The management of a 22-year-old woman with ocular sarcoidosis.
James Lowe of Eastbourne District General Hospital in England, and colleagues, explain the case of a 22-year-old woman with ocular sarcoidosis. The woman had a three-month history of red eyes and severely reduced vision in her left eye. She was experiencing vision loss, weight loss, facial swelling, night sweats and fatigue. Prior the presentation of these symptoms she was in good health. She was thin and pale on examination with her best corrected Snellen visual acuity was 6/5 on the right and 3/60 on the left. Slit lamp examination showed bilateral panuveitis (inflammation in the anterior and posterior segment). Her parotid glands were enlarged and two small volumn cervical nodes were palpable on the right. Â©SarcoidosisDesignuaShutterstock
A plain film chest radiograph showed symmetrical bilateral hilar lymphadenopathy. The main differential diagnosis for bilateral hilar lymphadenopathy, plus bilateral panuveitis and parotid gland involvement, is sarcoidosis or lymphoma. Sarcoidosis tends to have a symmetrical pattern; lymphoma tends to have an asymmetrical pattern. An ultrasound-guided biopsy of the right parotid gland was negative for acid fast bacilli, negative for cancer, but positive for infiltration of the lobules by non-caseating epithelioid granulomas, which confirmed sarcoidosis.Â©thailoei92ShutterStock
Because there is no specific diagnostic test, further tests are aimed at supporting a diagnosis of sarcoidosis or eliminating other diagnoses. The priority was preservation of vision. Most patients treated with corticosteroids regain normal vision. Topical agents may be sufficient but severe cases with posterior uveitis or optic nerve involvement require systemic treatment. In more severe cases, methotrexate is used (in preference to azathioprine or hydroxychloroquine), and infliximab was superor to placebo in a double blind study. Overall prognosis is good, with 54% of patients regaining normal vision and only 4.6% left with vision worse than 6/36 (20/120 U.S.) in both eyes.Â©ARZTSAMUIShutterStock
The patient was treated with oral prednisolone (starting dose of 40 mg a day) and topical steroid drops under ophthalmology. She was followed by ophthalmology over the course of the next month. Her vision returned to normal in both eyes in one month and her steroids were weaned at a rate of 5 mg a week until she was taking 20 mg once a day, then 5 mg a day until until her treatment course was completed. The vitreous inflammation continued to improve over the course of the next three months. Follow-up pulmonary function tests were normal. No oral steroids were necessary. The patient remains on a four-month follow-up schedule with her ophthalmologist and chest physician.Source: BMJ, Aug. 11, 2015. doi: 10.1136/bmj.h4178Â©MJTHShutterStock