1. PATIENT PRESENTATION
A 76‐year‐old woman presented to the emergency department with 1 month of right eye pain. Symptoms progressed to include right eye blurry vision and diplopia on rightward gaze. Physical examination revealed visual acuity of 20/350 oculus dexter (OD) and 20/20 oculus sinister (OS), a 6 mm right pupil and 4 mm left pupil associated with a right eye relative afferent pupillary defect (RAPD), and extraocular movement deficits (Figure 1).
FIGURE 1.
A composite 9‐gaze photo demonstrating ptosis, as well as partial right eye oculomotor (III), trochlear (IV), and abducens nerve (VI) palsies
2. DIAGNOSIS
2.1. Right‐eye orbital apex syndrome
The patient's right eye reduced acuity and associated RAPD were consistent with an optic nerve (II) palsy. This examination finding, associated with the patient's right eye partial III, IV, and VI palsies, provided evidence for a lesion localized to the right posterior orbit where the optic canal and the superior orbital fissure converge, a region called the orbital apex. 1 Magnetic resonance imaging of the orbits with intravenous contrast confirmed this diagnosis (Figure 2).
FIGURE 2.
Magnetic resonance imaging of the orbits with intravenous contrast demonstrating inflammatory morphology consistent with orbital apex syndrome
Orbital apex syndrome refers to dysfunction of cranial nerves II, III, IV, VI, and/or the ophthalmic branch of the trigeminal nerve (V1) due to a lesion where these nerves lie in proximity. 2 Cranial nerve II, passing through the optic canal, lies near cranial nerves III, IV, VI, and V1, passing through the superior orbital fissure, at the orbital apex. 1 Causes include inflammatory conditions such as sarcoidosis and lupus; infection, including invasive fungal sinusitis; neoplasm; cavernous sinus thrombosis; trauma; and idiopathic conditions. 2 Treatment involves addressing the underlying cause. The patient in this case, whose presentation resulted from an undifferentiated inflammatory condition, experienced dramatic improvement with intravenous steroids.
Baker JP, Maldonado N, Rho J. A woman with right eye pain and vision loss. JACEP Open. 2022;3:e12863. 10.1002/emp2.12863
REFERENCES
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