Duncan P. Anderson

Orbital infarction and melting in a patient with systemic lupus erythematosus

OBJECTIVE To present a patient with systemic lupus erythematosus who developed infarction and melting of the orbit secondary to her systemic disease. DESIGN A case report. PARTICIPANT A 61-year-old white woman with a 5-year history of systemic lupus erythematosus. METHODS The patient presented with left orbital pain, limitation of extraocular movements, and a fistula from the ethmoid sinus to the upper eyelid. A detailed examination with computerized tomography, ultrasound, and a comprehensive medical evaluation with laboratory testing was performed. Histopathologic analysis with special stains of the orbital tissues was also performed. RESULTS Histopathologic examination of the biopsy specimens revealed the features of an inflammatory process involving the orbit, similar to a panniculitis. These include a lymphocytic reaction with a predominance of plasma cells, vasculitis with occlusion, and thickening of the vessel walls, necrosis, and hyalinization of fat. CONCLUSION This is a unique case in which infarction and melting of the entire orbital structures occurred in the presence of systemic lupus erythematosus. The underlying disease process is a lupus-related panniculitis. The authors stress that this is a very rare entity and that other diseases should be ruled out before entertaining this diagnosis.

Orbital inflammation and optic neuropathy with zoledronic acid for metastatic prostate cancer

Bisphosphonates are commonly used for the treatment of osteoporosis, skeletal metastases, and other metabolic disorders such as Paget’s disease. Adverse effects include inflammatory conditions such as conjunctivitis, uveitis, and scleritis. There have been 4 reported cases of orbital inflammatory disease due to intravenous bisphosphonates treated successfully with corticosteroids. We report a case of orbital inflammation and ischemic optic neuropathy after zoledronic acid administration. A 68-year-old male with metastatic prostate cancer and hypertension developed redness and pain of the right eye 24 hours after intravenous zoledronic acid administration. The pain was worse with eye movement. One week after the onset of pain and redness, he had sudden visual loss in the right eye. Two weeks after onset, he presented with visual acuity of 20/400 OD and 20/30 OS. He had an inferior arcuate defect OD, confirmed by Goldmann perimetry (Fig. 1A). Pseudoisochromatic plates were not assessable OD and 16/17 OS. He had a right relative afferent pupillary defect. Intraocular pressures were 8 mm Hg OD and 12 mm Hg OS. Anterior segment examination revealed marked conjunctival chemosis with cells in the anterior chamber OD. There was no proptosis, and extraocular movements were normal. Fundoscopy showed diffuse swelling of the right optic disc (Fig. 1B). Fluorescein angiography showed a patch of delayed choroidal perfusion (Fig. 2A) and late leakage from the disc in the right eye. Ultrasound of the right eye showed a positive “T-sign,” indicating posterior scleritis. Computerized to mography demonstrated intraconal fat stranding in the right orbit. Magnetic resonance imaging revealed increased signal in the intraconal fat and optic nerve within the right orbit (Fig. 2B). Erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, antinuclear antibody, antidouble-stranded DNA antibodies, antineutrophilic cytoplasmic antibody, complement 3, complement 4, angiotensin-converting enzyme, and syphillis serology were normal, as were his chest x-ray and urinalysis. He was diagnosed with right orbital inflammation and anterior ischemic optic neuropathy. Treatment was commenced with oral prednisone, 100 mg daily, and ibuprofen, 400 mg daily. After 1 week, his conjunctival chemosis