Bilateral Orbital Masses, Blepharoptosis, and Epiphora as Only Initial Signs of Systemic Sarcoidosis

To report a rare case of systemic sarcoidosis initially presenting solely with bilateral nasolacrimal duct obstruction and lacrimal gland hypertrophy, without intraocular involvement. A 48-year-old male presented with bilateral epiphora, palpable orbital masses, and blepharoptosis. Clinical examination, imaging, and biopsy confirmed bilateral nasolacrimal duct obstruction and lacrimal gland enlargement with non-necrotizing granulomatous inflammation. Systemic work-up revealed elevated ACE levels and hilar lymphadenopathy, leading to the diagnosis of systemic sarcoidosis. Despite systemic immunosuppressive treatment, the patient required bilateral dacryocystorhinostomy and subsequent bilateral orbitotomy for mass excision. One year later, ptosis correction with Müller's muscle-conjunctival resection was performed. No recurrence was observed in follow-up. This is the first reported case of systemic sarcoidosis initially presenting solely with adnexal findings, specifically bilateral nasolacrimal duct obstruction and lacrimal gland hypertrophy, without intraocular manifestations.