A 25-Year-Old Woman With a Droopy Eyelid and Double Vision

Monica Saini, MD, MBBS


March 20, 2020

Mass lesions tend to show slow progression. However, tumors that present as RPON, especially schwannomas, have been reported; patients typically show complete resolution of deficits between episodes.[11,12,13] Most reported cases involve the oculomotor nerve, with lesions predominantly seen in the cisternal segment.

Suspicion for infiltrative lesions is typically suggested by a subsequent attack with incomplete recovery and/or persistent nerve enhancement on imaging. The mechanism of episodic headache and remitting cranial neuropathy in such cases is unclear. Postulated theories include the release of inflammatory substances from the tumor. The absence of histologic diagnostic confirmation is a limiting factor in almost all such reported cases.[11,12,13] Repeated inflammation in the nerve may itself trigger cellular proliferation and subsequent transformation into a neoplastic process.

The patient in this case received simple analgesics for 1 week. Neurologic improvement was noted over 10 weeks. Neuroimaging abnormalities remained stable. She is continuing to undergo follow-up and interval neuroimaging will be performed to monitor progression of the left oculomotor schwannoma.

In conclusion, neuroimaging is mandatory in patients who present with painful ocular neuropathies. RPON is a diagnosis of exclusion. Follow-up neuroimaging must be considered in patients with nerve abnormalities and is mandatory in patients who show incomplete recovery, to exclude neural tumors.


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