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JAMA Ophthalmology Clinical Challenge
June 2016

Man With Painful Proptosis of the Left Eye

Author Affiliations
  • 1Department of Ophthalmology, Duke Eye Center and Duke University Medical Center, Durham, North Carolina
  • 2Department of Neurology, Duke Eye Center and Duke University Medical Center, Durham, North Carolina
JAMA Ophthalmol. 2016;134(6):705-706. doi:10.1001/jamaophthalmol.2015.3605

A healthy man in his 20s presented to the emergency department with decreased vision in the left eye that was associated with intermittent left orbital pain progressing from a dull ache to throbbing pain over 2 days. Findings from the examination were remarkable for reduced visual acuity in the left eye (20/80), proptosis with hypoglobus in the left eye, S-shaped left blepharoptosis, and left retinochoroidal folds (Figure 1A). Magnetic resonance imaging (MRI) of the orbits with contrast demonstrated a well-defined superotemporal mass with homogeneous enhancement (Figure 1B). The patient was admitted for a trial of intravenous methylprednisolone, 1000 mg, for presumed inflammatory dacryoadenitis. Results of a complete blood cell count, comprehensive metabolic panel, antineutrophil cytoplasmic antibody, antinuclear antibody, Lyme titer and serum angiotensin-converting enzyme levels, chest radiograph, erythrocyte sedimentation rate, C-reactive protein levels, urinalysis, and IgG4 index were normal. The patient’s pain nearly resolved after 3 days of intravenous methylprednisolone treatment, and he was discharged with a regimen of 80 mg/d of oral prednisone.