A 70-year-old female presented with a history of painless swelling of the left lower eyelid for one year (Fig. 1A). She had no systemic complaints. On examination, her visual acuity was 20 / 20 (left eye), and a slitlamp examination of the left eye revealed no abnormalities except for corneal granular dystrophy. The lower eyelid of the left eye was diffusely swollen without any palpable mass. The left upper eyelid showed a 3-mm ptosis with 10-mm levator function, without swelling, and the ptosis resolved after administration of 2.5% phenylephrine in the left eye. No exophthalmos was present, and the extraocular movements were normal. A fundus examination revealed no abnormalities. A computerized tomography (CT) scan of the orbit was unremarkable (Fig. 1B and 1C).
The patient's white blood cell count, chemistry panel, and thyroid function tests were normal. The erythrocyte sedimentation rate was 31 mm in the first hour, and serum angiotensin converting enzyme (ACE) levels were 58 units (normal, 8 to 52 units). A chest radiograph revealed an old tuberculous lesion without hilar lymphadenopathy (Fig. 2), and a Mycobacterium tuberculosis antigen-specific interferon gamma assay was negative. As these results were inconclusive, surgical debulking of the swollen lower eyelid via an inferior conjunctival fornical approach for diagnosis and treatment was performed, as well as a conjunctivo-mullerectomy for ptosis correction. The operative findings showed stiff and coarse orbital fat particles, and the histopathologic examination demonstrated non-caseating granulomas consisting of epitheloid histiocytes in the orbital fat, most likely caused by sarcoidosis (Fig. 3). Special stains for acid-fast bacilli and fungi were negative.
The patient was further reviewed by a pulmonologist who noted hilar lymphadenopathy on the chest CT. The patient was diagnosed with orbital sarcoidosis, and started on prednisolone (10 mg/day) in consideration of the significant improvement in eyelid swelling after surgical debulking (Fig. 4). The symptoms completely resolved within one month, and she has been followed for 12 months without a recurrence.