Please have a look over MRI and suggest that the fibrotic is still visible on the MRI.

Hello,

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I saw the MRI (attachment removed to protect patient's identity), the sclerotic tissue from which we have to confirm that the pain you are experiencing is mainly neuropathic and emerging not from the sclerotic tissues as much as from the adjacent structures that are rich with nerves and blood vessels. Due to the anatomic changes that the eye has gone through, all the adjacent structures are still adapting to those newly acquired conditions, and that is what most probably is causing the pain. Whether it is from the compression or the disturbance in blood supply, currently, there is not much to do but to keep reducing the inflammation and prevent future reoccurrence with the prednisolone, but specific preventive measures such as undergoing a comprehensive eye exam as per the ophthalmologist recommendations are necessary. That examination should include tonometry - intraocular pressure, perimetry-visual fields, and optical coherence tomography to exclude any newly acquired changes that might require intervention. As for the diagnosis, although not much changes to the treatment will take place, it should be enforced with a blood test called ANA (antinuclear antibodies) profile to exclude any autoimmune disease that might develop on other organs. I would add a course of Neurobion, which is a complex of vitamins group B and might want to consult a physiotherapist on a method to improve blood circulation in the affected area.

I hope I have cleared a few of your questions, and please feel free to follow up with additional inquiries or test results.

Hello,

Welcome back to icliniq.com.

Yes. You understood perfectly. The common ocular manifestations of orbital pseudotumor may include periorbital edema, erythema, proptosis, ptosis, diplopia and pain with eye movements and all these symptoms fit your case unfortunately. Biopsies are usually ultrasound and are quite safe although there is always a possibility of damage to the adjacent tissues but I doubt that it was in your case. It is good that the doctors did not hesitate to do another biopsy and in the end, confirmed the diagnosis because it is a significant one and can be very progressive. Most probably the compression could be also present due to an ongoing swelling due to the inflammation but you are on steroids, the primary effect of which is to reduce the inflammation and swelling. Myositis also cannot be excluded but they are all associated with the possible swelling of different intensities in different locations of the orbit. Thickening of the muscles could have occurred during the onset and what he is seeing is the residual change. That is very easily identified if compared to a new scan which will show stability or progression of the process and will answer your questions below. Ultrasound and CT (computed tomography) scans are other imaging methods and can be very informative when done and evaluated by a professional. As we mentioned it reduces the swelling by suppressing the inflammation and that is what keeps your eye almost inflammation-free. Side effects of the medications along with anatomical changes can cause dryness of the eyes so I advise you to start using artificial tears at least four times daily in both eyes. I could not visualize the photos unfortunately but fluctuations of inflammatory liquids differ during the day of course, especially from a position lying down or sitting up. Do not miss out on your follow-up examinations, check the eye pressure every three months, and have an optical coherence topography done every six months. Use the artificial tears I told you indefinitely and please address me if you need any more help.

I hope this helps.

Thank you.

Hello,

Welcome back to icliniq.com.

Unfortunately, I did not find any attachments and could not see the scan. However, the diagnosis of temporal arteritis cannot be confirmed based on imaging tests only and requires a biopsy of the artery itself. Therefore I would advise you to consult your doctor for a more confirmative diagnosis based on pathological analysis of a biopsy.

I hope this helps.

Hello,

Welcome back to icliniq.com.

Yes, it does seem a bit distinct on all captured images (attachment removed to protect patient's identity). However nonetheless, temporal arteritis is quite a specific diagnosis and the information we get from the biopsy is the only way to confirm it.

I hope this helps.

Hello,

Welcome back to icliniq.com.

Again I cannot seem to see the images, based on the previous images, it could very well be calcification, and since it is evident and distinct on all images. If you want something less invasive than a biopsy and quite informative then a Doppler angiography would be of diagnostic value. Besides that, I will check your lipid profile and serum calcium and would want to see your radiology report too.

I hope this helps.

Hello,

Welcome back to icliniq.com.

Sorry for the delay I have been extremely busy lately. I went through all the reports and they were all quite interesting and informative (attachment removed to protect the patient's identity). The thickening of the medial rectus on the left eye along with the residual fibrosis could very well explain the persisting pain in the left eye. Prednisone is still helping because it excludes any recurrence of inflammation although I would advise you to taper it. Increased pain during visual activities described by your orthoptist also tells us that one of the main sources of pain is associated with the changes that have taken place during the inflammatory process and now we are dealing with its residual effect. The thermography test was quite interesting and new to me but very logical and hopefully efficient in guiding the doctors to a better conclusion and drawing us a clear picture of the extent and efficiency of blood supply. As I mentioned earlier, I also was able to see some of the MRI images of the left temporal artery and the asymmetry between the sides is quite significant and correlates with the thermography evaluation. However, I consider it a bit bold to bring out such a diagnosis as temporal arteritis without conducting the biopsy because as I mentioned earlier even MRI and CT will not be conclusive or informative enough. Besides that, temporal arteritis has a very distinct set of symptoms which thankfully you are not suffering from. Could you please update me on your condition today? What are the persisting symptoms, have you followed my previous recommendations, what are the medications you are currently taking?

I hope this helps.

Hello,

Welcome back to icliniq.com.

I understand it is very hard for you to get accustomed to the persisting discomfort and I can only imagine how tired you are from all of this. The thickening of the muscles, especially on the left side is of course one of the main sources of that pain along with the sclerotic and fibrotic changes that occurred after the inflammation. Considering that they are causing some kind of restriction of movement will induce that pain upon movement of the eyeball along with a possible tension on the nerve bundles in that area which will cause it to irradiate and you feel it in the whole socket. In addition to that and based on the thermography the blood supply due to the changed blood vessels on the left might also be exacerbating the condition by not providing enough oxygen to that area which also will cause pain. Your IgG levels are low due to the intake of Prednisolone which is a standard feature for immunity suppression by corticosteroids. The intake of Prednisolone as a primary treatment for your condition is efficient in the beginning but is efficient in only around 75 % and causes relapses of the disease. Recent studies have shown better outcomes for the treatment of your condition with radiotherapy so you might want to consult an onco ophthalmologist for that purpose. As for the changes in the left temporal artery, I stand by my advice that you conduct a biopsy to exclude arteritis; all the noninvasive methods are merely suggestive but not quite yet conclusive. I really wish I could help you more but orbital pseudotumor is quite a drastic condition and all the symptoms that you are still experiencing just confirm with the images.

I hope this helps.

Hello,

Welcome back to icliniq.com.

To provide you with a better answer concerning the perforation of lamina papyracea I would like you to provide me with the exact method that was used to take a biopsy. Such a perforation also occurs in traumas, which you have not received. It also causes entanglement of the lateral rectus muscle and might be a reason for your visual difficulties. I also have not seen any reports of perimetry. We could identify a lot of it.

I hope it helps.

Hello,

Welcome back to icliniq.com.

The report explains the perforation (attachment removed to protect the patient's identity), a mandatory step to get access to the orbit but based on the MRI images I did not detect any entanglement. The last recommendation that was given by the doctor was to try another type of pain relief to reduce the steroids that you have been on for such a long time and are already facing the complications of long-term intake of steroids which I warned you about in the very beginning. I did not see the report of the visual field test.

I hope this helps.