Cost-effectiveness in the diagnosis of sarcoidosis: The conjunctival biopsy

Abstract

Purpose Sarcoidosis is a multi-system disease that often affects ocular structures. The definitive diagnosis of sarcoidosis requires tissue biopsy for confirmation. Conjunctival biopsy is a simple and relatively inexpensive diagnostic tool. This study was undertaken to determine the utility and cost of conjunctival biopsy for the diagnosis of sarcoidosis compared with other diagnostic biopsy sites. Pulmonary involvement is the most common clinical manifestation of the disease. Transbronchial and mediastinal biopsy can be used to establish the diagnosis of sarcoidosis by directing the biopsy to clinically involved tissue. Bronchoalveolar lavage can contribute data supportive of sarcoidosis without a specific tissue diagnosis.2Involvement of the eye in sarcoidosis is common?--<> The most common ophthalmological manifestation is anterior segment granulomatous infiltration. Conjunctival biopsy has been described in the literature since the 1950s, with controversy surrounding the utility of performing a 'blind' biopsy?-12 This study was performed to compare the costs of conjunctival biopsy with biopsy of other tissue sites in patients eventually confirmed as having systemic sarcoidosis. Patients and methodsA retrospective chart review was performed for all patients who had conjunctival biopsy performed at the Mayo Clinic between 1982 and 1995 with the suspected clinical diagnosis of sarcoidosis. Forty-one patients undergOing conjunctival biopsy were diagnosed with sarcoidosis on the basis of a positive tissue biopsy at any site.Each conjunctival biopsy was performed following a complete ophthalmological evaluation. The biopsy sample size averaged 5 X 3 X 2 mm and was directed towards a suspicious lesion, if any (Table 1). Topical anaesthetic and subconjunctival infiltration of local anaesthetic into the inferior palpebral conjunctiva was employed. The lower lid was retracted and a strip of the ballooned conjunctiva was excised using Westcott scissors. Local pressure and irrigation with Dacriose solution provided adequate haemostasis. Topical antibiotic was then placed in the inferior fornix. There were no complications or morbidity associated with the procedure.Eye (1998) 12, 959-962

Directed conjunctival biopsy and impact of histologic sectioning methodology on the diagnosis of ocular sarcoidosis

“…In the literature, some institutions performed 5 to 6 serial sections at three levels [ 1 ] whereas others performed 10 serial sections at 6 different levels for a total of 60 sections [ 2 ]. No studies to date have evaluated the effect of number of serial sections on conjunctival biopsy yield, although the importance of careful sectioning has been previously emphasized [ 1 , 5 , 15 , 16 ].…”

“…The recovery of granulomas with conjunctival biopsy using careful sectioning technique approaches the yield obtained from other tissue sites [ 16 , 17 ], especially when conjunctival pathology such as nodules, follicles, or fibrous scarring is present [ 4 , 12 , 18 ]. No false positives have been reported in previous studies [ 18 , 19 ].…”

Neurosarcoidosis

“…39,40 Bilateral biopsy is recommended because abnormalities can often be seen only on one side. However, a more recent retrospective study evaluating the use of conjunctival biopsy in 440 suspected cases of neurosarcoidosis (the diagnosis had to be included as a surgical indication or in the neurology clinic notes) reported only a 3% (13 of 440) rate of abnormalities consistent with ocular sarcoidosis, of which 1% (4 of 440) was ultimately found to have another cause for the neurologic symptoms.…”

Infection, Immunodeficiency, and Inflammatory Diseases in Autoimmune Neurology

“…In rare cases, conjunctival biopsy may demonstrate granulomas; however, the routine use of this approach has not been established yet. While some studies suggested clinical utility with findings consistent with sarcoidosis in up to 55% of cases even in the absence of ocular disease, 81,82 a more recent study of 440 suspected cases of neurosarcoidosis reported only 13 of the 440 (3%) with an abnormal conjunctival biopsy. 83 Treatment for neurosarcoidosis is largely based on retrospective studies and expert opinion due to the lack of randomized clinical trials.…”