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Teenager has unilateral severe eye pain
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A 19-year-old male presented to the eye clinic with a chief concern of pain in the left brow that began 2 weeks ago. It had since spread to the left eye and was progressively getting worse. The pain was described initially as a dull throbbing sensation but had intensified and become excruciating over the last 3 days.
He also reported photophobia (but no tearing), pain with eye movements, frontal headaches and a gray area on the sclera of the left eye that appeared to have gotten larger. He denied any previous similar episodes. No symptoms were reported in the right eye. The patient denied experiencing flashes of light, floaters, diplopia, permanent loss or transient loss of vision or any other changes in vision. He stated that he previously had a sinus infection (self-diagnosed) a few weeks earlier, which, based on his description, was presumed to be maxillary. He had done nothing to treat the infection.
The patient’s medical, ocular and family histories were unremarkable. He was taking no medications, reported no known drug allergies, was not a smoker and used no illicit drugs.
Uncorrected visual acuities were 20/20 OD, OS and OU. Extraocular motilities were full without restrictions; however, the patient noted pain in the left eye throughout testing. Pupils were equal, round and reactive to light and tested negative for an afferent pupillary defect. Confrontational visual fields were full in all quadrants with finger counting method. IOPs were 20 mm Hg OD and 19 mm Hg OS.
External evaluation showed equal transillumination of the left and right frontal and maxillary sinuses. No proptosis was present, and both globes moved appropriately to retropulsion without resistance. The patient reported 3+ pain with palpation of the left globe and over the left frontal sinus. Slit lamp examination revealed trace diffuse injection of the bulbar conjunctiva in the left eye. The left eye also showed a patchy gray scleral hue superiorly and inferiorly. Anterior chambers were deep and quiet in each eye, and both corneas were clear without keratic precipitates. A dilated fundus exam of the left eye was unremarkable. There were no cells in the vitreous of the left eye.
MRI of both orbits with and without contrast and fat suppression displayed normal orbits, optic nerves, extraocular muscles and scleral thickness. There was mucosal thickening and secretions in both frontal sinuses as well as the left maxillary sinus. The left frontal sinus also showed fluid. It was noted that both ethmoid sinuses had moderate secretions, and there were mucous retention cysts in the right maxillary sinus.
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The patient was diagnosed with chronic pansinusitis. In addition, there was an accompanying acute sinusitis of the left frontal sinus that appeared to be the etiology of the patient’s complaints. It was the fluid in the left sinus that identified the acute component of the sinusitis.
Description
Sinusitis is an inflammation of one or more of the paranasal sinus cavities. Commonly, the sinuses become inflamed due to a viral upper respiratory infection. Other etiologies include nasal obstruction, cystic fibrosis, allergic rhinitis and bacterial or fungal infection. Sinusitis presents with difficulty breathing through the nose, yellow/green purulent drainage, and sinus pain and pressure that worsens when bending over. Patients will report headache and pain or tenderness with palpation of the tissue over the affected sinus. Our patient reported both frontal headaches and pain with palpation over the frontal sinus, consistent with acute frontal sinusitis.
Viral-induced sinusitis is the most common cause of sinus inflammation and often includes concurrent cough or fever (both of which were absent in our patient). One study found that more than half of children with upper respiratory infection had abnormal maxillary sinuses with imaging (Brook). However, most cases of viral-induced sinusitis resolve spontaneously. Therefore, medical intervention and imaging are usually not required.
In some sinusitis cases, more severe complications can occur if a bacterial superinfection develops. Although rare, inflammation or infection of certain sinuses – namely the sphenoid, ethmoid and frontal sinuses – carries a higher risk of secondary complications. Because of their anatomic locations, sphenoidal and ethmoid sinusitis are the most likely to lead to cavernous sinus thrombosis. Orbital cellulitis is more likely to arise from ethmoid sinusitis because of the paper-thin bony wall (lamina papyracea) that separates the ethmoid sinus from the orbit. Infection in the frontal sinus has an increased risk of spreading to the brain, causing meningitis or encephalitis. For this reason, MRI is indicated in patients with suspected complications of acute sinusitis who present with complications lasting longer than 48 hours after initiation of treatment.
Evaluation
Differential diagnoses for our patient included: scleritis, retrobulbar optic neuritis, orbital myositis and orbital pseudotumor. These etiologies were ruled out with a careful case history, ocular evaluation and appropriate imaging. (Of note: MRI with contrast and fat suppression is preferred when evaluating soft tissue.)
Scleritis is inflammation of the sclera, the white fibrous tissue underneath the conjunctiva and episclera, and its blood vessels. It predominantly occurs in women, and its incidence increases with age. Scleritis can be idiopathic but is often related to underlying autoimmune disease. It is characterized by deep boring eye pain and presents as a red eye that does not blanch with instillation of 2.5% phenylephrine (Gerstenblith and Rabinowitz). Episodes of scleritis can result in thinner areas of sclera, presenting as a gray or blue patch of sclera. Gray patches of sclera were present in our patient’s left eye. However, active scleritis was easily ruled out due to the white and quiet appearance of the patient’s sclera and no intraocular inflammation. The gray patch of the sclera in our patient was deemed to most likely be scleral melanocytosis, a congenital gray-blue pigmentation of sclera not associated with systemic conditions. Oculodermal melanocytosis, also known as Nevus of Ota, involves the sclera and eyelids and is associated with an increased risk of uveal melanoma.
Posterior scleritis is also inflammation of the sclera, but it occurs posterior to the ora serrata. Presentation varies, but signs can include optic nerve swelling, retinal hemorrhages, choroidal folds, hyperopic shift, exudative retinal detachment, choroidal detachment, restricted motilities and proptosis. The patient may come in complaining of eye pain worse with movement, double vision or blurred vision. Imaging is imperative in the diagnosis of posterior scleritis. B-scan ultrasonography can reveal subretinal fluid in Tenon’s capsule and posterior scleral wall thickness greater than 2 mm in approximately half of patients (Lavric, et al.). These findings are considered pathognomonic for posterior scleritis. Ultrasound, OCT and MRI or CT will show thickening of the sclera and/or choroid. Although our patient did present with severe eye pain, none of the posterior segment findings were present, and there was no choroidal thickening on MRI of the orbits.
Retrobulbar optic neuritis is an inflammation of the optic nerve posterior to the optic nerve head. As a result, anterior and posterior segment evaluation of the eye is unremarkable, as was the case with our patient. In addition, patients will complain of eye pain that worsens with eye movements. However, this condition was ruled out due to a lack of an afferent pupillary defect, no reduction in visual acuity and normal nerve appearance with MRI.
Orbital pseudotumor, also known as idiopathic orbital inflammatory syndrome, is a nonspecific inflammation of orbital tissue. Patients with orbital pseudotumor will present with periorbital pain, eyelid erythema and swelling. Depending on the severity, swelling and inflammation may result in proptosis and ophthalmoplegia. MRI or CT scan will reveal orbital inflammation. Proptosis, ophthalmoplegia, erythema and swelling of the eyelids were all absent in our patient. MRI ruled out orbital pseudotumor due to the lack of orbital inflammation.
Orbital myositis is a subcategory of orbital pseudotumor, wherein inflammatory cells have a higher predilection for muscle fibers compared to the generalized inflammation seen in orbital pseudotumor. Clinical presentation of orbital myositis varies but may include diplopia, eye pain, ptosis and injection over the inflamed muscle. Inflammation of the muscles and their tendons will be apparent with MRI, which was absent in our patient’s case.
Treatment
In most cases, treatment of acute sinusitis is not necessary, because it tends to be self-limiting and will resolve spontaneously in a few weeks. Palliative treatments include nasal sprays, decongestants and over-the-counter pain medications.
Severe sinusitis or bacterial infection may require treatment with oral corticosteroids and antibiotics. It is imperative to prevent the spread of infection to important proximal structures including the skin, orbits, brain and other intracranial structures. Patients presenting with signs and symptoms suspicious of orbital cellulitis or intracranial involvement need to be immediately admitted and begin intravenous antibiotic treatment. These signs and symptoms include: severe eye pain and swelling of periorbital tissues, high fever, neck stiffness, seizures and malaise. Cases of sinusitis not responding to treatment or with high risk of complication may warrant surgical drainage of the involved sinus. Prognosis of acute sinusitis is good, as complications are rare, and most cases will resolve without antibiotics. Cases of more severe bacterial sinusitis also have a more favorable prognosis with prompt initiation of antibiotics.
Outcome
Our patient was referred to the otorhinolaryngology service for further evaluation and management of his sinusitis. Nasal endoscopy revealed purulent drainage in the osteomeatal complex, confirming sinusitis. No culture was taken, as it was not indicated. Located in the middle turbinate of the nose, the osteomeatal complex is the common drainage channel for the maxillary, frontal and anterior ethmoid sinuses.
The patient declined hospital admission and intravenous antibiotics. Instead, he was treated empirically with oral prednisone (20 mg) three times per day and amoxicillin/clavulanate potassium (875 mg/125 mg) twice a day and scheduled for follow-up in 24 hours. The patient was also given fluticasone 50 µg to keep the osteomeatal opening patent by administering two nasal sprays per day. He was also educated on nasal irrigation techniques. He was advised that if the condition worsened, surgical drainage of the sinuses would be necessary.
Upon follow-up the next day, the patient’s symptoms had not worsened but had not significantly improved. He was kept on the same treatment regimen and scheduled to return in 4 days or sooner if symptoms worsened. The patient did not return for this appointment. He was seen 4 weeks later with no complaints of brow ache, eye pain or other sinusitis-related symptoms.
- References:
- Bowling B. Kanski’s Clinical Ophthalmology, A Systemic Approach, 8th ed. Philadelphia: Elsevier. 2016; Chapter 3:77-117.
- Bandyopadhyay R, et al. Indian J Otolaryngol Head Neck Surg. 2015;doi:10.1007/s12070-015-0874-z.
- Brook I. Pediatr Clin N Am. 2013;doi:10.1016/j.pcl.2012.12.002.
- Dye L, et al. Clinical Overview: Sinusitis. Elsevier Point of Care. https://www.clinicalkey.com. Updated March 13, 2018.
- Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 6th ed. Philadelphia: Wolters Kluwer. 2012;122-123.
- Kamili M, et al. Oman J Ophthalmol. 2009;doi:10.4103/0974-620X.53043.
- Lavric A, et al. Ocul Immunol Inflamm. 2015;doi:10.3109/09273948.2015.1005240.
- Tekes A, et al. J Am Col Rad. 2018;doi:10.1016/j.jacr.2018.09.029.
- Younis R, et al. Laryngoscope. 2002;doi:10.1097/00005537-200202000-00005.
- For more information:
- Kynndyl Giannonatti, BA, is a fourth-year optometry student at Pacific University in Forest Grove, Ore. She can be reached at: kynndyl@gmail.com.
- Scott Martinson, OD, practices at the Mayo Clinic Health System in Albert Lea, Minn. He can be reached at: martinson.scott@mayo.edu.
- Leonid Skorin Jr., OD, DO, MS, FAAO, FAOCO, practices at the Mayo Clinic Health System in Albert Lea, Minn., and is a member of the Primary Care Optometry News Editorial Board. He can be reached at: skorin.leonid@mayo.edu.
- Edited by Leo P. Semes, OD, FAAO, Professor Emeritus in the Department of Optometry and Vision Science at the University of Alabama at Birmingham and a member of the Primary Care Optometry News Editorial Board. He can be reached at: lsemes@uab.edu.
Disclosures: Giannonatti, Martinson, Semes and Skorin report no relevant financial disclosures.