Case history
Case history #1
A 67-year-old man presents to the emergency department with fever, headache, and right-eye pain. He reports that his condition started 3 weeks ago when he had an upper respiratory infection. His headache has become worse in the past 48 hours, and he has started to have severe right-eye pain, with associated nausea and vomiting. Self-treatment with warm compressors provides little relief. Past medical history is positive for hypertension, type 2 diabetes mellitus, and osteoarthritis of the knees. On physical examination, he appears acutely ill, with a temperature of 102°F (39°C). His head and neck exam is notable for bilateral periorbital swelling, tense bilateral proptosis, and both internal (blunted papillary response to light) and external ophthalmoplegia. Nasal exam shows purulence above the inferior turbinates.
Case history #2
A 50-year-old woman presents to the emergency department with a history of right-eye swelling and double vision. On examination, she is afebrile but tachycardic. Her right eye is proptotic, swollen, and red. Her left eye is normal. Complete physical exam shows edema of both ankles. She is a smoker and also reports that she has been diagnosed with a "kidney disorder". Past medical history is positive for antithrombin III deficiency secondary to proteinuria. Past surgical history is negative.
Other presentations
Loss of visual acuity is a possible feature occurring acutely or subacutely in less than 50% of people with cavernous sinus thrombosis (CST).[1] It may be due to papilledema, corneal ulceration secondary to proptosis and loss of the corneal reflex, occlusion of the internal carotid, ophthalmic or central retinal artery, orbital congestion or an embolic phenomenon. Seizure should raise suspicion of intracranial suppuration complicating septic CST. Visual changes in chronic, aseptic CST tend to present with slowly progressive eye symptoms (swelling, pain, proptosis and, ultimately, decreased vision) over a variable period of time (in the order of days to weeks).
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