Case #9 (03-26-2004)

[Andrew_Doan]

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CC: 60 y.o. man who was evaluated 1 wk ago for ?conjunctivitis? OS by internal medicine.

HPI: Patient complained of a painless, gradual redness of his left eye over the last several months. He does not report any pain, discharge, discomfort, or itching. He presented to the on-call ophthalmologist for evaluation. He pointed to some fullness of the superior aspect of the medial canthus OS with mild conjunctival injection. Pt also complained that things were "blurry" with a slight double image, which resolved when one eye was closed separately.

PMH: h/o non-Hodkin's lymphoma and in remission for numerous years. No other ocular history or medical problems. No h/o of ocular traumas or sugeries.

EXAM
Best corrected visual acuities: 20/20 OU.
Pupils: 4.5->3.5, no RAPD
EOM: elevation deficit OS with left hypotropia in primary gaze; VF Full to FC OU
IOP: 18 mmHg OD, 19 mmHg OS
DFE: retina exam notable for normal macula, vessels, and periphery OU. Optic nerves, normal.
SLE: OD normal, OS see photos below.

Hertel (base 113): 13 mm OD and 17 mm OS

EOM: Note the left hypotropia in primary gaze and elevation deficit OS with upgaze.

Left eye with superior conjunctival injection.

Left medial canthus with fullness. Note the asymmetric ptosis OS (more ptosis medially).

Feel free to discuss the following:

What tests should you order (I'll post labs when asked for them)?

What's the differential diagnosis?

What's the diagnosis?

What is the treatment of choice, surgically and/or medically?

 

[Redhawk]

He appears to have orbital involvement causing left proptosis and diplopia. Do you have an MRI?

Lymphoma can mimic conjuctivitis. I would think that the lack of itiching or burning would raise suspicions even higher.

 

[Kalel]

Yup, I agree. Lymphoma causing a mass effect in the orbit is the most probable diagnosis. The only other dx's in the differential that I could think about was cavernous venous thrombosis or some weird case of neurosarcoidosis? Anyways, w/u would begin with an MRI. If a tumor is seen, a CT of the whole body should be ordered to stage, and optho might be able to do a biopsy or needle aspiration to confirm the dx. CBC, CMP, HIV test, beta 2 microglobulin, LDH, HTLV should also be ordered.

 

[Andrew_Doan]

I got a CT because it's faster, and I wanted to see the boney architecture.

Coronal without contrast

Axial without contrast

 

[Redhawk]

Did you do a FNAB for histopathologic diagnosis? Does one typically try an FNAB prior to open biopsy, or just jump to open biopsy?

http://insight.med.utah.edu/opatharch/orbit/orbital_lymphoma.htm

 

[Kalel]

I was just thinking that an invasive biopsy may not be indicated in this case since the patient has already earned a previous dx of lymphoma. Given that the patient has compressive sx, he is probably indicated for a surgical intervention anyways. A full physical exam and a full body ct should still be done with my previously reccomended labs; the exam and scan may turn up some easier sources for histology.

 

[Andrew_Doan]

Originally posted by Kalel
A full physical exam and a full body ct should still be done with my previously reccomended labs; the exam and scan may turn up some easier sources for histology.

Originally posted by Redhawk
Did you do a FNAB for histopathologic diagnosis? Does one typically try an FNAB prior to open biopsy, or just jump to open biopsy?

I don't think we can get enough tissue for diagnosis with a FNAB. Path diagnosis of lymphoma requires multiple stains and to look at the organization of the lymphocytes, e.g. are they forming germinal centers. FNAB would make it very difficult to analyze.

Excisional biopsy is the most appropriate method to confirm the diagnosis. It's important to make a definitive diagnosis before treatment. The patient did have a full body CT scan which was negative.

The diagnosis and discussion are posted on the Iowa site:
http://webeye.ophth.uiowa.edu/eyeforum/case9.htm