Immunomodulatory drugs are cornerstone of care for minimizing morbidity. Establishing a diagnosis guides targeted patient care.
Medical management of orbital inflammatory disease (OID) is based on the use of non-specific and specific immunomodulatory drugs. Patient care is optimized by determining underlying etiology for the inflammation, according to Louise A. Mawn, MD, professor of ophthalmology and neurological surgery, Vanderbilt University Medical Center, Nashville, TN.
“Orbital inflammation is a response of the immune system and not a diagnosis in itself,” she explained.
When faced with medical management, Dr. Mawn said physicians first have to know what it is they are treating and how to manage the unknown.
“I tell patients who present with orbital inflammation that we may be at the beginning of a journey with a path we will walk together to better define their disease so that we can tailor the treatment,” she said.
Orbital inflammation can develop in association with several diseases, including infectious entities, structural problems, autoimmune disorders, and neoplastic diseases. It may also be idiopathic.
“If I call the inflammation idiopathic, however, I tell patients that we learned in medical school that the idiots do not know the pathology, and that I will continue to give vigilant attention to their disease because it may be in evolution,” Dr. Mawn said. “We only apply the term ‘nonspecific orbital inflammation’ to describe a condition after we have exhausted a search for a specific cause.”
Diagnosis in patients with OID involves a complete review of systems and physical examination, a laboratory work-up, imaging, and “bladeless” biopsy, but tissue biopsy may also be necessary.
The review of systems homes in on identifying symptoms of joint, gastrointestinal, sinonasal, and skin disease, as well as any personal or family history of endocrine or immune disease.
The evaluation also includes a drug history, recognizing that some medications (e.g., bisphosphonates and propylthiouracil) can cause orbital inflammatory reactions.
A CT scan is generally performed as initial imaging because of ease of access and lower cost compared with MRI. Patients with orbital inflammation may present first to the emergency department where a CT scan may be done.