Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

Successful Treatment of Conjunctival Sarcoidosis With Local Cryotherapy

Frederick W. Fraunfelder, MD; Dilsher S. Dhoot, MD

Abstract

Conjunctival sarcoidosis was successfully treated with liquid nitrogen cryotherapy using a 1.5-mm cryoprobe applied in a double freeze-thaw method. After an incisional biopsy of a portion of the conjunctiva, cryotherapy was applied using freeze times of 1 to 2 seconds, with thawing of 5 to 10 seconds between freezes. A 55-year-old woman with skin biopsy-proven sarcoidosis presented complaining of bilateral ocular foreign body sensation and erythema. On examination, she was found to have multiple conjunctival nodules. Cryotherapy with liquid nitrogen was applied to these nodules. A conjunctival biopsy of one of the nodules was also taken. The biopsy results confirmed the diagnosis of conjunctival sarcoid. The conjunctiva has remained free of any recurrent nodules. Cryotherapy appears to be a safe and effective alternative in the treatment of conjunctival sarcoidosis.

From Casey Eye Institute, Oregon Health & Science University, Portland, Oregon.

Supported in part by an unrestricted grant to Casey Eye Institute from Research to Prevent Blindness, New York, New York.

Dr. Fraunfelder is a consultant for Brymill. Drs. Fraunfelder and Dhoot have no financial or proprietary interest in the materials presented herein.

Address correspondence to Frederick W. Fraunfelder, MD, Casey Eye Institute, 3375 SW Terwilliger Blvd., Portland, OR 97239-4197.

Received: April 03, 2009
Accepted: December 08, 2009
Posted Online: April 2, 2010

Abstract

Conjunctival sarcoidosis was successfully treated with liquid nitrogen cryotherapy using a 1.5-mm cryoprobe applied in a double freeze-thaw method. After an incisional biopsy of a portion of the conjunctiva, cryotherapy was applied using freeze times of 1 to 2 seconds, with thawing of 5 to 10 seconds between freezes. A 55-year-old woman with skin biopsy-proven sarcoidosis presented complaining of bilateral ocular foreign body sensation and erythema. On examination, she was found to have multiple conjunctival nodules. Cryotherapy with liquid nitrogen was applied to these nodules. A conjunctival biopsy of one of the nodules was also taken. The biopsy results confirmed the diagnosis of conjunctival sarcoid. The conjunctiva has remained free of any recurrent nodules. Cryotherapy appears to be a safe and effective alternative in the treatment of conjunctival sarcoidosis.

From Casey Eye Institute, Oregon Health & Science University, Portland, Oregon.

Supported in part by an unrestricted grant to Casey Eye Institute from Research to Prevent Blindness, New York, New York.

Dr. Fraunfelder is a consultant for Brymill. Drs. Fraunfelder and Dhoot have no financial or proprietary interest in the materials presented herein.

Address correspondence to Frederick W. Fraunfelder, MD, Casey Eye Institute, 3375 SW Terwilliger Blvd., Portland, OR 97239-4197.

Received: April 03, 2009
Accepted: December 08, 2009
Posted Online: April 2, 2010

Introduction

Sarcoidosis is a multisystem chronic granulomatous disorder whose etiology remains unclear. The systemic manifestations of this disease are broad and of varying severities, often involving the lungs, skin, lymph nodes, and eyes. Sarcoidosis has a predilection for certain ethnic/racial groups, including African Americans, Scandinavians, and Irish Caucasians, and can occur at any age, although the peak onset is in the 20s.1 Ocular symptoms are present in 25% to 60% of patients with systemic sarcoidosis. The most common of these symptoms are uveitis and conjunctival nodules.2

Biopsy of conjunctival nodules is often performed to aid in the diagnosis of sarcoidosis. These nodules are typified by the presence of non-caseating granulomas that do not stain positive for mycobacteria or fungal elements. The nodules can create ocular irritation and foreign body sensation, and can be cosmetically unacceptable. To date, treatment of these nodules has been supportive with lubrication. More recently, cyclosporine has been suggested as a means of eliminating these nodules.3,4 We present an alternative method for the treatment of conjunctival sarcoid nodules: liquid nitrogen cryotherapy.

Prior to cryosurgery, a conjunctival biopsy was performed using 0.12 forceps and Westcott scissors and the specimen was placed in formalin and sent to the pathology department. A Brymill CRY-AC-3 liquid nitrogen container with a 300-mL capacity (Brymill Cryogenic Systems, Ellington, CT) was used. This unit can accommodate a variety of attachments, which are selected based on the disease being treated, in this case conjunctival sarcoid nodules. An “F” spray tip with a 0.11-inch aperture was selected. The boiling point for liquid nitrogen is −195.6°C.

Case Report

A 54-year-old woman was referred for evaluation of bilateral conjunctival nodules in February 2008. She had been diagnosed as having skin biopsy-positive sarcoid a month prior to referral, but was not given any systemic medication. Her medical history was otherwise significant for hypothyroidism, for which she took a thyroid supplement, and gastroesophageal reflux disease, for which she took a proton pump inhibitor.

The patient complained of ocular foreign body sensation, dryness, and mild erythema in both eyes. These symptoms had been present for the past 18 months. On examination, her visual acuity was 20/15 in both eyes. Anterior slit-lamp examination revealed many conjunctival nodules on the palpebral conjunctiva of her upper and lower eyelids; these findings were more prominent in her right eye (Figs. 1 and 2). Her anterior and posterior segments were unremarkable, except for mild meibomian gland dysfunction.

Slit-lamp photographs of eyelids prior to treatment demonstrating numerous conjunctival nodules.

Figure 1.

Slit-lamp photographs of eyelids prior to treatment demonstrating numerous conjunctival nodules.

Slit-lamp photographs of eyelids 3 months after treatment demonstrating resolution of conjunctival nodules.

Figure 2.

Slit-lamp photographs of eyelids 3 months after treatment demonstrating resolution of conjunctival nodules.

In April 2008, a conjunctival biopsy was obtained and revealed non-caseating granulomas, negative for acid-fast bacteria and fungus, consistent with her diagnosis of sarcoid (Fig. 3). Multiple conjunctival sarcoid nodules present on the palpebral conjunctiva bilaterally were treated with liquid nitrogen cryospray. The procedure was performed in an ambulatory surgery setting under local anesthesia with a combination of a single drop of topical proparacaine and subconjunctival and intratarsal injection of 0.5 mL of 1% lidocaine with epinephrine. Cryotherapy was performed on the lesions directly. Liquid nitrogen cryospray was applied using a Brymill F tip with a 0.11-inch aperture until the lesions(s) appeared chalk white. This took approximately 2 to 3 seconds. Using a double freeze-thaw technique, the lesion was allowed to thaw (approximately 5 to 10 seconds) and the process was repeated. Erythromycin eye ointment was placed on the eye and patients were instructed to place this in the fornix of the involved eye four times daily for 1 week. The patient has been seen in follow-up at 1 day, 2 weeks, 3 months, and 6 months and has remained free of any conjunctival nodules since treatment.

Conjunctival biopsy revealing non-caseating granulomas with associated lymphocytes and epithelioid cells (hematoxylin–eosin stain, original magnification ×10 [left] and ×20 [right]).

Figure 3.

Conjunctival biopsy revealing non-caseating granulomas with associated lymphocytes and epithelioid cells (hematoxylin–eosin stain, original magnification ×10 [left] and ×20 [right]).

Discussion

We present a novel method for the treatment of conjunctival sarcoid granulomas. Recently, cyclosporine has been advocated as an effective means for treating conjunctival sarcoidosis. Treatment consists of cyclosporine 0.05% used four times daily for 2 to 4 weeks followed by once daily maintenance therapy.3,4 Treatment of these nodules with cryotherapy allows for a one-time treatment and could eliminate the need of daily maintenance therapy. The authors acknowledge the limitations of a case report. Further patient treatment in a randomized fashion could be done to more effectively evaluate the efficacy of cryotherapy in the treatment of conjunctival sarcoidosis.

Complications from liquid nitrogen cryotherapy on the ocular surface and eyelids are rare if used correctly.5–11 Prolonged contact of the cryoprobe or cryospray with the surface of the globe can lead to an over-freeze of the tissue. Complications from cryotherapy include transitory uveitis, temporary chemosis, subconjunctival hemorrhage, corneal endothelial damage, and possible paralysis of extraocular muscles from cryotherapy over the muscle insertion sites. These complications rarely have long-term consequences. The authors would caution that practical experience is required to become comfortable with the use of liquid nitrogen to treat conjunctival lesions.

The exact mechanism whereby cryotherapy eliminates conjunctival nodules is unclear. Because these nodules are well vascularized, it is possible the destruction of small blood vessels through liquid nitrogen cryotherapy leads to destruction of the nodules and resolution of the conjunctival sarcoidosis.5 Liquid nitrogen cryotherapy has been shown to be safe and effective for a variety of other conditions, including conjunctival malignancies,6–8 benign conjunctival vascular tumors,5 advancing wave-like epitheliopathy,9 superior limbic keratoconjunctivitis,10 and pterygia.11 From this case report, liquid nitrogen cryotherapy appears to be a safe and effective alternative in the treatment of conjunctival sarcoidosis.

References

  1. Rothova A. Ocular involvement in sarcoidosis. Br J Ophthalmol. 2000;84:110–116. doi:10.1136/bjo.84.1.110 [CrossRef]
  2. Hunter DG, Foster CS. Ocular manifestations of sarcoidosis. In: Albert DM, Jakobiec FA, eds. Principles and Practice of Ophthalmology. Philadelphia: W. B. Saunders; 1994:443–450.
  3. Akpek EK, Ilhan-Sarac O, Green WR. Topical cyclosporine in the treatment of chronic sarcoidosis of the conjunctiva. Arch Ophthalmol. 2003;121:1333–1335. doi:10.1001/archopht.121.9.1333 [CrossRef]
  4. Oh JY, Wee WR. Cyclosporine for conjunctival sarcoidosis. Ophthalmology. 2008;115:222. doi:10.1016/j.ophtha.2007.08.024 [CrossRef]
  5. Fraunfelder FW, Fraunfelder FT. Liquid nitrogen cryotherapy of a conjunctival vascular tumor. Cornea. 2005;24:116–117. doi:10.1097/01.ico.0000134185.55310.1d [CrossRef]
  6. Eichler MD, Fraunfelder FT. Cryotherapy for conjunctival lymphoid tumors. Am J Ophthalmol. 1994;118:463–467.
  7. Jakobiec FA, Rini FJ, Fraunfelder FT, Brownstein S. Cryotherapy for conjunctival primary acquired melanosis and malignant melanoma: experience with 62 cases. Ophthalmology. 1988;95:1058–1070. doi:10.1016/S0161-6420(88)33058-7 [CrossRef]
  8. Fraunfelder FT, Wingfield D. Management of intraepithelial conjunctival tumors and squamous cell carcinomas. Am J Ophthalmol. 1983;95:359–363.
  9. Fraunfelder FW. Liquid nitrogen cryotherapy of advancing wavelike epitheliopathy. Cornea. 2006;25:196–198. doi:10.1097/01.ico.0000170691.67584.ec [CrossRef]
  10. Fraunfelder FW. Liquid nitrogen cryotherapy of superior limbic keratoconjunctivitis. Am J Ophthalmol. 2009;147:234–238. doi:10.1016/j.ajo.2008.07.047 [CrossRef]
  11. Fraunfelder FW. Liquid nitrogen cryotherapy of pterygia. Ophthalmology. 2008;115:2314–2314. doi:10.1016/j.ophtha.2008.06.027 [CrossRef]

10.3928/15428877-20100325-08

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