Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Ocular involvement can be the initial manifestation, occurring by itself, or it can be associated with other systemic signs of
sarcoidosis. A 31 years-old caucasian female presented a 10-day history of decreased vision and
pain in OS. Biomicroscopy revealed fine keratic precipitates, a mild reaction in the anterior chamber and in the vitreous cavity in both eyes and a small posterior synechiae in OS. Intraocular pressure was 12 mmHg in the OD and 9 mmHg in OS. Fundoscopy disclosed mild swollen and hyperemic optic discs and some subretinal yellowish nodules of 1/3 to 1 disc diameter, partially delimited, located in the posterior pole and midperiphery in both eyes. The Chest X-ray disclosed the suspicion of hilar
lymphadenopathy, especially on the left-side. The positron emission tomography (PET-scan) showed increased 18 F-fluorodeoxyglucose uptake in the paratracheal and bilateral hilar lymph nodes, indicating high local cellular metabolism. A mediastinal lymph node biopsy was performed afterwards, which depicted non-caseating
granulomas with multinucleated giant cells and absence of
acid-alcohol resistant bacilli. The patient was initially treated with oral
prednisone 60 mg/day with slow tapering over the next months. A decreased
papillitis and an increased size of the choroidal
granulomas was observed after a 6-month
therapy (Figs. 1B and 2B). Then, a combination of
methotrexate 20 mg/week and
prednisone 10 mg/day was given over the following months, which led to a gradual reduction in size and thickness of the choroidal
granulomas. A weak response to
steroid monotherapy was initially observed in this patient. The introduction of a non-
steroid immunosuppressant drug (
methotrexate) was associated with significant anatomic improvement in the following months. This report raises the suggestion that an early introduction of a nonsteroidal immunosuppressive
drug to systemic
steroids may be beneficial for a rapid remission of the
uveitis.