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A 76-year-old woman with progressive right-sided proptosis, blepharoptosis, vision loss, and ophthalmoplegia Digital Journal of Ophthalmology 2019 Volume 25, Number 3 August 25, 2019	Printer Friendly Download PDF

Grayson W. Armstrong, MD, MPH \| Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Harvard Medical School, Boston, Massachusetts Karen Jeng-Miller, MD, MPH \| Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Harvard Medical School, Boston, Massachusetts Patrick Oellers, MD \| Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Harvard Medical School, Boston, Massachusetts Michael K. Yoon, MD \| Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Harvard Medical School, Boston, Massachusetts
HISTORY EXAMINATION ANCILLARY TESTING TREATMENT DIFF. DIAGNOSIS DIAGNOSIS AND DISCUSSION REFERENCES
Differential Diagnosis
Our patient had a chronic and slowly progressive set of clinical signs and symptoms, including unilateral ophthalmoplegia, complete ptosis, optic neuropathy, right-sided jaw thrust and temporalis wasting, and seizurelike episodes. This collection of clinical findings localize any neurologic lesion to the right-sided cavernous sinus and Meckel’s cave. Any space-occupying lesion in this area could result in an identical presentation, although optic neuropathy from a lesion in the cavernous sinus and Meckel’s cave would only result from a lesion extending anteriorly to the orbital apex or superiorly to the optic nerve or chiasm. Unilateral complete ophthalmoplegia can result from multiple causes. Rapid-onset of symptoms can result from infectious etiologies (mucormycosis, orbital cellulitis, cavernous sinus thrombosis), vascular etiologies (traumatic carotid cavernous fistula, retrobulbar hemorrhage, pituitary apoplexy), traumatic etiologies (orbital floor fracture, orbital foreign body), or inflammatory etiologies (granulomatosis with polyangiitis, orbital pseudotumor, thyroid eye disease, sarcoidosis, Tolosa-Hunt syndrome). More chronic presentations with insidious onset can result from neoplastic etiologies (orbital apex tumors, cavernous sinus mass, paranasal sinus tumors, skull base tumors, metastases) and vascular etiologies (arteriovenous fistula, carotid aneurysm). Complete unilateral external ophthalmoplegia can result from neuromuscular etiologies, such as myasthenia gravis, although pupil involvement would not be expected.
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