Sarcoidosis revealed by simultaneous optic nerve and eyelid involvement: A case report

Ocular disease can be the initial manifestation in patients with sarcoidosis. It is most often associated with uveitis, but eyelid or optic nerve disease can also be presenting features. Although uncommon and easy to overlook in a patient presenting with visual loss, paying attention to the presence of eyelid granulomas in our patient proved to be very helpful in our diagnostic work up for optic neuropathy.

A young otherwise healthy patient was addressed with a 3 month history of bilateral painless visual loss. At presentation, best-corrected visual acuity was counting fingers in both eyes. Anterior segment slit-lamp examination was completely normal in both eyes. Eye fundus examination revealed subtle optic disc swelling in the left eye. Interestingly, flesh-colored nodular eyelid lesions were found bilaterally. Basic work-up for optic neuropathy showed elevated levels of serum lysozyme and serum angiotensin converting enzyme. More importantly, a biopsy specimen of an eyelid nodule demonstrated multiple non-necrotizing granulomas, a hallmark sign of sarcoidosis. Despite a delay in treatment of several months after onset of symptoms, response to systemic corticosteroids was prompt and important with visual acuity improving to 20/20 in both eyes as well as complete resorption of all eyelid lesions.

In the diagnostic work-up for optic neuropathy, the answer can sometimes be hiding where it's least expected: the possible presence of eyelid lesions should not be overlooked as they may orient us towards sarcoidosis as an underlying etiology.