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Year : 2019  |  Volume : 67  |  Issue : 10  |  Page : 1714-1715

Systemic sarcoidosis presenting as optic nerve head granuloma

Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission28-Nov-2018
Date of Acceptance26-Apr-2019
Date of Web Publication23-Sep-2019

Correspondence Address:
Dr. Vinod Kumar
Retina, Uvea and ROP Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1979_18

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Keywords: Optic nerve head granuloma, sarcoidosis, transbronchial lung biopsy

How to cite this article:
Padhy SK, Kumar V. Systemic sarcoidosis presenting as optic nerve head granuloma. Indian J Ophthalmol 2019;67:1714-5

How to cite this URL:
Padhy SK, Kumar V. Systemic sarcoidosis presenting as optic nerve head granuloma. Indian J Ophthalmol [serial online] 2019 [cited 2020 Aug 13];67:1714-5. Available from: http://www.ijo.in/text.asp?2019/67/10/1714/267414

A 41-year-old male patient presented with floaters and decreased vision OD for 3 months. The vision was poor in OS since childhood. Systemic review revealed intermittent dyspnea, weight loss, and fatigability for 8 months.

Examination revealed a best corrected visual acuity (BCVA) of 6/24 right eye and 1/60 left eye. Anterior segments and intraocular pressure were normal in both the eyes. There was no RAPD. Left eye revealed unilateral hypermetropia of +8 diopters and amblyopia. Dilated fundus of right eye revealed minimal vitritis and a 2-disc diameter large optic disc granuloma [Figure 1]a obscuring the optic disc. Overlying tortuous blood vessels, few hard exudates, flame-shaped hemorrhages, sheathing of blood vessels, and ILM folds at the posterior pole were present. Swept source OCT (SSOCT) through the lesion demonstrated presence of elevated lesion with shadowing underneath [Figure 2]a. In addition, vitreous attachment was seen attached to the surface of granuloma.
Figure 1: Color fundus photograph of right eye showing a large optic nerve head granuloma of approximately 2DD size (a), showing regression of the size of the granuloma at 2-month follow up (b), and slight increase in size at 6.month follow up (c)

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Figure 2: Swept source image through the granuloma demonstrating presence of an elevated lesion with shadowing underneath (a), decrease in both extension and height of the lesion at 2 months (b) but slight increase in height of the lesion noted at the 6th month of follow up (c)

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Complete blood count, liver, and kidney function tests were normal. Mantoux reading was 0 mm at 48 hrs. Serum angiotensin converting enzyme levels were elevated at 276 IU/L (8-52 IU/L). HRCT scan showed bilateral hilar lymphadenopathy. Transbronchial lung biopsy demonstrated presence of noncaseating granulomas, which were reticulin and acid-fast bacilli negative confirming pulmonary sarcoidosis. Patient was started on oral prednisolone 1mg/kg/day dose along with oral calcium supplements and proton pump inhibitors. Regression of granuloma was noted at two months [Figure 1]b and [Figure 2]b and BCVA improved to 6/9 in right eye, which was maintained at 6-month follow up though the granuloma had increased in size [Figure 1]c and [Figure 2]c. Patient was on continued on 10 mg/day oral steroid. Since the patient was asymptomatic and vision was stable, we didn't consider increasing the steroid dosage or starting of immunomodulators.

Ocular sarcoidosis, the commonest type of extra thoracic sarcoidosis, has been reported in 21–80% cases.[1] Optic nerve involvement (approximately in 1% cases) in sarcoidosis has been divided in to 5 different categories: optic disc edema secondary to posterior uveitis, optic disc edema secondary to raised intracranial pressure, optic neuritis, optic atrophy secondary to compression or infiltration and primary granuloma of the optic nerve head.[2] Sarcoid optic nerve involvement should be recognized and treated early to prevent visual field and vision loss. These lesions respond well to corticosteroids or steroid sparing immunosuppressants.[3] Ocular sarcoid can be the initial presentation of the multisystem disease as in our case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Lee SY, Lee HG, Kim DS, Kim J-G, Chung H, Yoon YH. Ocular sarcoidosis in a Korean population. Korean Med Sci 2009;24:413-9.  Back to cited text no. 1
Ingestad R, Stigmar G. Sarcoidosis with ocular and hypothalamic pituitary manifestations. Acta Ophthalmologica 1971;49:1-10.  Back to cited text no. 2
Ganesh SK, Kaduskar AV. Optic nerve head granuloma as a primary manifestation of ocular sarcoidosis-A tertiary uveitis clinic experience. Oman J Ophthalmol 2015;8:157-61.  Back to cited text no. 3
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