A 67-Year-Old Woman With Diplopia After Sinus Surgery

Sina Rezaei; Rod Foroozan, MD


January 18, 2018

Case Diagnosis

Tolosa-Hunt syndrome is a rare condition caused by idiopathic granulomatous inflammation of the cavernous sinus. The inflammation can involve cranial nerves III, IV, or VI, leading to ophthalmoplegia and diplopia. Typically, the diplopia is preceded by a constant, gnawing pain, which was absent in this patient. Although MRI is preferred in the evaluation of Tolosa-Hunt syndrome owing to its greater sensitivity, this patient had no pain, and the CT scan did not show any abnormalities in the cavernous sinus.

Orbital myositis is an idiopathic inflammatory disorder involving the extraocular muscles. Although it can cause horizontal diplopia, patients often also present with acute or subacute orbital pain, proptosis, ptosis, or conjunctival chemosis and injection. There was no evidence of these symptoms in this patient.

Thyroid eye disease would be suggested by thickening of the extraocular muscles, particularly the inferior and medial recti, which was not seen on the CT. Thyroid eye disease would most likely cause proptosis rather than the enophthalmos noted in this patient.

The CT showed a hyperdense area near the medial edge of the left orbit that is consistent with orbital tissue entering the left ethmoid paranasal sinus. The extraocular muscles were normal in size. Restrictive damage to the medial rectus secondary to ESS can cause esotropia and diplopia on left gaze. Given the CT findings and the location of the surgery, iatrogenic trauma (traumatic orbitopathy) is the most likely pathology.

Clinical Course

The patient was given a base-out Fresnel prism over the left lens of her glasses and noticed an improved range of binocular single vision, including in left gaze.

The diplopia persisted in later visits, but it continued to be well-managed with prism lenses.

The ocular misalignment remained unchanged over the ensuing 6 months.


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