Systemic corticosteroids led to anatomic regression of optic nerve head granuloma in sarcoidosisCorticosteroids help shrink a rare eye growth in sarcoidosis

BackgroundSarcoidosis is a multisystem granulomatous disorder of unclear etiology, histopathologically characterized by noncaseating granulomas. Ocular involvement is among the most common extrapulmonary manifestations, whereas optic nerve involvement occurs in fewer than 5% of cases. Direct granulomatous infiltration of the optic nerve represents the rarest form of optic nerve involvement. We report a rare case of a sarcoidosis-associated optic nerve head granuloma with prominent overlying vessels and describe its multimodal imaging features, clinical course, and treatment response, with a review of the clinical spectrum of sarcoid optic nerve head granulomas reported in the English-language literature.Case presentationA 31-year-old woman presented with floaters in the left eye. Best-corrected visual acuity was 20/20 in both eyes. Fundus examination of the left eye revealed a white elevated optic nerve head lesion with fine tortuous surface vessels, accompanied by vitreous inflammatory haze, retinal periphlebitis, and candle-wax drippings. Fundus fluorescein angiography demonstrated early filling of lesion-associated vessels with marked late leakage, and optical coherence tomography angiography detected abnormal flow signals corresponding to the lesion. Additionally, chest computed tomography revealed bilateral hilar lymphadenopathy, and transbronchial lung biopsy demonstrated chronic granulomatous inflammation with multinucleated giant cells and no definite necrosis. The overall findings supported the diagnosis of sarcoidosis. The lesion initially progressed after the patient declined corticosteroid therapy, but gradually regressed following systemic corticosteroid treatment, with parallel disappearance of the lesion-associated abnormal flow signals. At the final follow-up, the lesion had completely regressed, leaving only a thin gliotic membrane, while visual acuity remained 20/20 throughout the entire follow-up.ConclusionAlthough rare, sarcoid optic nerve head granuloma is a highly suggestive ocular manifestation that may be the presenting sign of systemic sarcoidosis and can mimic infectious or neoplastic optic disc mass lesions. Multimodal imaging is valuable for early recognition, assessment of treatment response, and longitudinal monitoring. Once the diagnosis is established, corticosteroid-based systemic therapy may be considered. In this case, systemic corticosteroid therapy was associated with anatomic regression of the optic nerve head granuloma, while visual acuity remained stable throughout follow-up.