DIAGNOSTIC DILEMMA Aimee K. Zaas, MD Thomas J. Marrie, MD, Section Editors
Totally One-sided: Painless Unilateral Proptosis Bharati Kochar, MD,a,b Shannon J.C. Shan, MD, MSc,c Gobind Anand, MD,a,b S. James Zinreich, MD,d Allan C. Gelber, MDa,b a
Thayer Firm, Osler Medical Service, Johns Hopkins Hospital and the Departments of bMedicine, cOphthalmology, and dRadiology, Johns Hopkins University School of Medicine, Baltimore, MD.
PRESENTATION An 88-year-old woman’s startling ophthalmologic symptoms were initially attributed to infection during an outpatient examination. When treatment offered no improvement, she presented to Johns Hopkins Hospital, where she reported progressive left eye swelling of 2 weeks duration. Seven years earlier, she had undergone mastectomy, chemotherapy, and radiation for breast cancer. Her medical history was also significant for a prior stroke, hypertension, and dementia. Initially, the patient noticed the onset of left-eye redness and swelling; she commented that her eye gradually “popped out.” An outside ophthalmology evaluation resulted in a diagnosis of conjunctivitis, and she was prescribed a regimen of tobramycin/dexamethasone ophthalmic suspension and moxifloxacin ophthalmic solution. Yet, her symptoms persisted. Two days prior to her presentation at the hospital, her son noticed ipsilateral cheek swelling. Given the progression of symptoms and her profoundly compromised appearance, the patient and her son sought further evaluation at the hospital. She did not have fever, chills, sweats, headaches, nausea, or vomiting. In addition, she denied having ocular pain, discharge, or visual compromise. She was admitted to the Osler Medical Service.
chemosis of the left eye (Figure 1), most notably inferiorly, with mild blepharitis, periorbital erythema, and injected sclera. While the patient had no visual defects by confrontation, anisocoria was noted, and in the left eye, she had an afferent pupillary defect, and extraocular movements were restricted in all direction of gaze. Her left cheek was mildly edematous, erythematous, and warm to the touch compared to the unaffected right cheek. No carotid or ocular bruits were evident. Cardiac, pulmonary, abdominal, and neurological examinations were otherwise unremarkable. Laboratory evaluation demonstrated a normal leukocyte count of 6.77 x 103 cells/mm3, a moderately elevated erythrocyte sedimentation rate of 46 mm/hr, and an increased C-reactive protein level of 1.5 mg/dL (normal,
Totally One-sided: Painless Unilateral Proptosis Bharati Kochar, MD,a,b Shannon J.C. Shan, MD, MSc,c Gobind Anand, MD,a,b S. James Zinreich, MD,d Allan C. Gelber, MDa,b a
Thayer Firm, Osler Medical Service, Johns Hopkins Hospital and the Departments of bMedicine, cOphthalmology, and dRadiology, Johns Hopkins University School of Medicine, Baltimore, MD.
PRESENTATION An 88-year-old woman’s startling ophthalmologic symptoms were initially attributed to infection during an outpatient examination. When treatment offered no improvement, she presented to Johns Hopkins Hospital, where she reported progressive left eye swelling of 2 weeks duration. Seven years earlier, she had undergone mastectomy, chemotherapy, and radiation for breast cancer. Her medical history was also significant for a prior stroke, hypertension, and dementia. Initially, the patient noticed the onset of left-eye redness and swelling; she commented that her eye gradually “popped out.” An outside ophthalmology evaluation resulted in a diagnosis of conjunctivitis, and she was prescribed a regimen of tobramycin/dexamethasone ophthalmic suspension and moxifloxacin ophthalmic solution. Yet, her symptoms persisted. Two days prior to her presentation at the hospital, her son noticed ipsilateral cheek swelling. Given the progression of symptoms and her profoundly compromised appearance, the patient and her son sought further evaluation at the hospital. She did not have fever, chills, sweats, headaches, nausea, or vomiting. In addition, she denied having ocular pain, discharge, or visual compromise. She was admitted to the Osler Medical Service.
chemosis of the left eye (Figure 1), most notably inferiorly, with mild blepharitis, periorbital erythema, and injected sclera. While the patient had no visual defects by confrontation, anisocoria was noted, and in the left eye, she had an afferent pupillary defect, and extraocular movements were restricted in all direction of gaze. Her left cheek was mildly edematous, erythematous, and warm to the touch compared to the unaffected right cheek. No carotid or ocular bruits were evident. Cardiac, pulmonary, abdominal, and neurological examinations were otherwise unremarkable. Laboratory evaluation demonstrated a normal leukocyte count of 6.77 x 103 cells/mm3, a moderately elevated erythrocyte sedimentation rate of 46 mm/hr, and an increased C-reactive protein level of 1.5 mg/dL (normal,
