A 36-Year-Old Woman With Painful Swelling and Ophthalmoplegia of the Right Eye

Sumaira Nabi, MBBS; Sadaf Khattak, MBBS; Mansoor Iqbal, MBBS, FCPS

Disclosures

June 11, 2014

Physical Examination and Workup

On physical examination she is an awake, alert young lady who is uncomfortable due to pain. Her vital signs include an oral temperature of 98.6°F, a regular pulse of 80 beats/min, and a blood pressure of 110/70 mm Hg. Her respiratory rate is 14 breaths/min. Her Glasgow Coma Scale score is 15/15. On ocular examination, she has a right complete external ophthalmoplegia (figures 1 and 2) with moderate proptosis (24 mm axial; figure 3). There is no chemosis, conjunctival injection, or crusting on the lashes. The globe is mildly tender to palpation. Her pupils are reactive to light from 4 mm to 2 mm, with no relative afferent pupillary defect (RAPD). Visual acuity is 6/12 (ie, 20/40) on the right side and 6/6 (ie, 20/20) on the left, with no visual-field defects.

On funduscopic examination, the disc margins are blurred on the right side. There are no signs of pyramidal weakness or incoordination. The rest of her cranial nerves (CNs) are intact and symmetrical, including CN V, VIII, IX, and X. Her neck is supple, with full range of motion and no adenopathy or masses. Her abdomen is soft and nontender. There is no clinical evidence of organomegaly or ascites. Her bowel sounds are audible. The patient's precordial examination reveals normal heart sounds. Auscultation of the lung fields shows normal vesicular breathing.

Laboratory analysis demonstrates a normal complete blood count (CBC) and erythrocyte sedimentation rate. The patient's liver function tests, renal function tests, serum glucose levels, and chest radiograph are unremarkable. Her antinuclear antibody (ANA), rheumatoid factor (RF), anti ̶ double-stranded DNA (anti-dsDNA), HIV serology, hepatitis B surface antigen (HBsAg), anti ̶ hepatitis C virus (anti-HCV) antibody, cytoplasmic antineutrophil cytoplasmic antibody (cANCA), and perinuclear ANCA (pANCA) are negative. Her thyroid function tests are also normal, and her antithyroid antibodies (anti-Tg and anti-TPO) are negative. Routine examination of her cerebrospinal fluid (CSF) is normal, and so are her serum angiotensin-converting enzyme (ACE) levels. Repetitive nerve stimulation is normal, and anti-acetylcholinesterase antibodies are negative.

Magnetic resonance imaging (MRI) of the brain and orbit with contrast reveals diffuse thickening and swelling of all of the extraocular muscles of the right orbit, with involvement of the tendinous insertions. (Figures 4 and 5.) No edematous changes are seen in the muscles. However, the right globe is proptotic. (Figure 6.) The right optic nerve is normal. The cavernous sinuses and the brain are also normal.

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