J Korean Ophthalmol Soc.  2017 Oct;58(10):1183-1188. 10.3341/jkos.2017.58.10.1183.

A Case of Surgical Diagnosis and Treatment of Idiopathic Orbital Myositis with Sudden Vision Loss

• Lee DE
• Park BG
• Moon SH
• Yang JW

• KMID: 2393171
• DOI: http://doi.org/10.3341/jkos.2017.58.10.1183

Abstract

PURPOSE
We report a case of idiopathic orbital myositis with sudden onset of unilateral visual loss and hypertrophy of the lateral rectus muscle at the apex of the orbit that was diagnosed using orbital biopsy and treated with intravenous corticosteroids.
CASE SUMMARY
We examined a 20-year-old woman who complained of decreased visual acuity and binocular diplopia for 2 weeks. She showed 40-prism diopter left esotropia at the primary position. Her visual acuity with eyeglasses was 0.7 and 0.2 in the right and left eyes, respectively. Brain magnetic resonance imaging (MRI) revealed a round mass on the left lateral rectus muscle at the apex of the orbit with optic nerve compression. We planned orbital biopsy to exclude orbital lymphoma and other biopsy-requiring diseases. After 3 weeks, the visual acuity of her left eye decreased to 0.02. Repeated MRI revealed enlargement of all extraocular muscles on the left orbit. With biopsy showing several lymphocytes infiltrating muscle fibers, we made a diagnosis of idiopathic orbital myositis. Intravenous injection of corticosteroids was administered during hospitalization. After 2 weeks of corticosteroid therapy, the visual acuity of her left eye was improved to 0.63, the esotropia disappeared, and the enlargement of the left lateral rectus muscle was improved on orbital MRI.
CONCLUSIONS
For non-specific idiopathic orbital myositis located at the apex of the orbit and enlargement of the extraocular muscle in a short period with decreased visual acuity, administration of intravenous injection of corticosteroids before orbital biopsy could help restore vision.

Keyword

Idiopathic orbital inflammation; Idiopathic orbital myositis; Orbital lymphoma

MeSH Terms

Adrenal Cortex Hormones
Biopsy
Brain
Diagnosis*
Diplopia
Esotropia
Eyeglasses
Female
Hospitalization
Humans
Hypertrophy
Injections, Intravenous
Lymphocytes
Lymphoma
Magnetic Resonance Imaging
Muscles
Optic Nerve
Orbit*
Orbital Myositis*
Telescopes
Visual Acuity
Young Adult
Adrenal Cortex Hormones

Figure

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  Figure 1. Humphrey automated perimetry central 30–2 threshold test results. (A) At the initial visit, Humphrey automated perimetry central 30–2 threshold test demonstrated generalized reduction of sensitivity of the left eye, mean deviation −10.01 dB with no specific pattern of visual field defect. (B) The day before surgery, Humphrey automated perimetry central 30–2 threshold test demonstrated deterioration of sensitivity of the left eye, mean deviation −21.67 dB with no specific pattern of visual field defect.

• 

  Figure 2. Patient's photographs. (A) At the initial visit, the patient showed 40 prism diopter left esotropia at the primary position and −3 limitation of lateral gaze of the left eye, however, there was no conjunctival injection, ptosis, chemosis or proptosis. (B) After 14 days of surgery, the patient showed ortho at the primary position and −1 limitation of lateral gaze of the left eye. (C) After 3 months of surgery, the patient showed ortho at the primary position and no limitation of lateral gaze of left eye.

• 

  Figure 3. Brain magnetic resonance imaging (MRI). (A) At the initial visit, T2 Axial MRI scan showing round shape mass on the left lateral rectus muscle at the apex of orbit. (B) T1 Axial MRI scan showing round shape mass on the left lateral rectus muscle at the apex of orbit. (C) T1 Coronal MRI scan showing enlargement of the left lateral rectus muscle at the apex of orbit.

• 

  Figure 4. Orbital magnetic resonance imaging (MRI). (A, B) The day before surgery, MRI scan showing suggestion of optic nerve compression due to enlarged muscles. (A) Enhanced T1 Axial MRI scan showing enlargement and enhancement of the left lateral rectus muscle and left medial rectus muscle with no involvement of tendon of both muscles. (B) Enhanced T1 Coronal MRI scan showing enlargement and enhancement of all extraocular muscles and lacrimal gland on the left orbit. (C, D) After 14 days of surgery, MRI scan showing resolution of optic nerve compression. (C) Non-enhanced and Enhanced T1 Axial MRI scan showing no enlargement of the left lateral rectus muscle and left medial rectus muscle. (D) Enhanced T1 Coronal MRI scan showing decrease of enlargement and no enhancement of all extraocular muscles and lacrimal gland on the left orbit.

• 

  Figure 5. Biopsy of lateral rectus muscle during the surgery. Biopsy showing several lymphocytes are infiltrated in muscle fibers (H&E, ×400).

Reference

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