A Case of Painful Ophthalmoplegia
A Case of Painful Ophthalmoplegia
Monocular ophthalmoparesis
Cavernous Sinus LocalizationOculomotor paresis?Horners?Loss of
corneal reflex?
ALL ENHANCE LOCALIZATION TO THE CAVERNOUS SINUS
History in Patients with Tolosa Hunt
Patients present with usually severe retro-orbital or
periorbital pain of acute onset. This pain may be described as
constant and "boring" in nature.
Diplopia related to ophthalmoparesis follows the onset of pain
(in rare cases, the ophthalmoparesis precedes the pain but this is
unusual).
Patients may report visual loss. This is noted if the
inflammation extends into the orbit to affect the optic nerve, and
it is not a factor in disease limited to the cavernous sinus.
Paresthesias along the forehead may be described if the first
division of the trigeminal nerve is involved.
Tolosa-Hunt syndrome is most often unilateral, although
bilateral cases have been described.
MRI with Contrast
Tolosa Hunt: LabsCBC Erythrocyte sedimentation rate (ESR)Thyroid
function testsFluorescent treponemal antibody (FTA), Antinuclear
antibody (ANA) DS DNAAntineutrophil cytoplasmic antibody (ANCA),
Serum protein electrophoresis and immunofixation Lyme titer
Angiotensin-converting enzyme (ACE) level, and HIV titre
Treatment of Tolosa HuntSteroidsSubstantial pain improvement
within 72 hoursImmunosupression for refractory casesAzathioprine
(Imuran), methotrexate, or radiation therapy
Ophthalmoparesis may take week to resolve and there are some
cases of permanent deficit
MRI Improvement After Steroid Treatment
When To WorryALWAYS! This is a diagnosis of exclusion!HoweverThe
ophthalmoplegia PRECEEDS the eye painIn THS ophthalmoplegia begins
coincident with or after onset of painFeverSignificant
proptosisCongestion of the sclera or chemosisNo response to
steroids after 72 hoursBilateral onsetHemicranial rather than
orbital pain
The As of Life Threatening Painful OphthalmoplegiaAcute headache
in the elderly with visual lossArteritis (Temporal arteritis)Acute
orbital apex syndrome in poorly controlled DMAbscess (especially
mucormycosis)Acute painful anisocoria suggesting 3rd nerve
palsyAneurysm (posterior communicating)Painful small pupil
(Horners)Arterial dissectionAcute bitemporal visual lossApoplexy
(Pituitary )
Causes of Painful Opthalmoplegia(but wait!...theres more!)
Causes of Painful Ophthalmoplegia
