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Publication Exclusive: Man presents with headache, ptosis and abnormal eye movements
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A 49-year-old Brazilian man with no known medical history was admitted to the hospital for headache, ptosis of the right upper eyelid and abnormal eye movements. He had been discharged from the hospital recently with a working diagnosis of migraine, only to be admitted again with worsening symptoms. The admitting team ordered an MRI of the brain that showed a possible cavernous sinus thrombosis. At this point, Ophthalmology was urgently consulted. On review of systems, the patient complained of a bifrontal headache but denied any ocular pain or changes in his vision.
Examination
Uncorrected visual acuity was 20/20 in both eyes. Both pupils were equally round, but the right pupil was sluggish to constriction while the left pupil constricted briskly. There was no afferent pupillary defect in either eye. IOP was within normal limits in both eyes. Confrontation visual fields were full. Extraocular motility was full in the left eye. However, the right eye had significantly limited motility; the patient had limited adduction, elevation and depression in the right eye. The anterior and posterior segments were completely unremarkable in both eyes.
Clinical course
The patient was discharged without a definitive diagnosis but was started on anticoagulation due to the unusual cavernous sinus findings on the MRI. He was also started on steroids for possible Tolosa-Hunt syndrome. His laboratory workup was notable for weakly positive RPR (negative CSF VLDR and treponemal antibody), negative QuantiFERON, normal ACEI and negative HIV. During this time, he missed his follow-up appointment with Ophthalmology. He initially improved on this empiric treatment. However, he began developing worsening headaches and bilateral ptosis. He was admitted 2 weeks later for the third time, and Ophthalmology was consulted again. On exam, both pupils were fixed and mid-dilated. He had a complete third, fourth and partial sixth nerve palsy of the right eye, and the left eye also became involved with a partial third, fourth and partial sixth nerve palsy.
• Click here to read the full publication exclusive, Grand Rounds at the New England Eye Center, published in Ocular Surgery News U.S. Edition, September 25, 2016.