Bilateral internal ophthalmoplegia in a patient with sarcoidosis.

Ocular signs are common in systemic sarcoidosis.Upwards of 50 per cent. of affected patients develop a granulomatous anterior uveitis, and fundus lesions are frequently observed.Ocular findings due to central nervous system involvement are less frequent, but can be the initial complaint.The subject of central nervous system involvement in sarcoidosis has been reviewed by Colover (I948) and Walsh and Hoyt (i 969a).In this paper, we report a patient whose initial ocular manifestation of sarcoidosis was an internal ophthalmoplegia.Her systemic illness went undiagnosed for many months until she developed a severe bilateral granulomatous uveitis and secondary glaucoma.The literature dealing with internal ophthalmoplegia in sarcoidosis is reviewed. Case reportAn obese 40-year-old Negro nurse was admitted to the hospital in October, 1970, because of a severe bilateral decrease in visual acuity.She had been well until February, 1970, when she developed a "flu-like" syndrome which was followed by persistent fever, malaise, anorexia, lower extremity weakness, myalgia, and paresthesias.She also developed a rash on the legs.In March, 1970, she was noted to have pyuria for which she was given Negram (9) and Furadantin (f), and she also complained of nervousness for which she was given chlorpromazine; 2 weeks later, she noted some blurred vision in the left eye and the chlorpromazine was discontinued, but the vision did not improve.She was next seen on May 7, 1970, in the psychiatric emergency room, complaining of depression, progressive weakness, and recurring spiking fevers to 1030 F.She was seen by the neurology service to rule out organic disease.Examination She had difficulty in walking, a temperature of I02° F., a 5 mm.diameter left pupil, with sluggish reaction, and a 2 mm.diameter reactive right pupil.Ocular motility and fundus findings were de- scribed as normal.A spinal tap revealed an opening pressure of I70 mm.Hg., 94 mg. per cent.protein and 48 per cent.glucose.The diagnosis of Adie's pupil was considered likely and a full medical examination planned.She was re-examined on May 26 because of increasing weakness and bilateral blurring of vision of 2 weeks' duration.At this time, the right pupil measured 5 mm.and the left 4 mm. in diameter.Both had sluggish reactions to light and accommodation.The patient was felt to have "hyperven- tilation syndrome" and anxiety.Ophthalmological examination She was first examined in the Eye Clinic on June 5, 1970.The visual acuity was 20/50 in the right eye, 20/20 with + I -5 D sph.; and 20/40 in the left eye, 20/20 with +os5 D. sph.There was slight ptosis, more marked on the right side.Applanation tensions were 14 mm.Hg Receised for ptublicationi