Bilateral sequential trochleitis as the presenting feature of systemic lupus erythematosus

A 26-year old woman presented with headache and pain in the left superonasal orbit, which worsened with vertical eye movements. She had no relevant medical history, and ophthalmologic evaluation was unremarkable. An orbital ultrasound showed enlargement of soft tissue in the region of the left trochlea consistent with trochleitis. Treatment with prednisone and multiple local injections of corticosteroids and analgesic nerve blocks failed to relieve her symptoms. The patient subsequently experienced right trochleitis, and 2 years after the onset of her initial symptoms, she developed systemic symptoms and signs that led to a diagnosis of systemic lupus erythematosus (SLE). Systemic immunosuppressive therapy was instituted, and the patient experienced marked relief in her ophthalmic symptoms. This case is unique in that not only bilateral sequential trochleitis was the presenting feature of SLE but also the ocular manifestations preceded the systemic manifestations of SLE by over 2 years.