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Arch Ophthalmol. 2003;121:1333-1335.

Sarcoidosis is a multisystem, T-lymphocyte–mediated granulomatous inflammatory process of unknown cause. The clinical spectrum varies in severity from single-organ involvement and self-limiting disease to multisystem inflammation with potential mortality. The characteristic noncaseating granulomatous infiltrations can affect almost any tissue, including conjunctivae.¹ The granulomatous inflammation of the conjunctivae in the form of conjunctival nodules resembling follicular conjunctivitis is a common initial finding.² We describe a patient with chronic conjunctivitis who was subsequently diagnosed as having sarcoidosis and successfully treated with topical cyclosporin.

Report of a Case
A 58-year-old white woman was referred for further management of ocular rosacea and keratoconjunctivitis sicca, which had been refractory to treatment with multiple medications, including oral and topical doxycycline, 1% topical prednisolone acetate, 0.5% ketorolac tromethamine, 0.1% olopatadine hydrochloride, and preservative-free artificial tears for 7 months. Her ocular history was remarkable for primary open-angle glaucoma, for which she underwent a bilateral laser trabeculoplasty 1 year prior to our initial examination. She was also a steroid-responder, with intraocular pressures rising up to the high 30s (mm Hg) while taking topical 1% prednisolone acetate. Her medical history was negative for any known diseases, and review of systems was remarkable only for mild exertional dyspnea.

On initial examination, the intraocular pressures were within normal limits while she was receiving treatment with topical 1% brinzolamide and 0.2% brimonidine. Visual acuity was 20/20 OU. External examination disclosed eyelid margin telangiectases and irregularity, along with mild meibomian gland dysfunction in both eyes. Slitlamp examination demonstrated moderate bilateral bulbar conjunctival hyperemia with subtle lower forniceal follicules and conjunctival subepithelial fibrosis (Figure 1). The corneas were clear with no punctate epitheliopathy. The rest of the anterior segment findings were unremarkable. Ophthalmoscopic examination showed a cup-disc ratio of 9/10 OU. A Schirmer test performed on the right eye with topical anesthesia revealed a wetting of 7 mm at 5 minutes.

View larger version (53K): [in this window] [in a new window] Figure 1. Slitlamp appearance of the right lower forniceal conjunctiva demonstrates subtle follicular reaction along with subepithelial fibrosis.

A conjunctival biopsy specimen was harvested from the inferior fornix of the left eye for diagnosis. Histopathologic examination of the specimen showed foci of noncaseating granulomas intermingled and surrounded by moderately intense infiltration of normal-appearing lymphocytes (Figure 2). No evidence of acid-fast bacilli, fungi, and foreign bodies was found. The patient underwent a systemic evaluation for presumed sarcoidosis, including complete physical examination, computed tomography of the chest, pulmonary function tests, and serum angiotensin-converting enzyme analysis. The angiotensin-converting enzyme level was within normal limits. Computed tomography showed bilateral hilar lymphadenopathy with no parenchymal involvement. Results of pulmonary function tests were normal.

View larger version (123K): [in this window] [in a new window] Figure 2. The conjunctival specimen shows foci of noncaseating granuloma intermingled and surrounded by a moderately intense infiltration of normal-appearing lymphocytes (hematoxylin-eosin, original magnification x12). Inset: higher magnification demonstrates a multinucleated giant cell in the center (original magnification x24).

A pulmonologist elected to defer the oral corticosteroid treatment and serial follow-up, as the patient was asymptomatic with stage I disease. A trial of topical 0.5% cyclosporin A drops (prepared in artificial tears), 4 times daily, resulted in dramatic improvement of conjunctival hyperemia and complete resolution of the lower forniceal nodules within 2 weeks (Figure 3). The patient is currently receiving maintenance therapy with cyclosporin drops, once per day, in each eye.

View larger version (56K): [in this window] [in a new window] Figure 3. Slitlamp appearance of the right lower fornix after a 2-week treatment with topical cyclosporin demonstrates complete resolution of follicles.

Comment
Cyclosporin is an immunomodulator with a selective inhibitory effect on CD4+ T-lymphocyte proliferation via inhibition of interleukin 2 receptor expression.³ Although the pathogenesis of sarcoidosis is not fully understood, T-lymphocyte–mediated hypersensitivity appears to play a central role, and corticosteroids remain the mainstay of therapy.⁴ Although no controlled trial data exist, uncontrolled case reports or small case series demonstrate favorable outcomes of oral cyclosporin therapy in refractory pulmonary sarcoidosis, neurosarcoidosis, and vision-threatening sarcoid-associated uveitis.⁵

Topical administration of cyclosporin has been highly effective in the treatment of various cell-mediated anterior segment inflammatory conditions.^6-8 In our patient, topical cyclosporin therapy was preferred, owing to the patient's history of increased intraocular pressures with topical steroid use. Dramatic improvement of symptoms and signs occurring within a short time suggests that sarcoid conjunctivitis may represent another indication for cyclosporin eyedrops.

AUTHOR INFORMATION

Esen Karamursel Akpek, MD; Ozge Ilhan-Sarac, MD; W. Richard Green, MD
Baltimore, Md

Corresponding author and reprints: Esen Karamursel Akpek, MD, Wilmer Eye Institute, 600 N Wolfe St, Maumenee Bldg 321, Baltimore, MD 21287-9238 (e-mail: esakpek{at}jhmi.edu).

REFERENCES
1. Kimani AP, Aguayo SM. Sarcoidosis: an overview for the primary care physician. Compr Ther. 1998;24:20-25. PUBMED 2. Obenauf CD, Shaw HE, Sydnor CF, Klinthworth GK. Sarcoidosis and its ophthalmic manifestations. Am J Ophthalmol. 1978;86:648-655. ISI | PUBMED 3. Nussenblatt RB, Palestine AG. CsA: immunology, pharmacology and therapeutic uses. Surv Ophthalmol. 1986;31:159-169. FULL TEXT | ISI | PUBMED 4. Costabel U. Sarcoidosis: clinical update. Eur Respir J Suppl. 2001;32(suppl):S56-S68. 5. Baughman RP, Lower EE. Steroid-sparing alternative treatments for sarcoidosis. Clin Chest Med. 1997;18:853-864. FULL TEXT | ISI | PUBMED 6. Holland EJ, Olsen TW, Ketcham JM, et al. Topical cyclosporin A in the treatment of anterior segment inflammatory disease. Cornea. 1993;12:413-419. FULL TEXT | ISI | PUBMED 7. Gottsch JD, Akpek EK. Topical cyclosporin stimulates neovascularization in resolving sterile rheumatoid central corneal ulcers. Trans Am Ophthalmol Soc. 2000;98:81-7; discussion 87-90. PUBMED 8. Akpek EK, Dart JK, Watson S, et al. A randomized trial of topical cyclosporin 0.05% in steroid-resistant atopic keratoconjunctivitis. Ophthalmology. In press.

SECTION EDITOR: W. RICHARD GREEN, MD

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