ORBITAL GRANULOMA (pseudotumor)
Sudden onset of orbital pain with lid oedema, proptosis and chemosis due to a diffuse granulomatous infiltrate of lymphocytes and plasma cells involving multiple structures within the orbit.
This condition usually occurs in middle age and seldom occurs bilaterally. CT scanning or MRI shows a diffuse orbital lesion, although one structure may be predominantly involved, e.g. optic nerve, extraocular muscles or the lacrimal gland. If diagnostic doubt remains, a biopsy is required. Most patients show a dramatic response to high dose steroid therapy. If symptoms persist, the lesion should respond well to radiotherapy.
The thyrotoxic patient with bilateral exophthalmos presents no diagnostic difficulty, but dysthyroid exophthalmos, with marked lid oedema, lid retraction and ophthalmoplegia may occur unilaterally without evidence of thyroid disease. Coronal CT scanning establishes the diagnosis by demonstrating enlargement of the extraocular muscles - primarily the medial and inferior recti. MRI shows a similar appearance.
Circulating thyroid hormone levels are often normal. Thyroid releasing hormone stimulation or thyroid suppression tests may support the diagnosis. Management
Steroids should help. A few patients require orbital decompression in an attempt to prevent corneal ulceration, papilledema and blindness.
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