radiomic analysis of orbital lymphoproliferative disorders? Findings Fused intra- and peritumoral features achieved significantly higher performance than intratumoral features, but had no significant difference to the peritumoral features. Clinical relevance Peritumoral contextual features, which characterize the invasion patterns of orbital lesions within the surrounding areas of the entire orbital cone, might serve as an independent imaging marker for differentiating between OAL and IOI.

The Relevance and Potential Role of Orbital Fat in Inflammatory Orbital Diseases: Implications for Diagnosis and Treatment

The orbit is an important structure within the skull that houses the eye, optic nerve, and extraocular muscles. It also contains adipose/fat tissue, which provides a protective cushion for these components. Inflammatory orbital disease can affect any or all components of the orbit, often arising from various underlying pathologic conditions, including autoimmune, infectious, and vascular diseases. Typical signs and symptoms of orbital inflammation include swelling, redness, pain, discomfort, and potential loss of function. The role of orbital fat in the pathogenesis of inflammatory orbital diseases has not been fully explored. This review aims to provide a comprehensive description of orbital fat, its relevance and the potential role in inflammatory diseases of the orbit, and the use of radiologic imaging studies for evaluating this fat depot in cases of as inflammatory orbital diseases. Additionally, this review discusses the various procedures available for the treatment and management of these conditions. A range of interventions, including pharmacotherapy and surgical procedures, will be evaluated as promising therapeutic options. This review also explores the characteristics and potential applications of orbital fat-derived stem cells, with an emphasis on their regenerative abilities and anti-inflammatory effects. Understanding the role of orbital fat and its contribution to inflammatory orbital diseases is essential for optimizing diagnostic and treatment strategies.

Use of a handheld ultrasound device for detecting orbital inflammation

Purpose

Orbital inflammatory disease has been historically diagnosed with computed tomography (CT) and magnetic resonance imaging (MRI). Orbital ultrasound has served as a non-radiation alternative that has been successful at diagnosing many orbital pathologies but is not commonly used in clinical practice due to need for specialized ultrasound training and equipment needs. We demonstrate use of handheld ultrasound for detecting orbital inflammation.

Observations

We present five patients with orbital inflammation where a handheld ultrasound probe was able to capture features consistent with concurrent CT scans.

Conclusions and importance

Handheld ultrasound is an accessible and portable method that can assist in the diagnosis and monitoring of orbital pathology.

Orbital inflammatory disease as a presenting feature of suspected Lyme neuroborreliosis: case report

Orbital inflammatory disease (OID) is an inflammatory condition of the orbital and periorbital region. This case reports suspected Lyme neuroborreliosis underlying an initial presentation of OID in a 37-year-old male. Myositis was confirmed by computed tomography (CT) imaging. Cranial neuritis of the third, fifth, and seventh cranial nerves was evidenced by magnetic resonance imaging (MRI). Serology was positive for Borrelia burgdorferi IgM, but did not seroconvert to positive IgG. Thus, the rare diagnosis of orbital myositis as a presenting feature of suspected Lyme neuroborreliosis was established.

Orbital Myositis and Strabismus: Clinical Profile, Management, and Predictive Factors for Recurrence

PURPOSE

To study the clinical profile of patients with orbital myositis and their management modalities and predictive factors for recurrence.

METHODS

The records of all consecutive patients diagnosed as having orbital myositis from 2010 to 2022 were reviewed. Patient demographics, presenting complaints, visual function, primary gaze deviation, and extraocular muscle involved were studied in the clinical profile. The radiological modalities and their management along with the recovery status and need for surgical intervention were documented.

RESULTS

Fifty-two patients (55 eyes) (69% women) were diagnosed as having orbital myositis with a mean age of 36 ± 16 years presenting with periocular pain (55%) followed by diplopia (49%). Disease was unilateral in 94%. Sixty percent had ocular misalignment in primary gaze. The medial rectus was the most involved muscle (58%), with abduction limitation in 73%. Computed tomography (42%), magnetic resonance imaging (42%), and combined imaging (16%) were used in localizing the disease. Muscle biopsy was done in 38% of patients. Systemic immunomodulators were required in 16%. Strabismus surgery was planned in 15% of patients and done in 11%. Recurrence was noted in 43%. Abrupt cessation of steroids was a significant risk factor in recurrence of the disease (P = .046). Recovery was partial in 44% of patients and complete in 47%.

CONCLUSIONS

Systemic steroids with slow taper has satisfactory outcomes in orbital myositis. Patients refractory to treatment ideally should undergo biopsy and begin taking steroid-sparing agents. Once the disease is in remission, residual disease can be surgically treated for better functional outcome. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XXX-XXX.].

Imaging of the skull base and orbital tumors

The skull base and orbit have complicated anatomical structures where various tumors can occur. The tumor may present with neurological symptoms; however, its diagnosis is clinically difficult owing to accessibility issues. Therefore, diagnostic imaging is crucial in assessing tumors in the skull base and orbit and guiding subsequent management. Notably, some tumors have a predilection for a specific site of origin, and identifying the site of origin on imaging can help narrow the differential diagnosis. At the skull base, chordomas typically occur in the clivus, chondrosarcomas in the paramedian areas, paragangliomas in the jugular foramen, neurogenic tumors, and perineural spread in the neural foramen. Among orbital tumors, cavernous hemangiomas usually occur in the intraconal space, and pleomorphic adenomas and adenoid cystic carcinomas occur in the lacrimal glands. Some skull base and orbital tumors exhibit distinctive imaging features. Chordomas and chondrosarcomas of the skull base show high signal intensities on T2-weighted images, with chondrosarcomas often displaying cartilaginous calcifications. Paragangliomas are characterized by their hypervascular nature. In the orbit, cavernous hemangiomas and pleomorphic adenomas present unique dynamic patterns. Immunoglobulin G4-related disease forms lesions along the nerves. Identifying the tumor origin and its imaging characteristics can help narrow the differential diagnosis of skull base and orbital tumors.

Differentiation of bacterial orbital cellulitis and diffuse non-specific orbital inflammation on magnetic resonance imaging

PURPOSE

To examine the radiological differences between bacterial orbital cellulitis (OC) and diffuse non-specific orbital inflammation (DNSOI) on magnetic resonance imaging (MRI).

METHODS

Retrospective study of patients with OC and DNSOI with an MRI orbital scan. Localised orbital inflammation (e.g., idiopathic dacryoadenitis and myositis), quiescent orbital inflammation and pre-septal cellulitis were excluded.

RESULTS

Thirty-two patients presenting between 2008 and 2023, including twenty-one OC patients (mean age: 42.5 ± 24.9 years old, male: 6), and eleven DNSOI patients (mean age: 52.3 ± 17.8 years old, male: 16). Both OC and DNSOI demonstrate orbital fat contrast-enhancement. However, whilst OC demonstrated a hyperintense T2 signal (P < 0.001), variable signal was observed in DNSOI, with a hypointense T2 signal more suggestive of DNSOI (P = 0.012). When the lacrimal glands were involved, indistinct margins were more likely in OC (P < 0.001), whilst gross enlargement and contrast-enhancement was observed in DNSOI (P = 0.032 and 0.017, respectively). Peripheral contrast-enhancement of the extraocular muscle (EOM) (P = 0.002) was more common in OC, whilst DNSOI demonstrated variable contrast-enhancement throughout the affected EOM (P < 0.001). The presence of contralateral abnormalities, such as lacrimal gland enlargement and EOM involvement, are more suggestive of DNSOI.

CONCLUSION

Several MRI features, beyond overt sinogenic disease, may help to differentiate OC from DNSOI, including the orbital fat signal intensity, EOM and/or lacrimal gland involvement, and contralateral orbital abnormalities. However, these features may not be specific, and thus highlights the ongoing radiological dilemma clinicians are faced when tasked with differentiating between infectious and non-infectious orbital inflammatory disease.

Optic Perineuritis Presenting with Transient Monocular Vision Loss (TMVL): Case Report

Optic perineuritis is an inflammatory condition that presents with reduced visual acuity and painful eye movement. The presentation of optic perineuritis is similar of optic neuritis which results in delayed diagnosis and management. Up to this date, we found a single case of optic neuritis that presented with transient monocular vision loss (TMVL). No cases of optic perineuritis were associated with TMVL. Here, we report a case of a 30-year-old woman who presented with recurrent attacks of painless vision loss in her left eye, reaching up to 30 attacks per day. Ophthalmological examination was otherwise unremarkable. Lab investigations were normal. Magnetic resonance imaging was done, which showed left optic nerve sheath enhancement suggestive of left-sided focal optic perineuritis. Patient was managed with 1 mg IV methylprednisolone for 3 days. We report this case to shed light on the importance of accurate and early diagnosis of optic perineuritis presenting with TMVL. Prompt management of optic perineuritis is crucial in reducing morbidity and risk of relapse.

Case report: Bilateral optic nerve sheath meningocele: clinical aspects

Optic nerve sheath meningocele is an enlargement of the sheath itself, consisting of a collection of cerebrospinal fluid along the perineural space. It should be considered primary if it is not associated with orbital-cerebral neoplasm or with cranio-orbital junction malformations. We report three cases of bilateral primary idiopathic optic nerve sheath meningocele, two of them with gradual vision loss. The first case presented a history of monocular blurred vision of the right eye and headache. It was initially treated with acetazolamide without any improvement, after which optic nerve sheath fenestration was required. The second case showed intermittent binocular diplopia with central 24-2 perimetry defects in the left eye. The third case was first presented as a subacute bilateral conjunctivitis with a suspected orbital pseudotumor. An incidental bilateral optic nerve sheath meningocele was found in the orbital imaging, being totally asymptomatic. In all the cases, orbital and cranial magnetic resonance with contrast and fat suppression was crucial in the diagnosis.

Light After Darkness: A Case Report of Isolated Optic Perineuritis

This is a report on remarkable visual recovery from blindness in a case of isolated optic perineuritis (OPN). A 68-year-old Chinese lady presented with a two-week history of progressive painless bilateral vision loss. Her vision was 6/18 on the right eye and no perception of light (NPL) on the left eye with positive relative afferent pupillary defect (RAPD). Fundus showed hyperaemic and swollen optic disc bilaterally. MRI of the brain and orbit revealed hyperintense periventricular white matter lesions, possibly early changes of multiple sclerosis (MS), and perineural enhancement of optic nerve bilaterally, consistent with OPN. All other investigations were negative. Intravenous methylprednisolone 1g/day for three days was started, followed with oral prednisolone, tapered in three months. At the third month of follow-up, her vision had improved to 6/12 on the left and 6/9 on the right. The hyperaemic and swollen disc has resolved. Intravenous megadose corticosteroid treatment is an effective first-line treatment for OPN.

Beyond Myelin Oligodendrocyte Glycoprotein and Aquaporin-4 Antibodies: Alternative Causes of Optic Neuritis

Optic neuritis (ON) is the most common cause of vision loss in young adults. It manifests as acute or subacute vision loss, often accompanied by retrobulbar discomfort or pain during eye movements. Typical ON is associated with Multiple Sclerosis (MS) and is generally mild and steroid-responsive. Atypical forms are characterized by unusual features, such as prominent optic disc edema, poor treatment response, and bilateral involvement, and they are often associated with autoantibodies against aquaporin-4 (AQP4) or Myelin Oligodendrocyte Glycoprotein (MOG). However, in some cases, AQP4 and MOG antibodies will return as negative, plunging the clinician into a diagnostic conundrum. AQP4- and MOG-seronegative ON warrants a broad differential diagnosis, including autoantibody-associated, granulomatous, and systemic disorders. These rare forms need to be identified promptly, as their management and prognosis are greatly different. The aim of this review is to describe the possible rarer etiologies of non-MS-related and AQP4- and MOG-IgG-seronegative inflammatory ON and discuss their diagnoses and treatments.

An Orbital Pseudotumor Secondary to Systemic Lupus Erythematosus: A Case Report

Nonspecific orbital inflammation (NSOI), the primary cause of painful orbitopathy mostly in adults, can either manifest as localized or diffused. Periorbital edema or swelling is the most common sign followed by proptosis. NSOI or orbital pseudomotor secondary to systemic lupus erythematosus (SLE) is very uncommon in the Kingdom of Saudi Arabia. This is the first reported case from Saudi Arabia. The patient first presented to the outpatient department during her gestational period. Her chief complaint was right eye swelling and pain when she woke up in the morning. Her past medical history was positive for irritable bowel disease and SLE. A slit lamp examination revealed chemosis with conjunctival injections in the right eye and mild temporal chemosis in the left eye. Funduscopic examination after pupillary dilation revealed hyperemic discs with venous tortuosity more prominent in the right eye. Serum albumin level was low at 29 g/L. Orbital magnetic resonance imaging without contrast showed bilateral diffuse preseptal soft tissue swelling more prominent on the right side with diffuse bilateral congestion of intraorbital fat, including intraconal and extraconal fat. There was associated fat stranding around the optic nerves bilaterally. The bilateral extraocular muscles showed a diffusely increased T2 signal compatible with edema. The patient was given a bolus of intravenous methylprednisolone for three days. She had a satisfactory recovery. Early diagnosis is important to rule out other differential diagnoses, such as orbital cellulitis and lymphoma.

Recurrence of Idiopathic Orbital Inflammation: An 11-year Retrospective Study

PURPOSE

The high recurrence rate of idiopathic orbital inflammation (IOI) has been reported. This study aims to determine existing predictive factors for the recurrence of IOI.

METHODS

This was an 11-year retrospective study with at least a 12-month follow-up. Fifty patients with biopsy-proven IOI admitted between 2006 and 2017 at our tertiary hospital were observed. We compared the clinical characteristics, histopathological profile, and biomarker expressions (mast cell, immunoglobulin G4, tumor necrosis factor-alpha, and transforming growth factor-beta) of 16 patients with recurrence (Group I) and 34 patients with no recurrence (Group II). Statistical comparison and multivariate analysis were performed to establish the predictive factors.

RESULTS

We discovered five recurrence predictive factors: presentation of proptosis (odds ratio [OR] 4.96, 95% confidence interval [CI] 1.36-18.03), visual impairment (OR 15, 95% CI 1.58-142.72), extraocular muscle (EOM) restriction (OR 3.86, 95% CI 1.07-13.94), nonanterior involvement (OR 7.94, 95% CI 1.88-33.5), and corticosteroid (CS) alone treatment (OR 7.20, 95% CI 1.87-27.8). On multivariate analysis, nonanterior involvement and CS alone treatment were validated as predictive factors (area under the curve = 0.807 [95% CI 0.69-0.92]). Histopathological profile and biomarker expressions were not associated with recurrence. However, there was a 22-fold higher recurrence risk for granulomatous-type patients given CS alone treatment.

CONCLUSION

Unlike the five clinical characteristics mentioned, both histopathology and biomarker variables were not associated with recurrence. CS alone treatment for patients with nonanterior involvement or granulomatous type is proven to increase the risk of recurrence. Therefore, we suggest not giving CS without any combination treatment with other modalities for this group of patients.

Radiopathological Correlation in Orbital Lesions

PURPOSE

The objective is to analyze the radiological diagnosis of orbital lesions and their correlation with the final histopathological findings. We compared the initial reports by extramural radiologists and an in-house radiologist specialized in orbital imaging to evaluate the diagnostic accuracy in the interpretation of orbital imaging.

METHODS

This was a retrospective chart review of forty patients referred to a Tertiary Eye Care Center in South India over a period of 7 years. These patients already had their imaging done elsewhere. The imaging was re-evaluated by an in-house radiologist. The radiological findings were correlated with the histopathological diagnosis. The diagnostic accuracy between the two radiologists was compared. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value in differentiating malignant from benign lesions were calculated in both groups. The sensitivity and PPV of the radiological diagnosis for neoplastic and inflammatory lesions in both groups were analyzed.

RESULTS

The accuracy in differentiating malignant from benign and inflammatory lesions by our in-house radiologist and extramural radiologists was 95% (κ = 0.9 [0.764, 0.997]) and 50% (κ = 0.036 [-0.160, 0.232]), respectively. The sensitivity and PPV of the radiological diagnosis by our in-house radiologist were 93.31% and 100% for benign lesions and 95.24% and 95.24% for malignant lesions. On the contrary, reports from the extramural radiologists showed a sensitivity and PPV of 76.92% and 66.67% for benign lesions and 14.28% and 60% for malignant lesions.

CONCLUSION

A high radiological diagnostic accuracy is possible when analyzed by radiologists experienced in orbital imaging.

Efficacy of Infliximab in Disease Control of Refractory Orbital Myositis

PURPOSE

Orbital myositis is a common cause of orbital inflammation with localized involvement of the extra ocular muscles. This study aimed to assess the value of infliximab in controlling orbital myositis and reducing its relapse rate.

METHODS

We conducted a retrospective review of the medical records of all consecutive patients with orbital myositis treated with infliximab between 2007 and 2016. We examined change in corticosteroid and immunomodulatory doses as well as relapse rates following treatment with infliximab.

RESULTS

The study included seven patients with an average follow up of 19 ± 13.4 months. The mean dose of systemic corticosteroid was reduced from 28.57 ± 14.35 mg/day at the time of infliximab initiation to 7.00 ± 6.83 mg/day at final follow-up (p = .003). Long-term remission was achieved in 85.7% (n = 6).

CONCLUSION

This study supports the role of infliximab in treating refractory orbital myositis and this was associated with clinical improvement, decreasing relapse rate with dose reduction of conventional treatment.

Clinical and imaging clues to the diagnosis and follow-up of ptosis and ophthalmoparesis

Ophthalmoparesis and ptosis can be caused by a wide range of rare or more prevalent diseases, several of which can be successfully treated. In this review, we provide clues to aid in the diagnosis of these diseases, based on the clinical symptoms, the involvement pattern and imaging features of extra-ocular muscles (EOM). Dysfunction of EOM including the levator palpebrae can be due to muscle weakness, anatomical restrictions or pathology affecting the innervation. A comprehensive literature review was performed to find clinical and imaging clues for the diagnosis and follow-up of ptosis and ophthalmoparesis. We used five patterns as a framework for differential diagnostic reasoning and for pattern recognition in symptomatology, EOM involvement and imaging results of individual patients. The five patterns were characterized by the presence of combination of ptosis, ophthalmoparesis, diplopia, pain, proptosis, nystagmus, extra-orbital symptoms, symmetry or fluctuations in symptoms. Each pattern was linked to anatomical locations and either hereditary or acquired diseases. Hereditary muscle diseases often lead to ophthalmoparesis without diplopia as a predominant feature, while in acquired eye muscle diseases ophthalmoparesis is often asymmetrical and can be accompanied by proptosis and pain. Fluctuation is a hallmark of an acquired synaptic disease like myasthenia gravis. Nystagmus is indicative of a central nervous system lesion. Second, specific EOM involvement patterns can also provide valuable diagnostic clues. In hereditary muscle diseases like chronic progressive external ophthalmoplegia (CPEO) and oculo-pharyngeal muscular dystrophy (OPMD) the superior rectus is often involved. In neuropathic disease, the pattern of involvement of the EOM can be linked to specific cranial nerves. In myasthenia gravis this pattern is variable within patients over time. Lastly, orbital imaging can aid in the diagnosis. Fat replacement of the EOM is commonly observed in hereditary myopathic diseases, such as CPEO. In contrast, inflammation and volume increases are often observed in acquired muscle diseases such as Graves' orbitopathy. In diseases with ophthalmoparesis and ptosis specific patterns of clinical symptoms, the EOM involvement pattern and orbital imaging provide valuable information for diagnosis and could prove valuable in the follow-up of disease progression and the understanding of disease pathophysiology.

Diagnostic Utility of Diffusion-Weighted Imaging and Apparent Diffusion Coefficient for Common Orbital Lesions: A Review

PURPOSE

To review and summarize the existing literature surrounding the clinical use of diffusion-weighted imaging and apparent diffusion coefficient (ADC) as diagnostic tools in differentiating common orbital lesions.

METHODS

A systematic literature review on the use of ADC and diffusion-weighted imaging sequences for orbital imaging was performed. Only original research articles that reported ADC values for benign or malignant lesions were included.

RESULTS

Malignant orbital tumors have an overall lower mean ADC value than benign masses. Orbital lymphoma is characterized by consistently lower ADC values compared with other malignant orbital masses; a threshold value less than 0.775 × 10 -3 mm 2 /s has been proposed to distinguish orbital lymphoma from other neoplastic and non-neoplastic orbital masses. To differentiate orbital inflammatory disease from lymphoma, an ADC threshold greater than 0.92 × 10 -3 mm 2 /s has been proposed.

CONCLUSIONS

Orbital masses encompass a host of benign and malignant etiologies and can present a diagnostic challenge on both clinical and radiological assessment. Recent advanced MRI techniques such as diffusion-weighted imaging and ADC can improve the diagnostic specificity for orbital disease, particularly in differentiating benign from malignant lesions and lymphoma from orbital inflammatory disease.

Canine idiopathic orbital inflammation: A case series of four affected dogs (five orbits)

PURPOSE

In humans, idiopathic orbital inflammation (IOI) is a diagnosis attributed to benign, inflammatory orbital conditions without identifiable local or systemic cause. We describe the clinical signs, imaging and histopathological findings, management and outcome of four dogs diagnosed with IOI.

METHODS

Multicentric retrospective study.

RESULTS

A total of four dogs (five orbits) of three different breeds (three cases were English Springer Spaniels [ESS] or ESS-cross) and ages ranging from 3 to 12 years were included. Initial presenting signs were unilateral and included exophthalmos, enophthalmos, globe deviation, thickening and protrusion of the third eyelid and conjunctival hyperemia. Computed tomography and magnetic resonance imaging identified heterogeneous space-occupying, contrast-enhancing orbital lesions in all cases. Sparing of the retrobulbar space was detected in four of five orbits. Histopathology revealed mixed inflammatory infiltrates of lymphocytes, plasma cells, and histiocytes. Immunohistochemistry was performed in two cases highlighting the presence of histiocytes and lymphocytes, predominantly T cells. Resolution of clinical signs was achieved in two cases managed with oral immunosuppressant medication (corticosteroids alone or combined with cyclosporine or azathioprine), one went into spontaneous remission, one resolved with topical corticosteroids, and one underwent exenteration. Recurrence occurred in two cases within 15 months of initial diagnosis and required further immunosuppressant medication. One case developed signs in the contralateral orbit within 8 months of presentation.

CONCLUSIONS

IOI is an uncommon condition in dogs. Its diagnosis relies on the combination of advanced imaging and histology. As in humans, it appears that spontaneous remission and recurrence may occur requiring long-term immunosuppressant medication.

Optic Perineuritis Associated With Cryptococcal Meningitis Presenting With a "Hot Orbit" in a Patient With Chronic Lymphocytic Leukemia

ABSTRACT

A 75-year-old man presented with 3 days of progressive left retro-orbital pain, eyelid swelling, tearing, and pain with extraocular movement. His medical history was significant for type II diabetes mellitus and chronic lymphocytic leukemia, stable on no therapy since diagnosis 8 years prior. The initial examination was significant for diffuse restriction of left ocular motility, marked lid edema, and mild dyschromatopsia. Computed tomography demonstrated asymmetric left periorbital soft tissue swelling and intraconal fat stranding with an irregular left optic nerve sheath complex and clear paranasal sinuses. He was hospitalized for orbital cellulitis and treated empirically with broad-spectrum intravenous antibiotics, but his visual acuity declined over the ensuing 2 days. Subsequent MRI demonstrated left-greater-than-right circumferential optic nerve sheath enhancement, and leptomeningeal enhancement. An orbital biopsy demonstrated monoclonal B-cell lymphocyte aggregation, whereas a lumbar puncture was positive for Cryptococcus antigen with subsequent demonstration of abundant Cryptococcus by Papanicolaou stain. The final diagnosis was optic perineuritis secondary to cryptococcal meningitis presenting with orbital inflammation. Although his clinical course was complicated by immune reconstitution inflammatory syndrome, symptoms and signs of optic neuropathy ultimately resolved after 1 month of intensive antifungal therapy.

Identification of Hub Genes Associated with Nonspecific Orbital Inflammation by Weighted Gene Coexpression Network Analysis

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.

Orbital myositis in systemic lupus erythematosus: a case-based review

Ocular complications occur in up to one-third of patients with systemic lupus erythematosus (SLE). Among them, orbital myositis (OM) is considered a rare manifestation that affects the extraocular muscles and causes pain and restriction with eye movement. We report a case of OM in a 48-year-old female with SLE and secondary Sjogren's Syndrome, who presented headache, periorbital edema, and painful ocular movements in both eyes, with no other systemic manifestations. An orbital magnetic resonance image revealed thickening of the right medial rectus and left lateral rectus muscles. Laboratory tests were normal and there was no further disease activity. The patient was treated with prednisone 1 mg/Kg/day with a resolution of symptoms. We found 13 additional cases of OM from our literature review (11 SLE patients and 2 with discoid lupus erythematosus). There was a female predominance in these cases with a mean age of 43.6 years (SD ± 16.9). Their main clinical features included eye pain, swelling, proptosis, diplopia, and limitations in extraocular muscles, while in most of them, there was no other active systemic manifestation. Treatment with steroids led to the complete resolution of symptoms in most of these patients. The available evidence suggests that it is essential to have a high index of suspicion for OM in SLE patients even when there is no systemic disease activity so that proper treatment is initiated early.

Orbital Muscle Enlargement: What if It’s Not Graves’ Disease?

Purpose of Review

To provide the radiologist with tools to recognize findings atypical for Graves’ ophthalmopathy and differentiate between the most important and common alternative causes of extraocular muscle enlargement on CT and MR imaging.

Recent findings

We introduce five ‘red flags’ representing features that are atypical for Graves’ ophthalmopathy: unilateral disease, atypical pattern of muscle involvement, adjacent structure involvement, restricted diffusion, and absence of pain.

Summary

About 95% of the cases with extraocular enlargement are due to Graves’ ophthalmopathy, other causes are less well known and recognized. The ‘red flags’ may aid in recognizing and suggesting alternative diagnoses.

Clinical, advanced imaging data and outcome of inflammatory and neoplastic orbital disease in 81 dogs and 16 cats in Australia (2010-2019)

OBJECTIVE

To characterize the clinical presentation, advanced imaging features, and outcome of orbital disease in a referral population of dogs and cats that underwent computed tomography (CT) or magnetic resonance imaging (MRI).

ANIMALS STUDIED

Client-owned animals.

PROCEDURES

Animals referred for orbital disease undergoing ophthalmic examination and either head MRI or CT were included. Demographic and imaging features were compared between animals diagnosed with inflammatory disease and neoplastic disease using Mann-Whitney U and Fischer's exact tests.

RESULTS

Ninety-seven animals (81 dogs and 16 cats) were included. Eighty-four and 13 patients underwent CT and MRI scanning, respectively. Inflammatory orbital disease was more frequently detected than neoplasia in dogs (59% vs. 41%) and cats (62% vs. 39%). Orbital cellulitis was the most common diagnosis in dogs (36/81, 44.4%) and cats (8/16, 80%). A foreign body was suspected in 36.1% of dogs with orbital cellulitis but only 3 were retrieved during orbitotomy. Multi-drug resistant bacteria were identified in 3 samples and influenced treatment plans. The most common neoplasms were sarcoma (10/30) and carcinoma (7/30) in dogs and lymphoma in cats (3/6). Imaging findings of osteolysis (p = 0.0002) and intracranial extension (p = 0.0001) were significantly associated with neoplasia in dogs. In contrast, osteolysis extension was present in cats with both inflammatory (7/10) and neoplastic (6/6) orbital disease.

CONCLUSIONS

Inflammatory disease, particularly orbital cellulitis, was more common than neoplasia in dogs and cats with orbital disease in our population. We recommend including bacterial culture and susceptibility as part of the diagnostic work up when orbital cellulitis is suspected.

[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.

Acute Proptosis in a Diabetic Patient: Diagnostic and Therapeutic Dilemmas

An elderly diabetic lady presented with a painful swollen right eye and blurred vision for one week, preceded by right eye redness for six months. Her right eye best-corrected visual acuity was finger counting at 1 m. There was right eye proptosis, limited extraocular muscle movements, corkscrew vessels, chemosis and elevated intraocular pressure, but no bruit. Fever was absent. Computed tomography of the brain and orbit showed thickened extraocular muscles and intraconal fat streakiness, with normal superior ophthalmic vein and concavity of the cavernous sinus. Intravenous antibiotics resulted in limited clinical improvement. The subsequent response to oral prednisolone was dramatic, with the improvement of visual acuity to 20/60 after three doses. In cases of atypical orbital cellulitis where antibiotics fail, one should consider differential diagnoses such as orbital inflammatory disease, vascular anomalies and masqueraders. We discuss the approach to the diagnosis of acute proptosis in a diabetic patient and highlight the role of corticosteroids in idiopathic orbital inflammatory disease.

Optic perineuritis

Optic perineuritis (OPN) is a rare inflammatory disorder in which the inflammation is confined to optic nerve sheath. It can be idiopathic or secondary to underlying systemic autoimmune disorder. It usually presents with unilateral progressive diminution of vision with pain on eye movements and optic disc oedema. Hence, clinically OPN mimics optic neuritis resulting in delayed diagnosis and suboptimal treatment. In contrast to optic neuritis, patients with OPN are usually of older age group and more likely show sparing of central vision. MRI is an important tool for diagnosis of OPN apart from optic nerve sheath biopsy. Perineural enhancement on MRI is diagnostic of OPN. Oral corticosteroid therapy gives dramatic and rapid improvement in signs and symptoms. Rapid tapering of steroids increases the risk of relapse. Overall, prognosis of OPN is generally good if adequate treatment is given timely.

Optic Perineuritis Associated with Nivolumab Treatment for Non-Small Cell Lung Cancer

We report the case of a 54-year-old man who was treated with nivolumab for recurrent squamous cell lung cancer. After 7 cycles of nivolumab treatment, the patient presented to our hospital with right eye vision loss. Gadolinium-enhanced magnetic resonance imaging of the brain showed enhancement around the optic nerve sheath. This finding and his symptoms led to the diagnosis of optic perineuritis (OPN). Steroid pulse therapy was administered twice although there was no remarkable improvement in his visual field defect. The relationship between OPN and nivolumab is unclear. However, immune-related adverse events caused by immune checkpoint inhibitors should be considered.

Periphlebitis of the Superior Ophthalmic Vein

Isolated orbital periphlebitis in the context of nonspecific orbital inflammation is rare. This case series describes 3 patients with periphlebitis of the superior ophthalmic vein, 2 of which were confirmed with pathology. All 3 cases had a history of Graves hyperthyroidism. Superior ophthalmic vein periphlebitis is a rare form of orbital inflammation presenting with proptosis and motility restriction yet few inflammatory signs. It may be associated with autoimmune hyperthyroidism and represent a rare feature of thyroid eye disease, or perhaps could be an overlap syndrome between thyroid eye disease and nonspecific orbital inflammation. Treatment response is variable and may require a prolonged course of steroids or other immunosuppressive medications.

Orbital Microscopic Polyangiitis With Secondary Angle Closure Due to Uveal Effusion

A 63 year-old man presented with 3 weeks of worsening, painless left-sided proptosis, ptosis, and diplopia. Examination of the affected eye revealed normal visual acuity, normal intraocular pressure in the presence of a shallow anterior chamber, grade 1 relative afferent pupillary defect, restricted motility in all directions of gaze, and 6 mm of proptosis. Ultrasound biomicroscopy revealed uveal effusions with anterior rotation of the ciliary body causing appositional angle closure. B-scan ultrasonography and MRI demonstrated enhancement of the posterior globe and an infiltrative mass involving the lacrimal gland and multiple extraocular muscles. Laboratory studies revealed positive perinuclear antineutrophil cytoplasmic antibody with elevated myeloperoxidase antibodies, consistent with a diagnosis of microscopic polyangiitis. Biopsy showed nonspecific dacryoadenitis. Intravenous and oral corticosteroids were associated with rapid improvement of all examination findings. The patient was later switched to rituximab steroid-sparing therapy and has shown no recurrence of disease at 3-months follow-up.

Graves' orbitopathy: a multidisciplinary approach

Orbitopathy is the main extra thyroidal manifestation of Graves' disease. It is a very challenging condition, which requires a cooperation between many specialists (endocrinologists, ophthalmologists, radiologists, radiotherapeutic, orbital surgeons) for an optimal clinical management. An accurate diagnostic assessment is required, in order to plan an adequate treatment of Graves' orbitopathy. Medical therapy, radiotherapy or surgery may be necessary to control the disease. In this review, the authors analyze the various therapeutic strategies, as well the more recent therapies based on pharmacologic immunomodulation.

Optic Perineuritis and Its Association With Autoimmune Diseases

Background: Optic perineuritis (OPN) is a special optic neuropathy that has a distinct etiology from neuromyelitis optica spectrum disorders (NMOSDs) or multiple sclerosis (MS)-related optic neuritis (ON). The mechanisms of how this inflammation developed and invaded the nerve sheath remain unknown. This study is aimed to analyze the etiology and different clinical characteristics of OPN in a Chinese patient population. Methods: Neuro-ophthalmological examination, orbit magnetic resonance imaging (MRI) and a series of blood samples were used in this retrospective observational cohort study to compare characteristics of OPN with idiopathic demyelination optic neuritis (IDON). Results: Forty-four OPN cases (74 eyes) and 61 IDON cases (78 eyes) were analyzed. OPN cases included 33 cases (59 eyes) were associated with specific autoimmune diseases, 10 cases (13 eyes) were associated with infection diseases, 1 case was idiopathic disease. The causes of OPN with CTD were Graves' disease, Immunoglobulin G4-related disease (IgG-4 RD), granulomatosis with polyangiitis (GAP), systemic lupus erythematosus (SLE), Sarcoidosis, Rheumatoid arthritis, scleroderma, Behcet's disease, and gout. All patients received orbital MRI. Overall, 33 cases showed orbit fat infiltration. Specifically, nine cases with IgG-4 RD showed trigeminal nerve branch involvement, 12 cases with Graves' disease showed extraocular muscle belly enlargement, and 4 cases with GAP showed pterygopalatine fossa pseudotumor. Compared to IDON patients, OPN patients were older (p = 0.004) and more likely bilateral involvement 26 (78.79%) patients had bilateral involvement in OPN group vs. 17 (27.87%) in the IDON group (p < 0.001). Visual acuity scores using LogMAR testing was better in OPN patients compared to those with IDON, 0.55 ± 0.91 vs. 1.19 ± 1.24 (p < 0.001). Other ophthalmologic findings unique to the OPN group include 11 (33.33%) cases of ptosis, nine (27.27%) cases of diplopia, and 10 (30.30%) cases of exophthalmos, compared to zero cases of these conditions in the IDON group. Eight (13.11%) IDON patients also had multiple sclerosis (MS) and 7 (11.48%) patients had neuromyelitis which was significantly more than the zero patients in OPN group (p = 0.04). Conclusions: OPN had distinct etiologies and clinical characteristics from IDON and is more often associated with autoimmune diseases. Using OPN characteristics to diagnose autoimmune diseases should prove useful for clinicians when presented with patients that have multiorgan dysfunction that include ophthalmologic findings.

Orbital tumour or a retained foreign body? An uncommon case of missed diagnosis

We report a case who presented with decreased vision, significant hypotropia, proptosis and gross limitation of extraocular motility for one year. Suspecting an orbital tumour, we asked for a computed tomography of the orbit which revealed a mass lesion in the inferior orbit. However, incisional biopsy reported inflammatory infiltration. Diagnosing it as orbital inflammatory disease, a course of oral steroids was given for four weeks. It was only after the reduction in inflammation that a foreign body was palpable in the inferior fornix. Surgical exploration revealed a large wooden foreign body measuring 3.3 × 1 × 0.3 cm. Though intraorbital foreign bodies are not rare, ambiguous history, delayed presentation and nonspecific CT findings made this case diagnostically challenging.

Usefulness of point-of-care ultrasound for the evaluation of non-traumatic eye emergencies

The role of clinical ultrasound or Point-of-Care Ultrasound (POCUS) in patients with urgent pathology has expanded exponentially in recent years. With clinical ultrasound, physicians can make a quick assessment and decide how to act in time critical situations. Ocular ultrasound is one of the most recently developed applications. In patients with severe non-traumatic ocular pathology it has numerous clinically relevant uses: retinal detachment, occlusion of the central retinal artery or optic nerve pathologies, among others. The technique is widely available, easy to perform, and can provide information even when fundoscopy is impossible. In this review, we describe the bases of clinical ocular ultrasound, focusing on the management of the main non-traumatic urgent ophthalmological pathologies that the physician may face in their clinical practice.

Imaging of Lacrimal Gland Pathologies: A Radiological Pattern-Based Approach

Despite their unassuming size, lacrimal glands can have a variety of pathologies affecting them which often poses a diagnostic challenge clinically in view of their nonspecific presentation as palpable lump in the superolateral aspect of the orbit. There are a myriad of pathological entities ranging from inflammatory to neoplastic lesions that can affect the lacrimal glands. Cross-sectional imaging is must for the detection, characterization, and mapping of these lesions. In this pictorial review, we propose a radiological pattern-based approach for various lacrimal gland lesions that provides a working algorithm for radiologists in the evaluation of lacrimal gland pathologies.

Histopathologic Findings in Idiopathic Orbital Myositis

PURPOSE

To report the histologic and clinical features of idiopathic orbital myositis (IOM) patients who underwent extraocular muscle (EOM) biopsy over 20 years, to provide the first methodical reference to the expected histopathologic findings, and to discuss the histopathologic differences from common differential diagnoses.

DESIGN

Cohort study.

PARTICIPANTS

All patients with a diagnosis of IOM who underwent EOM biopsy from 2000 through 2019 were included. Patients who had a different final diagnosis were excluded.

METHODS

Tissue samples of EOM and medical records of all participants were reviewed.

MAIN OUTCOME MEASURES

Histopathologic features of muscle biopsy, including tissue morphologic features and cellular composition.

RESULTS

Thirteen patients met both inclusion and exclusion criteria, and their tissue samples were revisited. Nine patients showed histopathologic findings that suggested a conclusive diagnosis of IOM, and the study focused on them. The average age at presentation was 49 years, and 66.7% of patients were women. The most commonly biopsied EOM was the medial rectus (44.4%). The most common indications for biopsy were nonresolving orbital disease with inadequate response to corticosteroids (44.4%) or a high suspicion of malignancy because of known pre-existing systemic malignancy or the presence of an atypical orbital mass in addition to enlarged muscles (44.4%). The histopathologic findings that suggested a diagnosis of IOM were splaying of muscle fibers by inflammatory infiltrates (n = 9) and mild fibrosis (n = 8) in the endomysium or replacing muscle fibers, with no granulomas or vasculitis. The inflammatory infiltrates identified were of chronic inflammatory cells, consisting of lymphocytes (n = 9), plasma cells (n = 6), and histiocytes (n = 6). Other less commonly identified cells were eosinophils (n = 4), polymorphonuclears (n = 1), and giant cells (n = 1). Muscle fiber degeneration or regeneration was evident in 5 patients. Four patients from the initial cohort showed inconclusive histologic findings on revision and were reassigned as suspected IOM.

CONCLUSIONS

The histopathologic features of involved muscles in IOM resemble those seen in idiopathic orbital inflammation and differ from those seen in common differential diagnoses. Extraocular muscle biopsy should be strongly considered whenever the presentation of orbital myositis is not typical or when significant underlying conditions are a possibility.

Multimodality imaging manifestations of Rosai-Dorfman disease

Background

Rosai-Dorfman disease (RDD) is a rare lympho-histiocytic disorder of indeterminate etiology usually presenting with lymph node involvement, and infrequently with extra-nodal manifestations. The diagnosis of this condition is challenging due to the wide spectrum of disease manifestations.

Purpose

To elucidate the radiologic features of this disease using multimodality imaging in histopathologically proven cases and to identify characteristic features that would enable its differentiation from its mimics.

Material and Methods

We retrospectively evaluated imaging studies of 19 patients with histopathologically confirmed RDD presenting to our institute between January 2004 and March 2016. Imaging modalities included magnetic resonance imaging (MRI), computed tomography, FDG-positron emission tomography (PET) CT, mammography, and ultrasonography.

Results

Lymphadenopathy was the most common imaging feature in our study, seen in 11 (57.8%) cases followed by sino-nasal involvement in 7 (36.8%) cases and intracranial masses in 5 (26.3%) cases. Bilateral homogeneously enhancing cervical lymphadenopathy with avidity on FDG-PET scans was the predominant abnormality on imaging. Sino-nasal involvement manifested as homogeneously enhancing soft-tissue masses occupying the paranasal sinuses. Intracranial disease manifested as sellar/suprasellar masses, dural-based lesions along the cerebral hemispheres and choroid plexus enlargement. Unusual disease manifestations included spinal, osseous, and breast lesions.

Conclusion

Due to the high likelihood of multifocal involvement, the recognition of RDD at one site necessitates screening of other sites for disease. Homogeneously enhancing, FDG-avid lymphadenopathy and sino-nasal masses in association with hypointense extra-nodal lesions on T2-weighted MRI are imaging features which could aid the diagnosis of RDD and facilitate its differentiation from pathologies that present in a similar manner.

Orbital diseases mimicking graves' orbitopathy: a long-standing challenge in differential diagnosis

Graves' orbitopathy (GO) is the most common cause of orbital tissue inflammation, accounting for ~ 60% of all orbital inflammatory conditions in the population aged 21-60 years, and for ~ 40% in the population aged > 60 year. GO is observed in 25-30% of patients with Graves' hyperthyroidism and more rarely in association with hypothyroid autoimmune thyroiditis. In addition, a small proportion of GO patients (1-2%) do not have a clinically overt thyroid dysfunction. Clinically, GO is characterized by proptosis, inflammation involving the eyelids and the conjunctiva, extraocular muscle hypertrophy, with consequent reduction of ocular motility and diplopia, and in the most severe cases, compression of the optic nerves at the orbital apex, with reduction of visual acuity. At CT scan or MRI, a muscle increase involving the superior, medial and inferior rectus is quite typical. In the most severe forms, compression of the optic nerves at the orbital apex can be observed. Euthyroid GO is usually an early sign of a full-blown Graves' disease; however, in some cases, the orbital disease can remain isolated. Moreover, euthyroid GO can rarely be unilateral, which makes the picture even more confusing. Under those circumstances, the diagnostic process becomes obviously quite difficult, having other conditions mimicking GO been excluded. A number of inflammatory conditions affecting orbital tissue can mimic GO, thereby requiring an accurate evaluation for a proper differential diagnosis. The majority of these conditions are immune mediated. Most of them are benign, but they can be rather aggressive and some can cause visual loss. The most common inflammatory condition affecting orbital tissues and mimicking GO is idiopathic orbital inflammation. Other, more rare, orbital diseases that should be considered in the differential diagnosis are infections, orbital manifestations of systemic diseases, primitive and secondary orbital neoplasms, and orbital vascular alterations. In most instances, when an orbitopathy occurs in the absence of hyperthyroidism, the diagnosis of the disease underlying the ocular symptoms and signs is based on exclusion of the other conditions. Here we review the conditions that can mimic GO and how to distinguish them from this obnoxious eye disease.

Orbital compartment syndrome as the first manifestation of SLE

The occurrence of orbital compartment syndrome is a rare and unusual complication of systemic lupus erythematosus (SLE). Patients will present with symptoms of ocular pain and diplopia and visible signs of proptosis. The condition is considered an ophthalmological emergency because the myositis involving the ocular muscles can cause irrevocable damage to the retina and optic disk, potentially leading to blindness. We report a case of a young African American male who developed orbital myositis with compartment syndrome as his initial manifestation of SLE. The patient underwent an emergent orbital decompression, followed by prompt initiation of immunosuppressant medications. To our knowledge, this is the first report of a case of myositis secondary to SLE complicated by compartment syndrome of the orbit.

PET/CT and PET/MRI in ophthalmic oncology (Review)

Orbital and ocular anatomy is quite complex, consisting of several tissues, which can give rise to both benign and malignant tumors, while several primary neoplasms can metastasize to the orbital and ocular space. Early detection, accurate staging and re-staging, efficient monitoring of treatment response, non-invasive differentiation between benign and malignant lesions, and accurate planning of external radiation treatment, are of utmost importance for the optimal and individualized management of ophthalmic oncology patients. Addressing these challenges requires the employment of several diagnostic imaging techniques, such as high-definition digital fundus photography, ultrasound imaging, optical coherence tomography, optical coherence tomography (OCT)-angiography, computed tomography (CT) and magnetic resonance imaging (MRI). In recent years, technological advances have enabled the development of hybrid positron emission tomography (PET)/CT and PET/MRI systems, setting new standards in cancer diagnosis and treatment. The capability of simultaneously targeting several cancer-related biochemical procedures using positron emitting-radiopharmaceuticals, while morphologically characterizing lesions by CT or MRI, together with the intrinsic quantitative capabilities of PET-imaging, provide incremental diagnostic information, enabling accurate, highly efficient and personalized treatment strategies. Aim of the current review is to discuss the current applications of hybrid PET/CT and PET/MRI imaging in the management of patients presenting with the most commonly encountered orbital and ocular tumors.

Optic perineuritis secondary to hyaluronic acid injections: a case report

BACKGROUND

Although a safe, excellent administration method for hyaluronic acid derivatives has been documented; improper injections can lead to devastating and irreversible consequences. Here, we present the first known case of optic perineuritis caused by hyaluronic acid.

CASE PRESENTATION

A young female experienced sudden orbital pain in the right eye after receiving hyaluronic acid injections to the eyebrows. She presented to the eye clinic two weeks later, after developing blurred vision in the right eye. Visual acuity was reduced significantly in the right eye. Automated visual field examination showed defects in both eyes. Fundus examination revealed bilateral swelling of optic discs. Magnetic resonance imaging of the brain demonstrated bilateral perineural enhancement consistent with optic perineuritis. The patient was treated with retrobulbar injection of hyaluronidase and oral prednisolone. Her vision improved with treatment.

CONCLUSIONS

The prognosis for visual outcomes in patients with optic perineuritis is generally excellent. However, a poor prognosis is associated with delays to the initiation of treatment. Recognizing this condition is important, and treatment with corticosteroids should be initiated early.