Conjunctival biopsy in the diagnosis of sarcoidosis.

We prospectively studied 47 sarcoidosis suspects and compared conjunctival and transbronchial lung biopsies in these patients. Thirty-four patients had positive findings on biopsy by either method. The transbronchial biopsy was positive in 31 patients, and the conjunctival was positive in 19. The transbronchial lung biopsy was more likely to be positive in black patients (p = 0.009) and in patients with pulmonary infiltrates on chest x ray (p = 0.0044). In comparison, the conjunctival biopsy was more likely to be positive in patients with conjunctival follicles (p = 0.036), ocular abnormalities consistent with sarcoidosis (p = 0.02), and in patients with pulmonary infiltrates on chest x ray (p = 0.029). Iritis was present in 12 patients, enlarged lacrimal glands in three, and vitritis in five. We conclude that the conjunctival biopsy is an effective means of diagnosing sarcoidosis and that every sarcoidosis patient should have an ophthalmic examination.     

Value of conjunctival biopsy in the diagnosis of sarcoidosis

PURPOSE: Retrospective study concerning the value of conjunctival biopsy in the diagnosis of sarcoidosis. PATIENTS AND METHODS: Between 1990 and 1996 we performed conjunctival biopsy in 11 patients (mean age 42.7 +/- 16.4 years) with suspect of sarcoidosis. RESULTS: In 8 of the 11 patients the diagnosis of sarcoidosis was established during the clinical course. In four of these eight patients conjunctival biopsy was positive. Five of the eight were under systemic steroids at the time of biopsy. Of the four patients with clinically established sarcoidosis and negative biopsy, three were under systemic steroids at the time of biopsy. In two patients diagnosis of sarcoidosis was established primarily by conjunctival biopsy. CONCLUSION: Conjunctival biopsy is a simple tool in the diagnostic of sarcoidosis. If possible, biopsy should be undertaken before systemic steroid treatment. We consider conjunctival biopsy to be useful as the first diagnostic tool before other invasive methods.     

Conjunctival deposits as the first sign of systemic sarcoidosis in a pediatric patient

PURPOSE: Sarcoidosis is an inflammatory disease of unknown cause, characterized by noncaseating granulomas. In this study, the authors present a sarcoidosis patient without systemic signs diagnosed by histopathologic analysis of conjunctival deposits. METHODS: A 10-year-old girl had bilateral, focal, multilobular, multiple pale yellow deposits in bulbar conjunctiva for a year. In the patient's biomicroscopic examination, numerous 0.50- to 2-mm diameter pale yellow deposits were determined in both bulbar conjunctivas. The patient had no other systemic or ocular complaints. A conjunctival biopsy was performed. RESULTS: The biopsy specimens showed noncaseating granulomas with prominent asteroid bodies. Serum angiotensin-converting enzyme levels were increased in the patient. Conjunctival deposits were the first manifestation of sarcoidosis in the patient and the diagnosis of sarcoidosis was confirmed with a conjunctival biopsy. CONCLUSIONS: To the authors' knowledge, this is the second study that reports a sarcoidosis patient with non-systemic involvement diagnosed after histopathologic analysis of conjunctival deposits.     

Conjunctival biopsy of anophthalmic socket in sarcoidosis

A case of sarcoidosis was diagnosed by a random conjunctival biopsy from an anophthalmic socket. A 22-year-old black female patient presented with anterior and posterior uveitis and subconjunctival nodules in the left eye. Her right eye was enucleated due to a penetrating injury 3 years before admission. Biopsy of subconjunctival nodules in the left eye failed to demonstrate granulomatous inflammation; however, a random conjunctival biopsy from the normal-appearing anophthalmic socket conjunctiva revealed noncaseating granulomas. Conjunctival biopsy is a safe, cost-effective means of diagnosis in sarcoidosis suspects. To our knowledge, this is the first reported case of sarcoidosis confirmed with random conjunctival biopsy from an anophthalmic socket.     

Optic nerve enlargement and chronic visual loss

We present four patients with sarcoidosis of the anterior visual pathways. The first patient presented with unilateral visual loss, a mass lesion at the optic nerve head, and an enlarged orbital optic nerve. The second patient presented with bilateral progressive painless visual loss, associated with optic nerve pallor and visual field loss. In these two patients, optic nerve biopsy was diagnostic of sarcoidosis. The third patient developed optic nerve and chiasmal involvement after sarcoidosis was established by lacrimal gland biopsy. The fourth pateint had optic nerve, pulmonary, and lymph node involvement with sarcoidosis. A conjunctival and lung biopsy were diagnostic. Computed tomography and magnetic resonance imaging have greatly facilitated diagnosis of sarcoidosis of the anterior visual pathways. Sarcoidosis of the anterior visual pathways may occur alone or in association with other ocular or systemic manifestations. A conjunctival or lacrimal gland biopsy may be preferable as the initial diagnostic approach. Treatment of patients with this condition may require systemic immunosuppression, in addition to corticosteroids, to prevent permanent visual loss.     

Conjunctival sarcoidosis

A biopsy from the lower conjunctival fornix, whether or not taken from follicles, is a method which yields a positive result in ± 25% of cases of suspected sarcoidosis. We saw a patient with chronic recurrent follicular conjunctivitis of the upper eyelid, without further ocular symptoms. He was known to suffer from allergy and chronic respiratory disease. As the conjunctivitis did not improve a biopsy was taken from the conjunctiva of the upper eyelid. The specimen showed non-necrotizing epithelioid-cell granulomata with multinucleate giant cells and asteroid bodies, and an increase in reticular fibres. The diagnosis of sarcoidosis was confirmed by finding parabronchial granulomata and a raised level of angiotensin-converting enzyme in the serum.Prolonged local corticoid therapy then gradually cleared up the conjunctival condition.     

Conjunctival non-caseating granulomas in a human immunodeficiency virus (HIV) positive patient attributed to sarcoidosis

PURPOSE: To report a rare case of isolated ocular sarcoidosis in an HIV positive patient. DESIGN: Case report. METHODS: A 47-year-old HIV+ Caucasian male was referred for chronic bilateral follicular conjunctivitis. RESULTS: A conjunctival biopsy that was performed on the right eye showed sarcoidosis. General medical evaluation including a spiral thin cut chest CT scan revealed no systemic involvement. The ocular signs and symptoms resolved completely with topical corticosteroid treatment. CONCLUSIONS: HIV infection and sarcoidosis rarely coexist, presumably because their immunopathogenesis mechanisms diverge. In the absence of systemic involvement, a definite diagnosis can only be made by biopsy of the ocular tissues.     

Conjunctival biopsy in the diagnosis of ocular sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown etiology that can affect almost every organ in the body, particularly the lungs, skin, eyes, and thoracic lymph nodes. A definitive diagnosis of sarcoidosis requires that a biopsy be performed. A specimen can be obtained from any affected ocular structure, including conjunctiva, lacrimal gland, eyelid skin, and orbit. Among them, conjunctival biopsy has been suggested as a sensible and safe procedure for confirming suspected sarcoidosis. We describe three patients in whom ocular symptoms were the sole initial manifestations of sarcoidosis and who were diagnosed based on the results of a conjunctival biopsy. We also discuss the efficacy of and indications for conjunctival biopsy.     

Conjunctival deposits as an initial manifestation of sarcoidosis.

PURPOSE: To report conjunctival deposits as an initial manifestation of sarcoidosis. METHODS: Case reports. RESULTS: Two patients with bilateral bulbar conjunctival white deposits underwent conjunctival biopsy. The biopsy specimens showed noncaseating granulomas with prominent Schaumann bodies. Serum angiotensin-converting enzyme levels were increased in both patients. The first patient had abnormal results of pulmonary function tests. Sarcoidosis was diagnosed in both patients. CONCLUSIONS: Conjunctival deposits may represent the initial clinical manifestation of sarcoidosis.     

Ophthalmologic peculiarities of sarcoidosis

The present paper deals with the frequency of different ophthalmic sarcoid changes and their morphological and photographic characteristics. In addition, the diagnostic value of conjunctival biopsy is evaluated. The findings were based on repeated ophthalmological examinations of an unselected group of 281 patients with histologically confirmed sarcoidosis. Conjunctival (37/218) and lacrimal gland (33/254) changes were encountered more often than sarcoid uveitis (22/281), and a conjunctival granuloma was the most frequent single sarcoid ophthalmic finding. Sarcoid changes in the eyes and the adnexae were often characterized by a scarcity of symptoms and a typical outward appearance. In some cases of sarcoid uveitis fluorescein angiography revealed in the iris and the retina nodules which showed features suggesting the proliferative nature of the disease. The iris infrared transillumination technique illustrated the affinity of sarcoid nodules in the pupillary area. Conjunctival biopsy showed epithelioid cell granulomas compatible with sarcoidosis in nearly half of the patients in whom it was suspected in a slit-lamp examination of the conjunctivae. In the diagnosis of sarcoidosis, conjunctival biopsy is a procedure to be recommended before more demanding methods are tried.     

Conjunctival Non-Caseating Granulomas in a Human Immunodeficiency Virus (HIV) Positive Patient Attributed to Sarcoidosis

Purpose: To report a rare case of isolated ocular sarcoidosis in an HIV positive patient. Design: Case report. Methods: A 47-year-old HIV+ Caucasian male was referred for chronic bilateral follicular conjunctivitis. Results: A conjunctival biopsy that was performed on the right eye showed sarcoidosis. General medical evaluation including a spiral thin cut chest CT scan revealed no systemic involvement. The ocular signs and symptoms resolved completely with topical corticosteroid treatment. Conclusions: HIV infection and sarcoidosis rarely coexist, presumably because their immunopathogenesis mechanisms diverge. In the absence of systemic involvement, a definite diagnosis can only be made by biopsy of the ocular tissues.     

Granulomatous Conjunctivitis Secondary to Treponema pallidum

A 41-year-old black man presented with bilateral iritis, conjunctivitis, and pulmonary and dermatologic manifestations, which were initially thought to be secondary to sarcoidosis. The patient’s serology was markedly positive and the definitive diagnosis of secondary syphilis was established by the identification of spirochetes consistent with Treponema pallidum in a conjunctival biopsy.     

Retinal cotton-wool spots as the first sign of systemic sarcoidosis.

Isolated retinal cotton-spots have not yet been reported as the sign of ocular sarcoidosis. We describe three patients with retinal cotton-wool spots of initially unknown etiology in whom systemic sarcoidosis was diagnosed 6-16 months later. The diagnosis was confirmed by conjunctival biopsy. These observations indicate that sarcoidosis should be included in the differential diagnosis of retinal cotton-wool spots and patients with these lesions should be followed for the development of this disease.     

Scleritis associated with sarcoidosis

PURPOSE: To review scleritis cases associated with sarcoidosis and to evaluate clinical features, medical treatment, and clinical course. METHODS: Two cases of diffuse anterior scleritis and a nodular scleritis case associated with systemic sarcoidosis were evaluated. Scleritis was the first manifestation of sarcoidosis in two of the patients and the diagnosis of sarcoidosis was confirmed with a conjunctival biopsy. The third patient had the diagnosis of systemic sarcoidosis when she developed scleritis. RESULTS: Based on the clinical and histological appearance, two patients presented with bilateral diffuse anterior scleritis and the third patient with an anterior nodular scleritis. One patient already had the diagnosis of systemic sarcoidosis at presentation, while ocular findings led to the diagnosis in the other two cases. Conjunctiva or skin biopsies revealed features compatible with the diagnosis of sarcoidosis. Scleritis attacks recurred in two patients. All patients responded well to systemic corticosteroid (prednisone) therapy. CONCLUSIONS: Scleritis associated with sarcoidosis has rarely been described and it may be the presenting sign of systemic sarcoidosis.     

Sarcoid granuloma simulating amelanotic melanoma of the iris

A 24-year-old black man had a unilateral vascular iris tumor associated with iridocyclitis. Clinically, the iris lesion appeared similar to an amelanotic melanoma. A systemic workup, including an angiotensin-converting enzyme determination, suggested a diagnosis of sarcoidosis. A conjunctival biopsy confirmed that diagnosis.     

Bilateral large conjunctival tumours as primary manifestation of sarcoidosis--successful treatment with steroid-depot-injections

INTRODUCTION: Ocular manifestations of sarcoidosis vary enormously. They include the conjunctiva, lacrimal gland, orbita, intraocular structures and eye-lid, either isolated or combined. We describe a female patient who presented with unusually large, bilateral conjunctival tumours as a primary manifestation of sarcoidosis. PATIENT: A 79-year-old white woman was referred to us for further management of a persisting "conjunctivitis", which had been refractory to treatment with multiple medications. Initial examination disclosed swollen eye-lids and bilateral large hard tumours of the inferior fornix. The obtained brush smear, which was cytopathologically evaluated, revealed epitheloid cells and multinucleate giant cells. After 4 weeks she developed three reddish-brown maculopapular lesions on her face. The subsequent biopsy from the left inferior fornix and the skin showed histopathologically a granulomatous epitheloid cell inflammation without central necrosis and without acid-proof bacilli. Therefore a sarcoidosis was included into the differential diagnosis. The systemic evaluation revealed no other manifestation. At first we tried to reduce the chronically inflammatory tumours with different immunomodulating local treatment forms. Only the repeated intralesional injection of a steroid depot showed a complete disappearance of all conjunctival and skin tumours. CONCLUSION: An isolated bilateral primary manifestation of sarcoidosis with large massive conjunctival tumours is very rare and clinically not typical. The non-invasive, cytopathological examination by means of brush smears offers a new perspective in the fast diagnosis of conjunctival manifestation of sarcoidosis. The tumours respond excellently to the intralesional injection of steroid depots.     

Chest computerized tomography in the evaluation of uveitis in elderly women

PURPOSE: To describe the usefulness of chest computerized tomography (CT) in the evaluation of uveitis in elderly women and the clinical characteristics of patients with an abnormal chest CT scan. DESIGN: Prospective noncomparative case series. METHODS: We evaluated 30 elderly women, aged 61-83 years, with chronic iritis, vitritis, or choroiditis and with no definitive cause for their uveitis. All patients underwent a battery of diagnostic laboratory studies and chest CT. RESULTS: The diagnostic examination in most patients included serum angiotensin converting enzyme level, serum lysozyme, rapid plasma reagin level, fluorescent treponemal antibody-absorption test, purified protein derivative skin test, and chest x-rays. Chest CT performed on all patients showed parenchymal, mediastinal, and/or hilar adenopathy in 17 patients (57%). Histopathologic confirmation of sarcoidosis with noncaseating granulomas in the biopsy specimens was obtained in 14 patients: eight by mediastinoscopy, two by bronchoscopy, two by conjunctival biopsy, one by nasal biopsy, and one by vitreous biopsy. CONCLUSIONS: Chest CT can be useful in elderly female patients with chronic uveitis for identifying mediastinal lymphadenopathy and other lesions suggestive of sarcoidosis, as well as to help guide tissue confirmation and to rule out other diagnoses including lymphoma.     

Scleritis associated with sarcoidosis

Purpose: To review scleritis cases associated with sarcoidosis and to evaluate clinical features, medical treatment, and clinical course. Methods: Two cases of diffuse anterior scleritis and a nodular scleritis case associated with systemic sarcoidosis were evaluated. Scleritis was the first manifestation of sarcoidosis in two of the patients and the diagnosis of sarcoidosis was confirmed with a conjunctival biopsy. The third patient had the diagnosis of systemic sarcoidosis when she developed scleritis. Results: Based on the clinical and histological appearance, two patients presented with bilateral diffuse anterior scleritis and the third patient with an anterior nodular scleritis. One patient already had the diagnosis of systemic sarcoidosis at presentation, while ocular findings led to the diagnosis in the other two cases. Conjunctiva or skin biopsies revealed features compatible with the diagnosis of sarcoidosis. Scleritis attacks recurred in two patients. All patients responded well to systemic corticosteroid (prednisone) therapy. Conclusions: Scleritis associated with sarcoidosis has rarely been described and it may be the presenting sign of systemic sarcoidosis.     

Conjunctival biopsy in sarcoidosis

In a prospective study of systemic sarcoidosis, 28 patients underwent 55 conjunctival biopsies. The incidences of positive granulomatous lesions in proven and suspected sarcoidosis cases were 71.4% (ten of 14 patients) and 28.5% (four of 14 patients), respectively. Thus, random, bilateral conjunctival biopsies should be performed as soon as possible in all cases of presumed sarcoidosis.