Clinician plays critical role in diagnosis, treatment of painful ophthalmoplegia

Chicago-Painful ophthalmoplegia may be a benign condition, such as microvascular ocular motor neuropathy, most commonly seen in the elderly with head and/or face pain, not requiring neuroimaging. On the other hand, it may be more serious with a combination of signs/symptoms that indicate a problem originating in the brain stem, cavernous sinus, or elsewhere, requiring a complete work-up, explained Gregory P. Van Stavern, MD.

"When someone comes in with painful diplopia, our job [as clinicians] is to put together their signs and symptoms and see if we can point to somewhere in the brain," said Dr. Van Stavern, assistant professor of ophthalmology and neurology, Kresge Eye Institute/Wayne State University, Detroit. "Physicians have to take a good history and at least be aware of some of the relevant neuro-anatomy."

During the Neuro-Ophthalmology Subspecialty Day Meeting at the American Academy of Ophthalmology annual meeting, Dr. Van Stavern covered four possible diagnoses of painful ophthalmoplegia: microvascular ocular motor neuropathy, pituitary apoplexy, carotid-cavernous fistulas, and cavernous sinus syndrome.

A 67-year-old man who had diabetes, hypertension, and painful diplopia existing for 2 weeks before presentation was examined at Dr. Van Stavern's clinic. On examination, a complete right abduction defect was found and there were no other localizing symptoms. A microvascular sixth nerve palsy was diagnosed and the patient did not require neuroimaging.

"It can be considered as a default diagnosis or diagnosis of exclusion," Dr. Van Stavern said.

In most of these cases, patients will recover over 3 to 4 months. However, if there has been no resolution of symptoms in 1 month or the patient's condition has not resolved between 4 and 6 months, neuroimaging should be considered. The development of new, localizing symptoms also suggests the need for neuroimaging, he said.

An emergency