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Summarizing your symptoms, you have pain in the eyes, restricted movements of the eyes and double vision. Also associated nausea.
This could be termed as painful ophthalmoplegia (paralysis of eye muscles).Since all your investigations including imaging studies have come out normal, there can be two very rare possibilities- Orbital Pseudotumor or Tolosa-Hunt Syndrome.
Orbital (eye socket) Pseudotumor is a condition in which there is inflammation and swelling of the eye muscles causing pain, loss of eye movements and double vision. This condition mimics a tumor in the eye but in fact there isn't one. Hence the name "pseudotumor".
Tolosa-Hunt Syndrome is another similar condition with similar symptoms where the location of inflammation differs. Here the cavernous sinus (a venous sinus, something like a thick vein, present within the brain) is inflamed. Since this sinus is surrounded by nerves supplying the eye muscles, it causes symptoms of eye paralysis, pain, double vision etc.
Both these conditions are self-limiting, meaning they resolve on their own but take some time. They also show a very good response to steroids. So for both, the treatment is with steroids.
The diagnosis is by a thorough workup to exclude all other causes of similar complaints. This can be done by doing the following tests.
- Contrast enhanced MRI. If the MRI which was done for you was a contrast enhanced one, there is no need to repeat. The MRI has to be studied for any eye muscle swelling or swelling of the cavernous sinus. These can be present in some cases of Orbital Pseudotumor and Tolosa-Hunt Syndrome respectively. MRI can be completely normal as well in these cases.
- When the MRI is normal or shows changes consistent with cavernous sinus inflammation, further evaluation should include blood and cerebrospinal fluid (CSF) testing to exclude other possible causes of orbital inflammation. Recommended blood testing includes:
- Complete blood count
- Electrolytes
- Glucose and hemoglobin A1C
- Renal and liver function tests
- Angiotensin converting enzyme
- Antinuclear antibody
- Anti-dsDNA antibody
- Anti-Sm antibody
- Antinuclear cytoplasmic antibody
- Fluorescent treponemal antibody test
- Lyme serologies
- Serum protein electrophoresis
- Erythrocyte sedimentation rate (ESR)
- C reactive protein
Cerebrospinal fluid should also be evaluated for protein, glucose, cell count with differential, cytology, Lyme and syphilis serology, angiotensin converting enzyme (for sarcoidosis), and cultures for bacteria, fungi, and mycobacteria. The expected findings in Orbital Pseudotumor or Tolosa-Hunt Syndrome are normal.
After excluding the tests already done for you from the above list, you can discuss with your doctor to get the rest of them done.
If all of them are normal, the diagnosis would be either Orbital Pseudotumor or Tolosa-Hunt Syndrome based on the location of inflammation.
- When this diagnosis is confirmed, Prednisone (steroid/glucocorticoid) is used in the treatment.
A suggested glucocorticoid regimen is:
Prednisone 80 to 100 mg daily for three days. This can be given intravenously.
If the pain has resolved, taper to 60 mg oral Prednisone daily, then 40 mg, then 20 mg, then 10 mg every two weeks.
Symptoms show rapid resolution, especially pain (within 24 to 72 hours). This helps to further confirm the suspected diagnosis. Improvement of paralysis and regression of MRI abnormalities (if any) over the next two to eight weeks provide further confirmation of the diagnosis.
- Close clinical follow-up with repeat MRI is necessary to be sure the glucocorticoid treatment remains effective and no evidence of another cause develops.
MRI scans to monitor improvement and maintenance of improvement on and then off treatment should be performed every one to two months until findings normalize. This should be followed by MRI scans every six months for a period of two years old patientfollowing the diagnosis. MRI and other diagnostic testing should be performed promptly if symptoms recur.
I hope this was helpful. Feel free to ask queries.
Thank you.