MAJOR REVIEW IgG4-Related Ophthalmic Disease. Part II: Clinical Aspects Alan A. McNab, D.Med.Sc, F.R.A.N.Z.C.O.*†, and Penny McKelvie, M.D., F.R.C.P.A.‡ *Orbital Plastic and Lacrimal Clinic, Royal Victorian Eye and Ear Hospital, Melbourne, Australia; †Centre for Eye Research Australia, University of Melbourne, Melbourne, Australia; and ‡Department of Anatomical Pathology, St Vincent’s Hospital, Melbourne, Australia fibrosis, usually of a storiform pattern, and in some organs, an Purpose: To review the current state of knowledge of IgG4- obliterative phlebitis. Serum IgG4 levels may be elevated or related ophthalmic disease (IgG4-ROD). normal. Large numbers of tissue eosinophils may also be seen, Methods: A review of the literature and personal experience as well as elevated numbers of circulating eosinophils. The orbit of the authors. is a frequently involved site (IgG4-related ophthalmic disease Results: IgG4-related disease is a recently recognized [IgG4-ROD]), and a significant proportion of patients with fibroinflammatory disorder that may affect 1 or more organs. It is orbital disease will have disease elsewhere at presentation, or characterized by lymphoplasmacytic infiltrates with large numbers of develop it subsequently. IgG4 positive plasma cells, storiform fibrosis, obliterative phlebitis, The disease is not “new,” but IgG4 was first implicated and and eosinophil infiltration as well as peripheral eosinophilia, and recognized by Japanese researchers in 2001, in a group of patients in some cases, elevated serum levels of IgG4. These features are with autoimmune pancreatitis (AIP) with elevated serum IgG4 not always seen, and the diagnosis should be made by integrating levels.1 It was soon recognized that extrapancreatic fibroinflamma- clinical, imaging, and histopathological data, with reference to tory lesions, rich in IgG4+ plasma cells, were common in patients recently defined diagnostic criteria. IgG4-ROD forms a significant with AIP.2 Since then, the condition has been described in almost proportion of what has previously been labeled “idiopathic all organs, the commonest being the biliary tree, retroperitoneum, orbital inflammation” or reactive lymphoid hyperplasia. Orbital salivary glands, orbit, lymph nodes, kidneys, lungs, meninges, disease may occur alone, at the same time as disease elsewhere, aorta, breast, prostate, thyroid, pericardium, and skin. or metachronously with systemic disease. Although almost any The first part of this review (published earlier) summa- ocular adnexal tissue may be affected, there are several commoner rizes the nomenclature, epidemiology, pathology and pathogen- recognizable patterns of IgG4-ROD: (1) sclerosing dacryoadenitis; esis, as well as published diagnostic criteria. This second part of 2) enlargement of orbital nerves (most commonly the infraorbital the review covers clinical aspects of IgG4-ROD. nerve) associated with orbital myositis and lacrimal gland disease, often in combination with paranasal sinus disease, eosinophilia, OCULAR ADNEXAL IGG4-RD and systemic involvement; and 3) sclerosing orbital inflammation. Patients with IgG4-ROD should be investigated and monitored for The pattern of ocular adnexal involvement in pathologi- other organ involvement. Some patients with IgG4-related disease cally diagnosed IgG4-ROD has been described in a Japanese may develop lymphoma, usually marginal zone lymphoma of study detailing 65 cases from 7 institutions.3 Of the 65 cases, mucosa-associated lymphoid tissue type. Treatment of IgG4-ROD 31 (57.7%) had lacrimal gland lesions alone, and 34 (52.3%) includes the use of corticosteroids and other immunosuppressants. had lesions in other areas, and of these, only 8 (12.3%) did not Rituximab has been shown to be very effective. Longer term studies have any lacrimal gland involvement. Next most common was on the natural course and treatment of IgG4-ROD are needed. trigeminal nerve involvement in 25 (38.5%), then extraocular Conclusions: Patients presenting with orbital inflammatory muscle (EOM) involvement in 16 (24.6%), diffuse orbital fat lesions should have biopsies obtained whenever possible. The disease in 15 (12.3%), a circumscribed orbital mass lesion in 11 examining pathologist should routinely look for features of (16.9%), eyelid lesions in 8 (12.3%), and 1 case of nasolacri- IgG4-ROD, and if found, the patient should be investigated mal duct disease. Six patients (9.2%) presented with optic nerve for other organ involvement. Early treatment may prevent compromise and 8 (12.3%) with restriction of ocular motility. destructive changes in affected tissues. Importantly, no patient reported sensory disturbance or pain in the distribution of the affected branches of the trigeminal nerve. (Ophthal Plast Reconstr Surg 2015;31:167–178) All but 2 patients had an elevated serum IgG4 level. A report from the United States on 21 patients with IgG4-ROD again found the lacrimal gland the most commonly gG4-related disease (IgG4-RD) is a recently recognized entity involved site (13/21, 61.9%).4 Four patients had EOM disease, 6 Icharacterized by tumefactive lesions with dense lympho- had orbital soft tissue involvement, and 2 had trigeminal nerve plasmacyctic infiltration, rich in IgG4-positive plasma cells, disease. In this group overall, 7 patients (37%) had a normal serum IgG4 level.4 The relative frequency of involvement of dif- Accepted for publication October 23, 2014. ferent anatomical sites within the orbit from these 2 large series The authors have no financial or conflict of interest to disclose. is summarized in Table. Presented in part at the Oculofacial Subspecialty Day of the American Commoner patterns of involvement in IgG4-ROD are: Academy of Ophthalmology meeting on November 2013 in New Orleans, LA. Address correspondence and reprint requests to Alan A. McNab, D.Med. Sc., F.R.A.N.Z.C.O., Suite 216, 100 Victoria Parade, East Melbourne 3002, 1. Dacryoadenitis (which may be unilateral or bilateral and may Victoria, Australia. E-mail: [email protected] be associated with salivary gland enlargement [previously DOI: 10.1097/IOP.0000000000000364 often labeled Mickulicz disease]) Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015 167 Copyright © 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited. A. A. McNab and P. McKelvie Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015 Frequency of involvement of anatomical sites within the orbit in 2 large series of pathologically verified IgG4-ROD cases Bilateral disease Lacrimal gland Trigeminal nerve EOM Orbital fat Eyelid NLD Sogabe et al.3(n = 65) 76% (93% of LG) 88% 39% 25% 40% 12% 1.5% Wallace et a.l4(n = 21) 71% 62% 9.5% 19% 28.6% 0% 9.5% EOM, extraocular muscle; NLD, nasolacrimal duct; LG, lacrimal gland. 2. Enlarged orbital nerves (usually the infraorbital) with EOM which had salivary gland disease as well.5 An evolution from and lacrimal gland involvement predominantly lymphoid hyperplasia to markedly atrophic 3. Orbital fat involvement (usually in combination with lacrimal lacrimal gland with fibrosis was noted in 1 patient who had gland and other tissue involvement) sequential biopsies. A further case with sequential biopsies has 4. Sclerosing orbital inflammation without lacrimal gland shown progressive fibrosis over time.11 (This contrasts with the involvement (less common). case illustrated in Figures 1 and 2, who had a short history with dense fibrosis on biopsy.) No cases showed obliterative phlebi- tis. This may be because lacrimal gland biopsies are generally IgG4-Related Dacryoadenitis. As noted above, lacrimal gland small and the venules in the lacrimal gland are also relatively involvement is the commonest manifestation of IgG4-ROD.3,5–10 small. It was also one of the earliest reported extrapancreatic sites of Soon after, a series of 4 cases of bilateral sclerosing IgG4-RD. dacryoadenitis, all associated with salivary gland disease, was An early report described 6 patients with chronic scle- reported.12 Three of 4 responded well to oral corticosteroids and rosing dacryoadenitis, 5 of which were bilateral, and 3 of the fourth, a diabetic, had the lacrimal glands excised. Other FIG. 1. Case 1. Unilateral sclerosing dacryoadenitis. A, A 27-year-old female, otherwise well, presented with 4 weeks increasing left upper eyelid swelling with mild ache, and a hard tender mass in the left lacrimal gland. B and C, CT scans show a grossly enlarged lacrimal gland with flattening of the globe. D and E, MRI shows a discrete lacrimal gland lesion, which enhances with gadolinium. CT chest, abdomen, and pelvis were normal. She responded well to a course of oral steroids but was lost to follow up after 6 months. 168 © 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Copyright © 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited. Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015 IgG4-Related Ophthalmic Disease case reports of sclerosing dacryoadenitis associated with sali- soft tissue disease associated with sclerosing cholangitis and vary gland disease have appeared.13,14 An illustrative case is rhinosinusitis is illustrated in Figure 4. shown in Figure 3. Interestingly, there may be reduced tear and saliva pro- A larger series of 12 patients with IgG4-related dac- duction in patients with AIP in the absence of lacrimal or sali- ryoadenitis found half had bilateral disease.15 Nine of