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JAMA Ophthalmology Clinical Challenge
June 6, 2019

Rare Case of Bilateral Orbital Masses

Author Affiliations
  • 1Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
  • 2Departments of Neurology and Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut
JAMA Ophthalmol. 2019;137(9):1074-1075. doi:10.1001/jamaophthalmol.2019.1053

A 60-year-old woman with a history of Lyme disease presented with polydipsia and polyuria and received a diagnosis of diabetes insipidus. Brain magnetic resonance imaging (MRI) results revealed a thickening and enhancement of the pituitary gland, stalk, and hypothalamus. The abnormal imaging findings improved on subsequent MRIs without treatment. Surveillance pituitary MRIs remained stable. Four years later, MRI results (Figure) revealed bilateral T1 and T2 low-intensity intraconal soft tissue masses with avid enhancement on postcontrast images. The optic nerves were encased with no evidence of infiltration of the nerves, vascular structures, or extraocular muscles. She reported the sensation of eye fullness and denied pain. Her best-corrected visual acuity was 20/20 OU. Her pupils were symmetric and responded to light and near effort; there was no relative afferent pupillary defect. The results of testing with an Amsler grid and Ishihara color plates were normal. Her visual fields were full to confrontation. The optic nerves and retina were normal bilaterally. There was bilateral periorbital swelling and proptosis. Exophthalmometry measurements on a base of 92 were 17 mm on the right and 19 mm on the left. Applanation tonometry results were 12 mm Hg on the right and 15 mm Hg on the left. Extraocular motility examination results revealed substantial (−3) deficits in both eyes. The remainder of the neurologic examination results were normal.