In this week’s issue

Journal: AJOCR 

Written by: Sophie Gorup 

Sarcoidosis: The great mimicker 

Always broaden your differential. Sarcoidosis is a systemic granulomatous disease that can affect any organ, including the eye. In the eye, sarcoidosis typically presents as uveitis or glaucoma. Rarely, sarcoidosis manifests as intraosseous pathology leading to intraorbital compression of the optic nerve. 

This case describes a 72-year-old male presenting with progressive vision loss in the left eye months after uncomplicated cataract surgery. Imaging revealed an intraosseous mass compressing the left optic nerve – sarcoidosis masquerading as a meningioma. Due to severe visual decline, he underwent a left orbitozygomatic craniotomy for gross total resection and debulking of the left sphenoid wing/clinoidal intraosseous mass and decompression of the left optic nerve. Pathology identified the mass as intraosseous sarcoidosis. The patient then underwent autoimmune testing and tested positive for serum markers for sarcoidosis (ACE and lysosomal), but no pulmonary or visceral manifestations were found on imaging. Postoperatively, his vision was stable, and he began prednisone and methotrexate therapy with guidance from Rheumatology. 

Ultimately, this case shows that even without systemic disease, sarcoidosis should remain a key part of the differential for vision-threatening skull-based lesions. 

Image:

(A) Axial T1 Fat Suppressed MRI of the orbit showing a compressive intraosseous lesion of the left orbital apex with tumor mass also located in the anterior cranial fossa (B) Coronal T1 Fat Suppressed MRI of deep orbital apex mass.

A 41-year-old male presents to the ophthalmology clinic with a complaint of a few days of blurriness in his right eye after passing out candy for Halloween at his house. He reports no pain in either eye but notes that objects appear slightly smaller and “weirdly bent” when looking at them with his affected eye. His past medical history is significant for seasonal allergies for which he uses fluticasone. He appears anxious during the encounter and reports he has been under significant stress at work for the past few weeks. Vital signs within normal limits. Visual acuity is 20/40 OD and 20/20 OS. Slit lamp examination is unremarkable. Dilated fundus exam reveals a localized, circular, dome-shaped elevation of the retina in the central macula without hemorrhage, exudates, or drusen. Optical coherence tomography (OCT) demonstrates subretinal fluid accumulation with a serous detachment of the neurosensory retina. What is the most appropriate next step in management?

A. Discontinuation of the fluticasone nasal spray

B. Immediate focal laser photocoagulation

C. Oral prednisone 60 mg daily followed by a taper

D. Intravitreal ranibizumab injection

E. Urgent pars plana vitrectomy

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