A Man With Double Vision After a Fight

C. Robert Bernardino, MD


October 31, 2012

In This Article

Clinical Presentation

A 38-year-old man complains of double vision. He was in an altercation the night prior and was struck on the left eye with a fist. He denies any loss of consciousness. His eye swelled closed last night, and he started noticing double vision in the morning. He also complains of numbness in his left cheek.

The patient has no significant medical history and is taking no medications.

Ocular examination revealed visual acuity of 20/20 in the right eye and 20/30 in the left eye. His pupils were equally reactive to light with no afferent pupillary defect. Motility of the right eye was full, but the left eye had a 15% limitation on upgaze. Intraocular pressures were 18 mm Hg in the right eye and 24 mm Hg in the left eye.

Palpation of the orbit revealed no step-off or crepitus of the orbital rim, but the patient had hypaesthesia of the left cheek. Hertel exophthalmometry, base 105, was 18 mm for the right eye and 19 mm for the left eye. External examination revealed ecchymosis and edema of the left upper and lower eyelids, defined by the orbital rim (Figure 1). Slit lamp examination revealed a subconjunctival hemorrhage in the left eye.

Figure 1. External photograph demonstrates ecchymosis and edema of the left upper and lower eyelids confined to the limits of the orbital rim in the setting of recent blunt trauma to the left eye.

Diagnostic Question

What is the differential diagnosis?

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