[Skip to Content]
[Skip to Content Landing]

Orbital Inflammation in an Adult With Crohn Disease

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man aged 57 years presented to the emergency department after 3 weeks of bilateral periorbital pain and swelling with associated headaches. He reported diplopia and pain with extraocular movement. There were no constitutional, dermatologic, or neurologic symptoms. The patient endorsed a history of Crohn disease, and his medication had been changed from infliximab to ustekinumab 6 weeks prior owing to persistent intestinal inflammation.

Clinical examination revealed bilateral periorbital edema, diplopia with decreased abduction in the right eye and decreased adduction in the left eye, chemosis, proptosis, and conjunctival hyperemia (Figure 1A). Visual acuity and neurologic and fundus examination findings were otherwise normal with no sign of optic neuropathy.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Medication-induced orbital myositis secondary to ustekinumab

B. Change therapies for Crohn disease

The patient had features of a corticosteroid-responsive bilateral orbital myositis (OM). OM was first described in 1903.1 It can occur at any age and more commonly affects women.2 It commonly presents as painful diplopia or orbital inflammation with chemosis, proptosis, or conjunctival hyperemia. The horizontal recti muscles are most frequently affected, although the superior or inferior recti can also be involved.3 The inflammatory process (Figure 2) appears to be mediated by helper T-cell type 1, with significant elevations in interleukin 12, tumor necrosis factor α, and interferon γ.4 Diagnosis of OM is based on physical examination and radiologic features excluding other etiologies and may require tissue biopsy when features are atypical or response to corticosteroids is inadequate.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Abhinav Vasudevan, BMedicine, MPH, PhD, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (abhinav.vasudevan@monash.edu).

Published Online: January 27, 2022. doi:10.1001/jamaophthalmol.2021.4676

Conflict of Interest Disclosures: Dr Vasudevan reported receiving nonfinancial support from Ferring Pharmaceuticals to attend an educational conference. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Gleason  JE .  Idiopathic myositis involving the extraocular muscles.   Ophthalmic Rec. 1903;12:471-478.Google Scholar
2.
Siatkowski  RM , Capó  H , Byrne  SF ,  et al.  Clinical and echographic findings in idiopathic orbital myositis.   Am J Ophthalmol. 1994;118(3):343-350. doi:10.1016/S0002-9394(14)72959-9PubMedGoogle ScholarCrossref
3.
Costa  RM , Dumitrascu  OM , Gordon  LK .  Orbital myositis: diagnosis and management.   Curr Allergy Asthma Rep. 2009;9(4):316-323. doi:10.1007/s11882-009-0045-yPubMedGoogle ScholarCrossref
4.
Wladis  EJ , Iglesias  BV , Gosselin  EJ .  Characterization of the molecular biologic milieu of idiopathic orbital inflammation.   Ophthalmic Plast Reconstr Surg. 2011;27(4):251-254. doi:10.1097/IOP.0b013e31820768f7PubMedGoogle ScholarCrossref
5.
Mannor  GE , Rose  GE , Moseley  IF , Wright  JE .  Outcome of orbital myositis. clinical features associated with recurrence.   Ophthalmology. 1997;104(3):409-413. doi:10.1016/S0161-6420(97)30300-5PubMedGoogle ScholarCrossref
6.
Garrity  JA , Coleman  AW , Matteson  EL , Eggenberger  ER , Waitzman  DM .  Treatment of recalcitrant idiopathic orbital inflammation (chronic orbital myositis) with infliximab.   Am J Ophthalmol. 2004;138(6):925-930. doi:10.1016/j.ajo.2004.06.077PubMedGoogle ScholarCrossref
7.
Lakatos  L , Pandur  T , David  G ,  et al.  Association of extraintestinal manifestations of inflammatory bowel disease in a province of western Hungary with disease phenotype: results of a 25-year follow-up study.   World J Gastroenterol. 2003;9(10):2300-2307. doi:10.3748/wjg.v9.i10.2300PubMedGoogle ScholarCrossref
8.
McNab  AA .  Orbital myositis: a comprehensive review and reclassification.   Ophthalmic Plast Reconstr Surg. 2020;36(2):109-117. doi:10.1097/IOP.0000000000001429PubMedGoogle ScholarCrossref
9.
Pirbhai  A , Rajak  SN , Goold  LA ,  et al.  Bisphosphonate-induced orbital inflammation: a case series and review.   Orbit. 2015;34(6):331-335. doi:10.3109/01676830.2015.1078380PubMedGoogle ScholarCrossref
10.
US Food and Drug Administration. FDA Adverse Events Reporting System (FAERS) Public Dashboard. Updated October 22, 2021. Accessed September 12, 2021. https://www.fda.gov/drugs/questions-and-answers-fdas-adverse-event-reporting-system-faers/fda-adverse-event-reporting-system-faers-public-dashboard
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close