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KD is a 43-year-old woman who had a history of recent cough and shortness of breath, a nodular rash on her legs, and reduced vision in her left eye with mild aching. Examination revealed some sheathing of the mid-peripheral retinal vessels and moderate edema of the optic disc with several disc hemorrhages.

Echography demonstrated thickening of the optic nerve to 4.5 mm on A-scan and some increased lucency of subtenon’s space by B-scan at the globe/optic nerve junction (Fig. 1). The 30° test was negative with no significant change in nerve diameter on abduction of the globe. Later workup included a chest CT, serum angiotensin- converting enzyme levels, and a parotid gland biopsy that demonstrated noncaseating granulomas. The patient was referred for bronchoscopy, which supported the diagnosis of sarcoidosis.

Fig. 1
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B-scan of sarcoid involvement of optic neuritis with increased subtenon’s lucency (arrow)

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Rarer causes of optic neuritis include herpes simplex and herpes zoster, syphilis, Lyme disease, and other infectious etiologies. Pain accompanies these entities to varying degrees. There is usually some degree of visual loss, and clinical examination reveals a spectrum of optic disc swelling from a normal appearance in purely retrobulbar neuritis to fulminant papilledema. Echography is useful in the workup of inflammatory optic nerve processes by revealing the presence of one or a combination of the following: fluid around the nerve, parenchymal edema, and solid infiltration of the nerve. It can also assist in identifying causes of pseudopapilledema, such as optic disc drusen or anomalous disc morphology.

Orbital pain can be due to pathology of the subperiosteal space, such as infection or inflammation. Acute sinusitis may respond initially to antibiotic treatment, but the patient may not fully recover after several weeks, which should alert the clinician to the possibility of a subperiosteal abscess. The patient may show initial improvement with antibiotic treatment but then stagnates clinically with chronic lid edema, tenderness, and pain. Echographic studies demonstrate thickening of the subperiosteal space and low reflectivity consistent with inflammatory infiltration. This condition often requires surgical drainage to resolve the problem. Echography is a cost-effective and safe way to follow up the effectiveness of treatment.