Patient case: what’s your diagnosis for this patient with new onset pain behind the right eye?
Optometry 360 presents “Patient Case: What’s Your Diagnosis?” Stephanie Martich, OD, an optometrist and assistant professor at the University of Colorado School of Medicine, walks you through an interactive patient case file. Can you make the diagnosis?
Stephanie Martich, OD:
Today, the case is regarding a 73-year-old white male that presented to the clinic with oblique double vision, pain behind the right eye, and a right upper eyelid droop. The double vision had been present for about a month, but what prompted the patient to come in was the new onset pain behind the right eye, the eyelid drooping, and the double vision seemingly to worsen.
The patient’s ocular history was notable for just age-related cataracts. His medical history was pertinent for factor 7 deficiency anemia, renal insufficiency, adenocarcinoma of the prostate, multiple myeloma, pancytopenia, hypogammaglobulinemia, arthritis, and sleep apnea.
The patient’s entering visual acuity was 20/25 in the right eye and 20/30-2 in the left eye. Confrontation visual fields were full in both eyes and pupils were round, reactive to light without an APD in either eye.
Extraocular motility findings were notable for an abduction deficit in the right eye and a supraduction deficit in the right eye. Cover testing showed a right hypotropia that varied in magnitude from about 3 to 6 prism diopters depending on gaze position. The patient also had a right esotropia that was only present in right gaze, up gaze, and down gaze. Internal ocular health was pretty much normal besides the cataracts and noncontributory.
So based on these exam findings, what are your diagnoses and what would you like to do next?
The diagnoses here are a right abducens palsy, which is the sixth cranial nerve, and then a partial right oculomotor palsy, which is the third cranial nerve. The abducens nerve accounts for the patient’s abduction deficit or their inability to move the right eye to the right, which presents as an esotropia. The oculomotor palsy accounts for the supraduction deficit along with the right ptosis, and the reason this is a partial oculomotor palsy is because in a full oculomotor palsy, as we all know, the eye would be down and out and the pupil would be blown, but in this case, the eye was down and it was in and the pupil was spared.
When patients present with multiple cranial nerve palsies affecting their eyes, there’s a really high suspicion for cavernous sinus pathology. The cavernous sinus houses numerous important structures including cranial nerve 3, 4, the first and second branches of cranial nerve 5, cranial nerve 6, and the internal carotid artery.
If cavernous sinus pathology is suspected based on the eye exam, a stat MRI of the brain with and without contrast should be ordered. In the suspicion of a carotid cavernous fistula, a magnetic resonance angiogram should also be ordered.
Before revealing the results of this MRI, what is your thought for the etiology of this patient’s complaints?
Some differentials I had thought about in this case were a primary cavernous sinus tumor, a secondary cavernous sinus tumor, potentially Tolosa-Hunt syndrome given the fact that the patient did have pain, or a carotid cavernous fistula. One interesting thing to note is that the patient reported to me that he had had a PET scan a month prior to his appointment and that this was all clean.
Answer
The MRI revealed a lesion in the right cavernous sinus. Both the patient’s oncology team and our neuro-ophthalmology team were consulted and it was felt that this lesion likely represented a metastasis of the patient’s multiple myeloma. Interestingly, upon additional review of the patient’s PET scan, this lesion was visible a month prior on that scan, but it was just missed on the radiology report. A biopsy was deferred due to the high suspicion for multiple myeloma, and the patient was treated with oral dexamethasone and palliative radiation to the right cavernous sinus. This provided a rapid improvement in symptoms, and the patient’s double vision, eye pain, and ptosis all resolved within three months of treatment.
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