|Year : 1984 | Volume
| Issue : 4 | Page : 195-199
Ocular involvement in sarcoidosis in India
Arup Das, Shyamal Chatterjee, SC Bagchi, Samir K Gupta
Department of Ophthalmology and Sarcoidosis Research unit Respiratory Diseases Department, Calcutta Medical Research Institute, Calcutta, India
S C Bagchi
Department of Ophthalmology, Calcutta Medical Research Institute, 7/ 2, Diamond Harbour Road, Calcutta-700 027
|How to cite this article:|
Das A, Chatterjee S, Bagchi S C, Gupta SK. Ocular involvement in sarcoidosis in India. Indian J Ophthalmol 1984;32:195-9
|How to cite this URL:|
Das A, Chatterjee S, Bagchi S C, Gupta SK. Ocular involvement in sarcoidosis in India. Indian J Ophthalmol [serial online] 1984 [cited 2013 Jun 18];32:195-9. Available from: http://www.ijo.in/text.asp?1984/32/4/195/27387
Sarcoidosis is considered to he a rare disease in tropical countries though 75 cases of proven sarcoidosis have been analysed lately in India. The incidence of ocular involvement in sarcoidosis has been variable in the Western countries,.
This study was undertaken during the period from 1978 to 1981 to assess critically the extent of ocular involvement in proven cases of systemic sarcoidosis and importance of conjunctival biopsy in the diagnosis of sarcoidosis.
| Material and methods|| |
Thirty four histologically confirmed cases of sarcoidosis with strong clinical, biochemical and radiological evidence of multisystem involvement formed the material of the present study. Following investigations were done in all these cases: Hb%, total and differential count of WBC, ESR (1 hour, Westergren), serum calcium, phosphorus, alkaline phosphatase, thymol turbidity, serum proteins with paper electrophoresis, serum transaminases, routine stool and urine examination, urinary calcium (on 3 successive days on milk-calcium restricted diet), Mantoux Tests (successively with 1 TU, 10 TU and 100 TU, if earlier tests were negative) and PA view of chest radiogaph (with lateral views, if necessary). Tomograms were done if there was any doubt regarding hilar adenopathy. Pulmonary function studies and blood gas studies were routinely done at rest and after exercise. Biopsy was taken from a number of sites like scalene node (right side), palpable lymph nodes, pleura, lung, liver, Kveim test site, skin etc.
A thorough slit-lamp examination and ophthalmoscopy were performed for both eyes in each case. Conjunctival biopsy was done in 13 cases. taking tissues from the suspected nodules in the lower fornix and also from the normal looking conjunctiva i.e. blind biopsy. Under local anaesthesia with a few drops of lignocaine 4% and with the help of a binocular loupe, a 2 mm x 2 nmm piece of conjunctiva was grasped with the forceps and removed with a scissors.
All these tissues were examined by three different pathologists without any knowledge of their clinical details, by routine H. & E. Stain as well as by Reticulin Stain. They were also checked against polaralized light for any birefringent material.
| Observation|| |
In our series of 34 histologically confimed cases of systemic sarcoidosis, only three patients (8.8%) had ocular involvement. Ocular findings in these 3 cases are reported below, with the results of investigations and biopsies [Table - 1]. The detailed investigationprofile of all these 34 cases are given in [Table - 2].
| Case reports|| |
CASE 1. A 54 year-old man came with the complaint of blurred vision in his right eye of one month duration (Visual acuity : 6/60). It was gradual in onset with very little pain. Slitlamp examination revealed oedema of the endothelium and a few "mutton fat" keratic precipitates. The iris was dull in colour and there were few deposits on the iris surface with posterior synechiae. A diagnosis of iridocyclitis was returned. It was treated with atropine and local steroids. His Kveim test was positive [Figure - 1].
CASE 2. A 19-year-old girl presented with pain, photophobia and diminution of vision in her right eye of one week duration (Visual acuity: FC at 4 ft.). Along with ciliary congestion, a small nodule, very tender at the limbus nasally, was seen. On slit-lamp examination, the aqueous flare and keratic precipitates were present. There was also posterior synechiae echiae at places with pigments on the lens surface. The case was diagnosed as episcleritis with acute iridocyclitis and treated with atropine and local steroids. She had a positive conjunctival biopsy done elsewhere but this was not confirmed by the reticulin stain. However her lung biopsy was positive for sarcoidosis [Figure - 2] as well as the liver.
CASE 3. A 45-year-old man was seen with a painless swelling of gradual onset of 6 months duration in the outer corner of the upper lid of his left eye. He also complained of foreign body sensation and discomfort in that eye. The palpable mass (2 cm. x 2 cm.) was non-tender. elastic with ill-defined margins and lobulated character. Tuberculosis of lacrimal gland was diagnosed elsewhere and anti-tuberculous treatment given. He had no benefit and was referred to our unit. The mass was excised and on histopathological examination it showed non-caseating multiple. uniform. epitheloid granulomas with giant cells, suggestive of sarcoidosis [Figure - 3]. He had a past history of recurrent iridocyclitis in both eyes.
In all 13 patients in whom conjunctival biopsy was done in our unit, the conjuncitval tissue showed no infiltration suggestive of sarcoidosis. Only case No. 2 had a positive conjunctival biopsy elsewhere but was not confirmed by reticulin stain. She had however positive sarcoid granuloma from other tissues.
| Discussion|| |
Ocular lesions are not uncommon in sarcoidosis patients in the Western countries. Uveitis is the most frequent manifestation the incidence varying from 27% to 50%,. Crick et al have demonstrated conjunctival nodules histologically in 14.3% cases of sarcoidosis, whereas Bornstein et al found the same in 25% cases of their series. Lacrimal gland involvement and episcleritis are among the less frequent findings reported in sarcoidosis,.
In our series of 34 proved cases of sarcoidosis, the eye involvement was rather uncommon (8.8%) with one case of iridocyclitis, one case of episcleritis with iridocyclitis and another case of lacrimal gland enlargement associated with recurrent iridocyclitis. In a series of 24 cases of sarcoidosis from Delhi, Chakraborty and Damodaran could not find a case of ocular involvement. In 17 other reported cases of sarcoidosis from India ocular lessions were found in two cases onlyone case with acute iridocyclitis and the other with primary optic atrophy and granulomatous iridocyclitis Compared to the Western series, the incidence of eye lesions in sarcoidosis seems to be less common in India. The same phenomenon is noticed with certain other lesions like bone cysts, erythema nodosum, bilateral hilar lymphedenopathy etc,.
Conjunctival biopsy has been found positive in varying frequency in some series of sarcoidosis (20% by Crick et a1,16% by Karma & Sutines). James et a1 have however doubted the role of conjunctival biopsy in diagnosis sarcoidosis (5 positive out of 442 confirmed cases). In our experience too, we have not been able to find the histological proofof conjunctival involvement in any case of proven sarcoidosis, even after selecting tissues from some of the suspected nodules in the lower fornices. The only positive result, reported from another hospital, could not be confirmed by reticulin stain and other diagnostic parameters.
| Summary|| |
Thirty four case of histologically proved sarcoidosis in Calcutta were examined for ocular involvement. The incidence of eye lesions was 8.8%, much less than that in the Western countries. It is interesting to observe that none of the conjunctival biopsy in 13 cases in this series came out to be positive.
| Acknowledgement|| |
Our thanks are due to Dr. S. Das, Medical Superintendent, Calcutta Medical Research Institute, and Dr. M. Roy, their help in the study.
| References|| |
|1.||Hinshaw,H.C.andMurrar.J.P.1980.Sarcoidosis: in Diseases of the Chest. 4th Ed.. W.B. Saunders. Philadelphia, P. 797. |
|2.||Gupta,SamirK.Chatterjee,S.&RoyM.,1982,Lung India. 1:5. |
|3.||Crick, R., Hoyle, C. and Smellie H., 1961. Brit, J. Ophthalmol..45:461. |
|4.||James. D.G., 1968. Trans. Opthalmol. Soc., UK 88:711. |
|5.||Woods., A.C. 1961 Endogenous Inflammations of the Uveal Tract. Willarns & Willkins. Baltimore. |
|6.||Bornstein. J.S., Frank, M.II and Raciner. D.B., 1961 New Eng. J. Med.. 267:60. |
|7.||Mitchell, D.N. Mikhail. J.R. and Jackson. H.. 1972, Revue Suisse de medicine, P. 144. |
|8.||Charkrahorty. S.C. and Damodaran, V.N.. 1978, J. Ind. Med Assoc., 70:97. |
|9.||Ahuja, G.K., Ramachandran. P. and Roy S.. 1979, J. Asso Phys. Ind. 27:1097. |
|10.||Agarwal, R.K., Dwivedi, S.. Gupta. R.. Shukla, S.K. & Dwivedi, M.. 1980. Ind Heart J. 82:389. |
|11.||James, D.G., Personal communication : 1982. |
|12.||Karma. A. and Sutinen. S.. 1975. Acta Ophthalmol. Supple., 125:52. |
|13.||James, D.G., Anderson, R., Langley, D. and Ainslie. D., 1964, Brit. J. Ophthalmol., 48:46 . |
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2]
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