Case Report of a Man with Right Eye Pain and Double Vision

A 39-year-old previously healthy male presented with three days of right eye pressure and one day of binocular diplopia. He denied history of trauma, headache, or other neurological complaints. He had normal visual acuity, normal intraocular pressure, intact convergence, and no afferent pupillary defect. His neurologic examination was non-focal except for an inability to adduct the right eye past midline on cranial nerve examination, with left-beating nystagmus noted in the left eye. MRI brain was obtained, showing right cavernous sinus lateral wall contrast enhancement. No other evidence of neoplasm, ischemia, infection, or aneurysm was found. The patient’s deficits rapidly improved with corticosteroids. This is the hallmark of Tolosa-Hunt syndrome (THS), characterized as idiopathic inflammation of the cavernous sinus. The patient was discharged on a prednisone taper, with continued improvement at outpatient neurology follow-up. Tolosa-Hunt syndrome is one of the rare disorders recognized by the National Organization for Rare Disorders (NORD), and has an estimated incidence of one case per million per year. TOPICS: Tolosa-Hunt syndrome, cranial nerve deficits, diplopia, neurologic examination.