Low dose corticosteroid in association with methotrexate for therapy of ocular sarcoidosis: report of a case

Abstract

Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Ocular involvement can be the initial manifestation, occurring by itself, or it can be associated with other systemic signs of sarcoidosis. A 31 years-old caucasian female presented a 10-day history of decreased vision and pain in OS. Biomicroscopy revealed fine keratic precipitates, a mild reaction in the anterior chamber and in the vitreous cavity in both eyes and a small posterior synechiae in OS. Intraocular pressure was 12 mmHg in the OD and 9 mmHg in OS. Fundoscopy disclosed mild swollen and hyperemic optic discs and some subretinal yellowish nodules of 1/3 to 1 disc diameter, partially delimited, located in the posterior pole and midperiphery in both eyes. The Chest X-ray disclosed the suspicion of hilar lymphadenopathy, especially on the left-side. The positron emission tomography (PET-scan) showed increased 18 F-fluorodeoxyglucose uptake in the paratracheal and bilateral hilar lymph nodes, indicating high local cellular metabolism. A mediastinal lymph node biopsy was performed afterwards, which depicted non-caseating granulomas with multinucleated giant cells and absence of acid-alcohol resistant bacilli. The patient was initially treated with oral prednisone 60 mg/day with slow tapering over the next months. A decreased papillitis and an increased size of the choroidal granulomas was observed after a 6-month therapy (Figs. 1B and 2B). Then, a combination of methotrexate 20 mg/week and prednisone 10 mg/day was given over the following months, which led to a gradual reduction in size and thickness of the choroidal granulomas. A weak response to steroid monotherapy was initially observed in this patient. The introduction of a non-steroid immunosuppressant drug (methotrexate) was associated with significant anatomic improvement in the following months. This report raises the suggestion that an early introduction of a nonsteroidal immunosuppressive drug to systemic steroids may be beneficial for a rapid remission of the uveitis.

Sarcoid Uveitis: An Intriguing Challenger

“…No specific therapy is currently available for OS, but there are different unspecific treatment options to manage the inflammation before the affected eyes develop permanent damage [137]. Therapeutic algorithms for bilateral complicated uveitis have been previously suggested [186][187][188][189][190][191][192][193][194][195][196][197][198].…”

“…Systemic corticosteroids (CS) are introduced when local CS are ineffective, as well as in cases of either bilateral or posterior involvement [188,189].…”

Characteristics and management of ocular sarcoidosis

“…In the recommendations by IWOS, the order of recommended steroid-sparing drugs is methotrexate, azathioprine, mycophenolate mofetil, and cyclosporine [40]. Although methotrexate is an off-label use, it is widely used for ocular [43,44] as well as systemic sarcoidosis [45], as a steroid-sparing agent in the world.…”