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Cause for pain, blurred and DOUBLE VISION in eye.

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I am 67 years old patientold and have had no problems with my eyes just until last Saturday -- I am now lying in a hospital bed unable to see straight and in severe pain and the doctors cannot determine the cause.

First I felt pain in my left eye -- first on the far left side of my eye when I looked to my left...this went on for a few steadily got worse. On Tuesday night, I was reading and I looked up and saw double. I went to the hospital emergency room on Weds (of this past week), and they pointed out that my left eye was not moving. Since then, the pain has gotten worse, deeper in my eye and moved over to the right eye which now has limited movement. I also also have pain and nauseas, despite being given medicine to alleviate those symptoms.

The hospital has done many tests, including cat scan, mri, carotid artery, CBC, thyroid, diabetes....they have ruled out everything. They cannot determine what is causing this problem (frozen eyes and pain). They put a patch over my left eye to make it somewhat tolerable to see.

I have no primary care doctor here. There is only the hospitatlist who has brought in a neurologist.

I had my eyes checked a couple of months before in June, there were no problems. I have had no major health concerns.

I am otherwise active and work, but this makes me nonfunctional.

So, the doctors here have exhausted their ideas of what might be causing this. This pain and eye dysfunction seems to be progressing such that I might completely lose my ability to see, and function (because of the sever pain and the significant double vision). This may be a race against time.

What other possible causes should be looked into?

Thank you,

PS: They have given me percoset, adavan, nausea med, blood pressure med, and low dosage of thyroid med. All common causes have been ruled out.

Category: Ophthalmologist

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Category: Ophthalmologist
 22 Doctors Online

Thank you for your query at
I understand your concern and will do my best to help you.
Summarizing your symptoms, you have pain in the eyes, restricted movements of the eyes and double vision. Also associated nausea.
This could be termed as painful ophthalmoplegia (paralysis of eye muscles).Since all your investigations including imaging studies have come out normal, there can be two very rare possibilities- Orbital Pseudotumor or Tolosa-Hunt Syndrome.
Orbital (eye socket) Pseudotumor is a condition in which there is inflammation and swelling of the eye muscles causing pain, loss of eye movements and double vision. This condition mimics a tumor in the eye but in fact there isn't one. Hence the name "pseudotumor".
Tolosa-Hunt Syndrome is another similar condition with similar symptoms where the location of inflammation differs. Here the cavernous sinus (a venous sinus, something like a thick vein, present within the brain) is inflamed. Since this sinus is surrounded by nerves supplying the eye muscles, it causes symptoms of eye paralysis, pain, double vision etc.
Both these conditions are self-limiting, meaning they resolve on their own but take some time. They also show a very good response to steroids. So for both, the treatment is with steroids.
The diagnosis is by a thorough workup to exclude all other causes of similar complaints. This can be done by doing the following tests.

- Contrast enhanced MRI. If the MRI which was done for you was a contrast enhanced one, there is no need to repeat. The MRI has to be studied for any eye muscle swelling or swelling of the cavernous sinus. These can be present in some cases of Orbital Pseudotumor and Tolosa-Hunt Syndrome respectively. MRI can be completely normal as well in these cases.

- When the MRI is normal or shows changes consistent with cavernous sinus inflammation, further evaluation should include blood and cerebrospinal fluid (CSF) testing to exclude other possible causes of orbital inflammation. Recommended blood testing includes:

  • Complete blood count
  • Electrolytes
  • Glucose and hemoglobin A1C
  • Renal and liver function tests
  • Angiotensin converting enzyme
  • Antinuclear antibody
  • Anti-dsDNA antibody
  • Anti-Sm antibody
  • Antinuclear cytoplasmic antibody
  • Fluorescent treponemal antibody test
  • Lyme serologies
  • Serum protein electrophoresis
  • Erythrocyte sedimentation rate (ESR)
  • C reactive protein

Cerebrospinal fluid should also be evaluated for protein, glucose, cell count with differential, cytology, Lyme and syphilis serology, angiotensin converting enzyme (for sarcoidosis), and cultures for bacteria, fungi, and mycobacteria. The expected findings in Orbital Pseudotumor or Tolosa-Hunt Syndrome are normal. After excluding the tests already done for you from the above list, you can discuss with your doctor to get the rest of them done.
If all of them are normal, the diagnosis would be either Orbital Pseudotumor or Tolosa-Hunt Syndrome based on the location of inflammation.

- When this diagnosis is confirmed, Prednisone (steroid/glucocorticoid) is used in the treatment.
A suggested glucocorticoid regimen is:
Prednisone 80 to 100 mg daily for three days. This can be given intravenously.
If the pain has resolved, taper to 60 mg oral Prednisone daily, then 40 mg, then 20 mg, then 10 mg every two weeks.
Symptoms show rapid resolution, especially pain (within 24 to 72 hours). This helps to further confirm the suspected diagnosis. Improvement of paralysis and regression of MRI abnormalities (if any) over the next two to eight weeks provide further confirmation of the diagnosis.

- Close clinical follow-up with repeat MRI is necessary to be sure the glucocorticoid treatment remains effective and no evidence of another cause develops.
MRI scans to monitor improvement and maintenance of improvement on and then off treatment should be performed every one to two months until findings normalize. This should be followed by MRI scans every six months for a period of two years old patientfollowing the diagnosis. MRI and other diagnostic testing should be performed promptly if symptoms recur.

I hope this was helpful. Feel free to ask queries.
Thank you.

Dr. Manish Malhotra
Category: Ophthalmologist
Fellowship: L. V. Prasad Eye Institute, Hyderabad
Fellow Pediatric Ophthalmology & Squint (L.V. Prasad Eye Institute, Hyderabad)
Medical School, Residency: MBBS, DOMS, FLVPEI, Nagpur university, 1995
Dr. Manish Malhotra and 4 other Medical Specialists are ready to help you

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