|Year : 1966 | Volume
| Issue : 2 | Page : 94-96
Orbital myositis associated with acute sclerotenonitis
Dept. of Ophthalmology, Medical College, Aurangabad, India
|Date of Web Publication||12-Jan-2008|
D L Maria
Dept. of Ophthalmology, Medical College, Aurangabad
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Maria D L. Orbital myositis associated with acute sclerotenonitis. Indian J Ophthalmol 1966;14:94-6
Myositis has an important place among orbital pseudotumours. According to Francois, Rabey and Evans (1956), it occurs in three forms, degenerative (congenital and acquired), acute and chronic. About 73 cases have been reported in the literature according to Sureyya Gorduren (1962). Orbital myositis may show entirely different clinical forms and therefore some cases may be misdiagnosed even after careful investigations and operation (Valiere-Vialeix, 1948, Francois and others, 1956, Varcea and Vaighel, 1957). Pure orbital myositis is extremely rare. Bertelsen (1960) claimed that many cases reported in the literature were mostly complicated by associated sclerotenonitis or cellulitis.
Confirmation of diagnosis is difficult as the clinical features can be mimicked by many conditons so that the differential diagnosis covers a wide field. This was well demonstrated by Covens (1951). Treatment of the lesion can be rational only when the causation is understood. Even today the etiology remains clinically obscure in many cases, though pathological examinations reveal the cause in some, and clinical follow up enables to trace the causative factor in others. This explains the lack of standardized treatment as most writers have agreed that numerous factors may produce orbital pseudotumours.
The condition occurs mostly in males. The average age at onset is 40, but Colley (1935), has seen it in a child aged 12 years. No such case so far appears to have been reported from India. Due to the rarity the following case is being reported.
| Case Report|| |
A boy aged 13 years was admitted to the Ophthalmic department of the Government Medical College, Aurangabad on 4-1-1964 with bilateral exophthalmos of two days duration with mild pyrexia of 99°F. Prior to his admission to this hospital he was treated in a mission hospital at Jalna for a continuous low grade fever. Patient was constantly complaining of frontal headache and pain in the eye balls.
Local examination of the eyes: Both eyes were axially proptosed. (22 mm RE, 20 mm LE). The proptosis was slightly reducible. There was ptosis of the right upper lid. A firm nodular swelling could be palpated along the supraorbital margin in both eyes. There was marked chemosis involving the lower part of the conjunctiva which was covering on both sides, the lower part of the cornea, more so on the right side. There was slight exposure keratitis on the right side. Movements of the eyeballs were painful and restricted on all sides, the eye balls maintaining the primary position. The anterior chambers and iris were normal.
Pupillary reaction was sluggish on the right side, normal on the left side. Fundus examination was possible only on the right side which revealed oedema of the disc, with haemorrhages, engorgement of veins and oedema of the retina surrounding the disc. Vision in both the eyes was reduced to hand movements. There was no enlargement of preauricular glands (plate l). General physical examination revealed that the patient was anaemic and slightly toxic. There was no other positive finding of any importance. After a few days the anaemia became severe for which blood transfusion of 200 cc. was given.
| Investigations|| |
Blood count showed a high leucocytic count of 30,000 with 78% lymphocytes, and 18% polymorphs. There was hypochromic anisocytosis. Haemoglobin was 12,E on admission. The E.S.R. was 11 mm. after the first hour.
The bone-marrow showed a normoblastic reaction, there was no evidence of any leucocytic changes and the iron reaction was negative.
All other serological and laboratory tests including lumbar puncture, examination of stools and urine were normal and non-contributory.
X-Ray examination of the skull, orbits and chest did not reveal any abnormality.
Orbital aspiration and surgical biopsy were purposely avoided.
Bone marrow was normoblastic in reaction. There was no evidence of leucocytic changes and was negative for iron reaction.
| Treatment and Progress of the Case|| |
Treatment was started with high doses of crystalline penicillin which showed no response. Later on tetracycline and prednisolone were started in heavy doses. Patient started showing signs of improvement as regards proptosis and chemosis but her anamia became too severe (haemoglobin 3%,) for which blood transfusion of 200 cc. was given along with other antianaemic measures. After a few days the patient's general condition improved remarkably and chemosis completely disappeared from the left eye with marked improvement in proptosis, the vision improving to finger counting at 4 m.
Fundus picture showed regressive oedema with absence of haemorrhages. The patient developed a corneal ulcer on the right side though chemosis was much less, probably due to heavy doses of corticosteroids. The corneal ulcer healed under treatment with a dense central leucoma. Blood picture went on improving towards normality. Patient was discharged on 8-2-64 with complete recovery of proptosis in both the eyes and marked improvement of vision in the left eye. Vision in the right eye was finger counting 2 feet (plates 2 and 3).
| Discussion|| |
It has been seen from previous reports that most of these cases were males, average age being 40 years except for two cases in which the ages were 12 and 13 years (Colley 1935 and Sureyya Gorduren 1963). Our case was a male, 13 years old.
Most of the reported cases came with unilateral exophthalmos involving the second eye after a long interval but the present case was admitted with a bilateral onset. As it has been pointed out in the introduction that the clinical picture of sclerotenonitis with myositis is variegated and the diagnosis difficult, this case made us think about various causes of bilateral axial exophthalmos of acute onset. These varied causes were ruled out with the help of clinical appearance and progress of the case and special laboratory investigations. I will like to stress that the surgical biopsy and orbital aspiration were purposely omitted (as pointed out by Sureyya Gorduren 1962) for fear of aggravation of the condition. The etiology is still obscure. It is now clear that tuberculosis, syphilis and focal infections play no important part in the disease. Poisoning, avitaminosis, heredity, allergy, glandular dysfunctions, infectious disease and trauma have also been suggested as etiological factors. In view of the remarkable improvement with broad-spectrum antibiotics, the most likely cause in our case should be infection, the nature of which could not be determined.
| Summary|| |
A case of bilateral axial exophthalmos of acute onset in a boy of 13 years is reported, clinically diagnosed as sclerotenonitis with orbital myositis of mild degree which responded to heavy doses of corticosteroids with broad spectrum antibiotics. At the time of discharge the patient's ocular mobility was perfectly normal with vision reduced to finger counting 2 feet in right eye due to leucoma and 6/ 12 vision in the left eye.
| References|| |
Bertelsen, T. I., (1960), Act Ophthal (Kbb) 38, 136.
Colley, T., (1935), Brit. J. Ophthal, 19, 93.
Cowan. T. W. (1951), A.M.A. Arch. Ophthal 46, 390.
Francois, J. Rabaey, M., and Evans, L. (1956). Ophthalmologica, 131, 105.
Sureyya Gorduren, (1962), Brit. J. Ophthal. 46, 568-572.
Valiere Vialeix, (1948), Ann. d'Oculist 181, 1.
Vancea, M. P., and Vaighel, V. (1957), Arch. Ophthal. 17, 191.
[Figure - 1], [Figure - 2], [Figure - 3]