Journal of Neuro-Ophthalmology, June 2001, Volume 21, Issue 2

Neuro-Ophthalmic Manifestations of Sarcoidosis

OBJECTIVE: To familiarize the reader with the neuro-ophthalmic manifestations of sarcoidosis. MATERIALS AND METHODS: All patients underwent systemic evaluations (chest radiograph, magnetic resonance imaging and/or computed tomography, serum angiotensin-converting enzyme level, and gallium scan). Histologic confirmation was preferred (11 of 15 patients underwent biopsy, ten of whom [82%] had positive biopsies, and four refused). Otherwise, the diagnosis of clinical sarcoidosis was based on laboratory evaluation. RESULTS: We report our experience with 15 patients who had neuro-ophthalmic manifestations of sarcoidosis other than optic neuropathy or chiasmal disease. Eight of 15 (53%) did not have known sarcoidosis at the time of presentation. Thirteen of 15 (87%) patients demonstrated lesions consistent with sarcoidosis on magnetic resonance imaging of the brain. Treatment with corticosteroids and/or other immunomodulatory agents was necessary in all cases. CONCLUSIONS: Neuro-ophthalmic manifestations of sarcoidosis are rare. They may be the presenting signs of otherwise occult disease. Suspicion and inclusion in the differential are a key to establishing the diagnosis. A strategy for the detection and evaluation of these cases is presented.

Journal of Neuro- Ophthalmology 21( 2): 132- 137, 2001. © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia Case Report Neuro- Ophthalmic Manifestations of Sarcoidosis: Clinical Spectrum, Evaluation, and Management Larry P. Frohman, MD, Ruben Grigorian, MD, and Leonard Bielory, MD Objective: To familiarize the reader with the neuro- ophthalmic manifestations of sarcoidosis. Materials and Methods: All patients underwent systemic evaluations ( chest radiograph, magnetic resonance imaging and/ or computed tomography, serum angiotensin- converting enzyme level, and gallium scan). Histologic confirmation was preferred ( 11 of 15 patients underwent biopsy, ten of whom [ 82%] had positive biopsies, and four refused). Other­wise, the diagnosis of clinical sarcoidosis was based on labo­ratory evaluation. Results: We report our experience with 15 patients who had neuro- ophthalmic manifestations of sarcoidosis other than optic neuropathy or chiasmal disease. Eight of 15 ( 53%) did not have known sarcoidosis at the time of presentation. Thirteen of 15 ( 87%) patients demonstrated lesions consistent with sarcoidosis on magnetic resonance imaging of the brain. Treatment with corticosteroids and/ or other immunomodulatory agents was necessary in all cases. Conclusions: Neuro- ophthalmic manifestations of sarcoidosis are rare. They may be the presenting signs of otherwise occult disease. Suspicion and inclusion in the differential are a key to establishing the diagnosis. A strategy for the detection and evaluation of these cases is presented. Key Words: Sarcoidosis- Diagnosis- Neuro- ophthalmic manifestations- Magnetic resonance imaging- Gallium scan. Sarcoidosis is a worldwide disease affecting all ethnic groups with an overall incidence of 6 to 10 per 100,000 ( 1). There appears to be a racial predilection for the development of the disease with a prevalence of sarcoid­osis in the United States of 5 in 100,000 in whites and 40 in 100,000 in blacks ( 2,3). Women seem to be more Manuscript received December 21, 2000; accepted January 31, 2001. Supported in part by a grant from Research to Prevent Blindness, Inc. and the Eye Institute of New Jersey. From the Departments of Ophthalmology ( LPF, RG, LB), Neuro-science ( LPF), and Medicine ( LB), UMD- New Jersey Medical School, Newark, New Jersey. Address correspondence and reprint requests to Larry Frohman, MD, Department of Ophthalmology, UMD- New Jersey Medical School, 90 Bergen Street, DOC 6th Floor, Newark, NJ 07103- 2441. commonly affected than men ( 2). The peak incidence is in the young adult population ( 1). The ophthalmic mani­festations of sarcoidosis are reported to occur in 22% of patients sometime in its course ( 4). Neurologic involve­ment has usually been reported to occur in approximately 5 to 16% of patients with sarcoidosis ( 5). When it occurs, central nervous system ( CNS) involvement may be an early manifestation of the disease, unmasking otherwise undetected systemic sarcoidosis ( 6). Various neurologic manifestations have been observed, including seizures, cognitive or psychic manifestations, hypothalamic and pituitary involvement, focal pseudotumors, and hydro­cephalus ( often associated with lymphocytic meningitis). Furthermore, cranial nerve palsies, particularly palsy of the facial nerve, are not uncommon. Inclusion of facial nerve palsies that are peripheral ( e. g., secondary owing to sarcoidosis of the parotid gland, the so- called Heer-fordt disease) may make the incidence of primary neu­rologic sarcoidosis in reported series seem misleadingly high. Neuro- ophthalmic involvement is rare but often se­vere. Patients with neuro- ophthalmic sarcoidosis, unlike those with nonspecific neurologic signs such as headache or irritability, may present early in its course, as the symptoms of diplopia and visual loss are typically im­mediately noted by the patient and reported to their phy­sician. When the neuro- ophthalmic symptom is isolated, it may be difficult to diagnose the underlying disease. SUBJECTS AND METHODS A retrospective review of all patients seen on the Neuro- Ophthalmology Service from 1989 to 1999 re­vealed 15 patients ( 11 women [ 73%] and four men), with an age range of 27 to 76 years, who presented with neuro- ophthalmic findings other than disease of the optic nerve, chiasm, and optic tract, which ultimately was di­agnosed as owing to sarcoidosis. As experience evolved during the decade, the evaluation of suspected neuro-ophthalmic sarcoidosis became more standardized. 132 NEURO- OPHTHALMIC MANIFESTATIONS OF SARCOIDOSIS 133 TABLE 1. Clinical presentation Patient no./ age/ race/ sex Neuro- ophthalmic manifestations Pain Preexisting sarcoid Ocular sarcoid Biopsy proven Patient no./ age/ race/ sex Neuro- ophthalmic manifestations Pain Preexisting sarcoid Ocular sarcoid Biopsy proven 1/ 30/ B/ F 6th nerve palsy +, headache - - +, lymph node 9/ 29/ B/ F § 7th nerve palsy, 8th nerve palsy, ON +, headache - + EL -, lacrimal gland, skin 2/ 27/ B/ F 6th nerve palsy, nystagmus +, headache + + AU +, lung 10/ 16/ B/ F 7th nerve palsy, nystagmus, periorbital swelling +, ocular + - +, conjunctiva 3/ 60/ B/ M 6th nerve palsy, proptosis +, headache - OM + EL, CJ +, lacrimal gland 11/ 25/ B/ F Parinaud syndrome, nystagmus - + SN+ PL +, skin 4/ 40/ B/ M 6th nerve palsy, 7th nerve palsy, ON +, ocular - AU, EL + PB, PL 12/ 45/ B/ F Tolosa- Hunt syndrome, ON +, ocular - - 5/ 76/ W/ F 3rd nerve palsy, ON +, ocular - + OM 13/ 47/ B/ M Diplopia, f nystagmus photophobia +, headache + + AU +, lacrimal gland 6/ 39/ B/ F 3rd nerve palsy, 4th nerve palsy, 5th nerve palsy, 6th nerve palsy, proptosis, ON +, headache - + EL 14/ 46/ B/ F Diplopia, % homonymous field defect, proptosis, APD, ON +, headache + + AU +, conjunctiva 7/ 35/ W/ F 3rd nerve palsy, 5th nerve palsy, 7th nerve palsy, ON +, headache - + S, AU, V -, lung 15/ 48/ W/ M Paracentral homonymous field defect, 8th nerve palsy, ON +, headache + - +, kidneys 8/ 43/ W/ F 5th nerve palsy, 7th nerve palsy, nystagmus, ON +, headache + + K +, skin lesion of hand * Not performed. f Diplopia was treated 18 months before neuro- ophthalmologic assessment was performed and not characterized. £ Diplopia was not characterized. § Patient was sent for neuro- ophthalmology consult and cranial nerve involvement was not isolated; we included her in the study. AU, anterior uveitis; B, black; CJ, conjunctivitis; EL, enlarged lacrimal gland; GL, glaucoma; K, Koeppe nodules; OM, orbital mass; ON, optic neuropathy; PB, periphlebitis; PL, papilledema; RS, retinal sheathing; S, scleritis; SN, synechia; V, vitreitis; W, white. In most cases, the following laboratory evaluations were performed at presentation: chest radiograph ( CXR), magnetic resonance imaging ( MRI) of the brain ( with fat- suppressed views of the optic nerves, with and with­out contrast), anergy panel, purified protein derivative ( PPD), serum angiotensin- converting enzyme ( ACE) level, 24- hour urine calcium, pulmonary function testing ( PFT), lumbar puncture ( LP), and gallium scan. Biopsy was performed in the 11 patients who permitted it. CLINICAL PRESENTATION Eleven women and four men with a mean age of 39.6 years ( range, 27- 76) were included in the study ( Tables 1 and 2). Eight of 15 ( 53%) patients did not have known sarcoidosis at the time of neuro- ophthalmic presentation. Six of 15 ( 40%) patients had an abducens nerve palsy: three had isolated involvement; one had a combined le­sion with a facial nerve palsy; one had combined oculo­motor, trochlear, trigeminal, and abducens nerve palsies; and one had pseudo Tolosa- Hunt syndrome. Three of 15 ( 20%) patients had an oculomotor nerve palsy: one had an isolated pupil- sparing third nerve palsy, one is a pa­tient described previously, and one patient had combined pupil- sparing oculomotor, trigeminal, and facial nerve palsies. Five of 15 ( 33%) patients had a facial nerve palsy: one had an isolated involvement, two patients with a combined involvement were described previously, one patient had it combined with fifth nerve palsy, and one had it combined with eighth nerve palsy. One patient had Parinaud syndrome. Two ( 13%) patients had unspecified diplopia. One ( 6.7%) patient had paracentral homony­mous field defect with involvement of the occipital lobe. Fourteen ( 93%) of the patients had pain ( headache, n = 10 [ 71%]; ocular pain, n = 4 [ 29%]) at the time of neuro- ophthalmic presentation. Eleven ( 73%) patients also had intraocular or orbital manifestations of sarcoid­osis: five of these had anterior uveitis; one patient had scleritis, and one had vitreitis. Two ( 13%) patients had TABLE 2. Neurologic/ ophthalmic manifestations of sarcoidosis ( excluded optic neuropathy) Manifestation Cranial neuropathy 3rd ( oculomotor) Isolated Multiple 4th ( trochlear) with multiple 6th ( abducens) Isolated Multiple 7th ( facial) Isolated Multiple Parinaud syndrome Unspecified diplopia Paracentral homonymous field defect ( involvement of the occipital lobe) No. (%)* 3( 20) 1( 7) 2( 13) 1( 7) 6( 40) 3( 20) 3( 20) 5( 33) 1( 7) 4( 27) 1( 7) 2( 13) 1( 7) * Refers to all patients ( 15) in the study. J Neuro- Ophthalmol, Vol. 21, No. 2, 2001 134 L. P. FROHMAN ET AL. an orbital mass, and one also had an enlarged lacrimal gland and conjunctivitis. Three ( 20%) patients had enlarged lacrimal gland with proptosis, one ( 7%) pa­tient had pupillary synechia, and one ( 7%) patient had Koeppe nodules. ILLUSTRATIVE CASE: PATIENT 1 A 30- year- old black woman was admitted to Neurol­ogy Service with a dull headache, bilateral blurred vi­sion, and binocular diplopia that increased on right gaze, which progressed in severity over 1 week. Her medical history was significant for classic migraine. At presen­tation, her best visual acuity was 20/ 30 OU, examination revealed moderate abduction deficit OD, consistent with abducens paresis. The rest of her neurologic and oph­thalmic examinations was normal. She was about to be discharged after a negative contrasted computed tomog­raphy ( CT) scan of the head, with a working diagnosis of a first episode of ophthalmoplegic migraine; however, neuro- ophthalmic consultation believed that diagnosis to be unlikely. Because her pain was noted to be distributed in the first and second branches of the trigeminal nerve, a MRI scan of the brain, with contrast for attention to the cavernous sinus, was performed and demonstrated en­hancement of the right cavernous sinus with a dural tail ( Fig. 1). Because of the suspicion of sarcoidosis, the patient's evaluation included a normal serum ACE level and LP, a positive PPD ( the patient later remembered that she had received Bacille Calmette- Guerin), and a normal CXR. Gallium scan revealed enhancement in the right axilla ( Fig. 2) and led to axillary node biopsy, which revealed FIG. 1. Magnetic resonance imaging scan, contrasted axial view, demonstrates enhancement of right cavernous sinus with dural tail. i FIG. 2. Gallium scan demonstrates uptake in the right axilla. diffuse nonnecrotizing and necrotizing granulomas consistent with sarcoidosis. The patient was placed on 60 mg of oral prednisone daily, and her symptoms rap­idly resolved. Comment The combination of a sixth nerve palsy and the tri­geminal distribution of her pain localized the process to the cavernous sinus; thus, directed neuroimaging was performed. Sarcoidosis is in the differential of painful cavernous sinus masses with a dural tail ( in the pre- MRI days, many such cases were labeled as Tolosa- Hunt syn­drome). Gallium scan was used to indicate where to per­form a tissue biopsy to obtain a histologic diagnosis. LABORATORY EVALUATION A CXR was performed on all patients: 10 ( 67%) pa­tients had lesions on CXR consistent with sarcoidosis, six of which were histologically confirmed ( Table 3). Of the five patients with a negative CXR, three permitted biopsy, and all had lesions consistent with sarcoidosis. Note that these three all had abnormal gallium scans, two of which had pulmonary uptake. The gallium scan was positive in 10 ( 71%) of the 14 patients tested. / Neuro- Ophthalmol, Vol. 21, No. 2, 2001 NEURO- OPHTHALMIC MANIFESTATIONS OF SARCOIDOSIS 135 TABLE 3. Laboratory evaluation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Patient no. Total of abnormal tests Total % of abnormal tests CXR - + - + -- + + + - + + + + + 10/ 15 67 MRI/ CT + + + + + + + + + - + - + + + 13/ 15 87 PPD + - + ---- * - ---- + - 3/ 14 21 Gallium scan + Lm - + L, S + L K + L, Pn + S + Lm - + L + Lg, Pl - + L + L - * 10/ 14 71 Anergy panel A R * R A A R R R R R R R R R 3/ 14 21 24- hour urine calcium - ------- - ------ 0/ 15 0 PFT - - * ----- - ---- * * 0/ 12 0 LP - * * - + --- - - + - * -- 2/ 12 17 ACE - - + - + + -- - ---- + - 4/ 15 27 Confirmed by biopsy + lymph node + lung + lacrimal gland * * * - lung + skin lesion of hand - lacrimal gland, skin + conjunctiva + skin * + lacrimal gland + conjunctiva + kidney 9/ 11 82 * Not performed. A, anergy; K, kidney; L, lung; Lg, lacrimal gland; Lm, lymphoid node; PI, pelvis; Pn, Pancreas; R, reactive; S, submandibular. Magnetic resonance imaging revealed lesions consis­tent with sarcoidosis in 13 ( 87%) cases, eight of which were confirmed by biopsy. The most common picture that we saw on the MRI scan was dural thickening with involvement of the cavernous sinus. In the three patients with a negative MRI, two had biopsy confirma­tion of sarcoidosis. Only three of 14 ( 21%) patients tested showed anergy. The serum ACE level was elevated in only four ( 27%) of 15 cases. Although serum ACE level is often said to be a marker for pulmonary activity, note that of the 11 pa­tients in whom the ACE was negative, nine had an ab­normal CXR, four of whom also had pulmonary uptake on gallium scan. PFTs were negative in all cases. The spinal fluid was abnormal in 2 of the 12 patients who had a LP ( both revealed pleocytosis). Biopsies were consistent with sarcoidosis in 9 ( 82%) of 11 cases. Seven patients ( 47%) had biopsy- proven preexisting sarcoidosis. The two ( 13%) patients ( patients 7 and 9) whose biopsy was negative had findings con­sistent with sarcoidosis on CXR and MRI ( dural thick­ening under the temporal lobe, causing widening of the cavernous sinus and dural enhancement) and had an ab­normal gallium scan; PPD was negative in both cases. Patients 4, 5, 6, and 12 refused biopsy. Patient 5 had an abnormal MRI scan suggesting sarcoidosis and an ab­normal gallium scan, cutaneous anergy, an elevated se­rum ACE, and spinal fluid findings suggesting sarcoid ( lymphomonocytic pleocytosis). Patient 6 had MRI and gallium scans suggestive of sarcoid as well as cutaneous anergy and an elevated serum ACE level. Patient 12 had an abnormal CXR and gallium scan, and patient 4 had CXR, gallium scan, and MRI suggestive of sarcoid. The two ( 13%) remaining patients ( patients 1 and 3) had no history of sarcoidosis and ultimately had positive biop­sies. Sarcoid was suggested in patient 1 by a MRI scan, an abnormal gallium scan, and anergy ( illustrative case). In patient 3, sarcoidosis was suggested by consistent MRI and gallium scan, an elevated ACE level, and or­bital and lacrimal masses, with the latter yielding a posi­tive biopsy. TREATMENT COURSE The initial therapy of neurosarcoidosis is systemic cor­ticosteroids ( Table 4). All our patients received oral prednisone ( initial dose, 1- 1.5 mg/ kg daily). The dose was tapered when the symptoms resolved ( or in one case, withdrawn when there was no improvement). One pa­tient developed adverse effects at levels of corticoste­roids required to control his disease process. These were intolerable weight gain and steroid- induced diabetes and necessitated the addition of cyclosporine as a steroid-sparing agent. One patient did not respond to prednisone therapy and was changed to cyclosporine. DISCUSSION Sarcoidosis is a systemic disease of unknown cause that commonly involves the eye and infrequently in­volves the CNS. The etiology of sarcoidosis is unknown. Evidence suggests that sarcoidosis occurs as the result of an imbalance in T- cell location and function, causing an exaggerated cellular immune response and an increased T- helper/ inducer response ( 1). There are several candidates for the inciting antigen; recent evidence points to infectious agents, especially J Neuro- Ophthalmol, Vol. 21, No. 2, 2001 136 L. P. FROHMAN ET AL. TABLE 4. Treatment course Patient no. Treatment modality Corticosteroids Cyclosporine Comment Outcome 10 11 12 13 14 15 Started on cyclosporine owing to inability to tolerate corticosteroids Cyclosporine started because of inability to stabilize symptoms with corticosteroids Symptom free, residual diplopia in end gaze Symptom free, residual diplopia in end gaze Symptom free, residual diplopia corrected with the prism Symptom free Symptom free Symptom free 7th nerve palsy remains; other symptoms resolved Symptom free Symptom free Symptom free Residual diplopia in end gaze Symptom free Symptom free Symptom free Residual homonymous field defect Mycobacterium species ( 5). Sarcoid granulomas are typically noncaseating and consist of epithelioid cells that are surrounded by a border of mononuclear cells, usually lymphocytes ( 7). Organ dysfunction seems to result from distortion of the normal architecture of the affected tissue by granulomas and subsequent fibrosis rather than by production of mediators that lead to dam­age ( 1). Neurologic sarcoidosis represents an uncommon but serious manifestation of sarcoidosis ( 8). When neu­rologic involvement occurs in the course of known sar­coidosis, the diagnosis of neurosarcoidosis is typically suspected. However, the neurologic involvement may occur long before the onset of systemic symptoms, and oftentimes sarcoid is not included in the differential di­agnosis. Involvement of the nervous system poses a dif­ficult diagnostic problem for the clinician unmasking previously occult sarcoidosis ( 9). MRI is the investiga­tion of choice in detecting parenchymal changes in the brain of patients with sarcoidosis ( 10). It has been re­ported that MRI has high sensitivity and specificity for evaluation of neurosarcoidosis ( 9- 11). Involvement of the nervous system can range from peripheral or cranial neuropathy to CNS disease ( 12,13). Lower et al. ( 8) identified patients with neurologic manifestations of sarcoidosis. At their institution, 71 ( 13%) of 554 patients with sarcoidosis ( definite or probable status) had evidence of nervous system involve­ment. Seventh ( facial) cranial nerve palsy was the most common manifestation identified in 39 ( 55%) patients, including 24 ( 34%) patients with facial nerve palsy as the only manifestation of neurologic sarcoidosis. Facial nerve palsy is the most frequent neurologic presenta­tion of sarcoidosis ( 14). Oculomotor, trochlear, and abducens nerve palsies were identified in only eight ( 11%) of their cases. Optic neuropathy ( excluded in our current series) was seen in seven ( 10%) of the patients of Lower et al. Other peripheral or cranial nerve involve­ment and CNS manifestations were observed in 16 ( 22%) patients. Recio et al. ( Clinical and radiological analysis of neu­rosarcoidosis, Paper presented at the 1997 North Ameri­can Neuro- Ophthalmology Society Meeting, Keystone, CO, February 1997) reported their series of 520 patients with biopsy- proven sarcoidosis. Thirty- two ( 6.3%) had neurologic symptoms; 13 ( 41%) had their neurologic symptoms associated with systemic signs, the most com­mon of which were weakness ( n = 14), facial paresis ( n = 7), headache ( n = 8), seizures ( n = 8), and visual loss ( n = 7). In our series, 13 of 15 ( 87%) patients had symptoms or findings suggestive of one of the CNS palsies, except one patient who developed only homonymous paracentral field defect ( involvement of the occipital lobe on MRI) and one with Parinaud syndrome ( Table 1). MRI re­vealed lesions consistent with sarcoidosis in 13 ( 87%) patients ( Table 3). Five ( 33%) patients had evidence of seventh nerve involvement, four of whom had character­istic changes for sarcoidosis on MRI. Neuro- ophthalmic manifestations of sarcoidosis are rare and include optic neuritis, parachiasmal involve­ment, and lesions of the optic tract ( anterior visual path­way disease has been excluded in this article and will be the subject of a separate report), and disorders of ocular motility. They can be the presenting sign of sarcoidosis. In eight ( 53%) of our cases, it was a neuro- ophthalmic finding that led to investigation and diagnosis of the systemic disease. In the other seven ( 47%) of our pa­tients, neuro- ophthalmic signs developed after the sys­temic diagnosis was made. Physicians need be aware that sarcoidosis can present initially with a neurologic- ophthalmic manifestation. MRI of the brain or orbits is the best choice for initial imaging study. If sarcoidosis is suggested by the MRI findings, which may include lacrimal gland, meningeal / Neuro- Ophthalmol, Vol. 21, No. 2, 2001 NEURO- OPHTHALMIC MANIFESTATIONS OF SARCOIDOSIS 137 or hypothalamic enhancement, and pituitary stalk in­volvement, then a focused diagnostic evaluation is indi­cated. We recommend that CXR, anergy panel, PPD, ACE, gallium scan, and spinal tap be performed, al­though LP is more frequently abnormal in cases of an­terior visual pathway disease than in this series. PFTs and 24- hour urine calcium were not helpful in identify­ing cases of sarcoidosis; it appears that they are useful in cases of anterior visual pathway disease ( Frohman, Un­published data). Computed tomography scan of the chest may prove to be a useful adjunct. Kosmorsky et al. ( 15) presented a series of elderly white women with bilateral chronic uve­itis. All had a negative CXR. Chest CT showed medias­tinal lymphadenopathy in all cases, which led to ultimate histologic confirmation of sarcoidosis, although it may identify the same cases that gallium scan identifies. Systemic corticosteroids are the mainstay of therapy and should be given to all cases with acute neurologic involvement. Other immunomodulatory agents such as cyclosporine may be effective in refractory cases or when the patient cannot tolerate the dose of corticoste­roids required to control the disease process. Because cyclosporine has specific inhibitory effects on monocyte and T- cell activation via decreased interleukin- 1 and in-terleukin- 2, blocks B- cell activation, and improves hy­perglycemic control, it should be an effective therapeutic agent for refractory sarcoidosis. Low- dose cyclosporine is a safe and effective therapeutic alternative in granulo­matous disease ( 16). Others used azathioprine, cyclo­phosphamide, chlorambucil, and methotrexate as alter­native treatment ( 17). In our series, neuro- ophthalmic symptoms, when treated acutely, generally responded well to therapy. REFERENCES 1. Seamone CD, Nozik RA. Sarcoidosis and the eye. Ophthalmol Clin North Am 1992; 5: 567- 76. 2. Breznitz EA, Strom BL. Epidemiology of sarcoidosis. Epidemiol Rev 1983; 5: 124- 56. 3. Thomas PD, Hunninghake GW. Current concepts of the pathogen­esis of sarcoidosis. Am Rev Respir Dis 1987; 135: 747- 60. 4. Obenauf CD, Shaw HE, Sydnor CF, et al. Sarcoidosis and its ophthalmic manifestations Am J Ophthalmol 1978; 86: 648- 55. 5. Lama P, Frohman L. Annual review of systemic disease- 1997. II. J Neuroophthalmol 1998; 18: 127^ t2. 6. Valeyre D, Chapelon- Abric C, Belin C, et al. Sarcoidosis of the central nervous system. Rev Med Interne 1998; 19: 409- 14. 7. Yanoff M, Fine BS. Granulomatous inflammation. In: Ocular Pa­thology: A Text and Atlas. 3rd ed. New York: Harper and Row, 1989: 68- 101. 8. Lower EE, Broderick JP, Brott TG, et al. Diagnosis and manage­ment of neurological sarcoidosis. Arch Intern Med 1997; 157: 1864- 8. 9. Kadakia JK, Collette PM, Sharma OP. Role of magnetic resonance imaging in neurosarcoidosis. Sarcoidosis 1993; 10: 98- 9. 10. Miller DH, Kendall BE, Barter S, et al. MRI in central nervous system sarcoidosis. Neurology 1988; 38: 378- 83. 11. Lexa FJ, Grossman RI. MR of sarcoidosis in the head and spine: spectrum of manifestations and radiographic response to steroid therapy. AJNR Am J Neuroradiol 1994; 15: 973- 82. 12. Delaney P. Neurologic manifestations in sarcoidosis. Ann Intern Med 1977; 87: 336- 45. 13. Chen RC, McLeod JG. Neurological complications of sarcoidosis. MedJAust 1992; 156: 815. 14. James DG. Differential diagnosis of facial nerve palsy. Sarcoidosis Vase Diffuse Lung Dis 1997; 14: 115- 20. 15. Kosmorsky GS, Meisler DM, Rice TW, et al. Chest computed tomography and mediastinoscopy in the diagnosis of sarcoidosis-associated uveitis. Am J Ophthalmol 1998; 126: 132- 4. 16. Bielory L, Frohman L. Low- dose cyclosporine therapy of granu­lomatous optic neuropathy and orbitopathy. Ophthalmology 1991; 98: 1732- 6. 17. Agbogu B, Stern B, Sewell C, et al. Therapeutic consideration in patients with refractory neurosarcoidosis. Arch Neurol 1995; 52: 875- 9. J Neuro- Ophthalmol, Vol. 21, No. 2, 2001