J Korean Ophthalmol Soc.  2018 Aug;59(8):797-801. 10.3341/jkos.2018.59.8.797.

Abducens Nerve Palsy and Optic Perineuritis Caused by Fungal Sphenoidal Sinusitis

• Seo Y
• Kim KJ
• Kim WJ

• KMID: 2418509
• DOI: http://doi.org/10.3341/jkos.2018.59.8.797

Abstract

PURPOSE
To report a case of abducens nerve palsy and optic perineuritis caused by fungal sphenoidal sinusitis.
CASE SUMMARY
A 48-year-old male visited emergency department for retrobulbar pain, decreased vision, and horizontal diplopia for 3 days. He reported that previous medical history was non-specific, however, blood glucose level was 328 mg/dL (70-110). He had experienced severe headache for 7 days. The best corrected visual acuity was 20/20 at right eye and 20/25 at left eye. The pupil of left eye did not have relative afferent pupillary defect. Left mild proptosis was noted. The extraocular examination showed 30 prism diopters left esotropia at primary gaze and −4 abduction limitation of left eye. The left eye showed mild optic disc swelling and inferior field defect by field test. Brain magnetic resonance imaging showed enhancement of sphenoidal sinus, ethmoidal sinus, and around optic nerve at left eye. Three days after antibiotics treatment, the vision of left eye deteriorated to 20/40 and periorbital pain developed. The drainage and biopsy of sphenoidal sinus were performed. The histopathologic examination showed hyphae consistent with aspergillosis. The ocular symptoms were improved with anti-fungal treatment. Follow-up magnetic resonance imaging performed 1 month after treatment showed improvement of lesion at left orbit. Five months after surgery, the visual acuity of left eye was improved to 20/25. The patient showed orthotropia at primary gaze without limitation.
CONCLUSIONS
The abducens nerve palsy and optic perineuritis can be caused by fungal sphenoidal sinusitis. The early diagnosis and appropriate treatment can lead to favorable outcome.

Keyword

Abducens nerve palsy; Fungus; Optic perineuritis; Sphenoidal sinusitis

MeSH Terms

Abducens Nerve Diseases*
Abducens Nerve*
Anti-Bacterial Agents
Aspergillosis
Biopsy
Blood Glucose
Brain
Diplopia
Drainage
Early Diagnosis
Emergency Service, Hospital
Esotropia
Ethmoid Sinus
Exophthalmos
Follow-Up Studies
Fungi
Headache
Humans
Hyphae
Magnetic Resonance Imaging
Male
Middle Aged
Optic Nerve
Orbit
Pupil
Pupil Disorders
Sphenoid Sinusitis*
Visual Acuity
Anti-Bacterial Agents
Blood Glucose

Figure

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  Figure 1. Findings of ocular examination at initial visit. (A) Image of the patient in nine diagnostic position of gaze demonstrating esotropia at primary gaze and abduction limitation of the left eye. (B) Fundus examination shows mild swelling of optic disc at the left eye. (C) The visual field test reveals inferior visual field defect at the left eye (Humphrey Field Analyzer, Carl Zeiss Meditec, Inc., Dublin, CA, USA).

• 

  Figure 2. Findings of brain magnetic resonance (MR) imaging during follow-ups. (A-C) The initial magnetic resonance (MR) imaging. (A) Axial T1-weighted gadolinium-enhanced MR image showing an enhancement of the circumferential mucosa in the sphenoid sinus and the ethmoidal sinus (arrowhead). (B, C) Axial and coronal T1-weighted gadolinium-enhanced MR images demonstrate an enhancement of the left optic nerve sheath (arrow). (D-F) The follow-up MR imaging at 1 month after the anti-fungal treatment. The patient underwent an endoscopic endonasal surgery for sinusitis. (E, F) Axial and coronal T1-weighted gadoli-nium-enhanced MR images showing a normalization of the left optic nerve.

• 

  Figure 3. Histopathology of the sphenoid sinus tissue showed hyphae, consistent with the aspergillosis. (A) Grocott's methenamine silver stain ×200. (B) Haematoxylin and eosin stain ×200.

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  Figure 4. Finding of ocular motility at 5 months after the anti-fungal treatment. Images of the patient in nine diagnostic position of gaze at 5 months after the anti-fungal treatment, he showed stable ocular alignment without abduction limitation.

Reference

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