Case 703 -- A 70 year old female with eye pain and periorbital swelling

Contributed by Rebecca Ocque, MD and Sarah Navina, MD


CLINICAL HISTORY

A 70 year-old female with a past medical history significant basal cell carcinoma of the right eye resected twenty-years ago and transient ischemic attacks (TIA) presents with progressive ocular muscle weakness and periorbital edema. The patient reported that for a few months she had right ocular muscle weakness and proptosis which had led to double vision. In the last month, her right eye had become injected and painful to palpation associated nausea, vomiting, and dizziness.

On physical exam at the time of admission, she was afebrile. The sclera of her right eye was injected and the globe and soft tissue surrounding the right orbit were tender to palpation. Her extraocular movements were decreased on the right: no lateral, superior, or inferior motion and minimal medial motion.

A CT scan of the head did not show any acute intracranial process but showed severe inflammatory change in both the preseptal and postseptal compartment of the right orbit (see Figure 1). A subsequent MRI of the head showed diffuse abnormal enhancement involving the right orbit and extra-ocular muscles (see Figure 2). The right optic nerve was normal in size and the globe was unremarkable with no extension of enhancement posterior to the orbit. The left orbit and globe were unremarkable.

DIFFERENTIAL DIAGNOSIS?


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