A 48-year-old woman with a history of migraine with and without ophthalmic aura, smoker, came to the emergency room for blurred vision in the RE and binocular diplopia of two days onset.
The exploration revealed a limitation of the right eye and was diagnosed with paralysis of the VI right pair.
The rest of the examination was normal.
The following tests were performed on an outpatient basis: complete blood count and normal biochemistry, thyroid hormones, microsomal antibodies, normal antithyroglobulin antibodies, normal serology, rheumatoid factor CSG3-C4, basic coagulation and
Chest X-ray showed no findings.
Cranial CT showed no abnormalities.
Normal supraaortic trunk duplex.
While these studies were being conducted, the patient returned to the emergency department complaining of periorbital pain and right malar, with nocturnal worsening, which did not include NSAIDs.
The examination showed a greater limitation of OD without facial paresthesias, with the rest of the normal examination.
Days later, there is a limitation of supraduction and infraduction, with VA corrected by OD 0.6 with a stenopeic hole 0.8; OI 1.
Eye fundus examination remains normal.
At that time, a campimetry was performed, with central defects of greater intensity on the temporal side of the RE, with the LE being normal.
A cranial MRI was requested with study in potentiated T1-T2 sequences, protonic density T1 with gadolinium in both orbits, above all the inferior rectus accent muscles increased ex rectus size.
There is no evidence of sinus malformations.
1.
Due to these MRI findings, in addition to the possibility of a paralysis of the VI cranial nerve and other possible oculomotor affections that were initially considered, the restriction of ocular motility - supraduction and swelling - due to the thickening is added.
Lumbar puncture was performed.
The CSF showed opening pressure, cellularity, glucose, proteins and proteins within normal limits.
Treatment was started with intravenous methylprednisolone at a dose of 250 mg/day for 3 days with significant improvement of pain and paresis especially of the lower rectus, internal rectus and oblique muscles.
There was also improvement of the external rectus muscle.
Treatment with Prednisone 60 mg/day was continued for 10 days with a descending pattern for one month.
Complete remission of symptoms and disappearance of symptoms is achieved at the end of treatment.
