Fooled Thrice

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Identifier walsh_2019_s3_c3-slides
Title Fooled Thrice
Creator Jonathan A. Micieli, MD, CM
Subject 3rd Nerve Palsy; Radiation
Description A 40-year-old healthy man presented with a one-month history of left ptosis and binocular horizontal diplopia. Examination revealed normal afferent visual function. He had left ptosis and there was limitation of elevation, depression, adduction and a dilated, sluggishly reactive pupil in the left eye. CT angiogram was normal and MRI of the brain with contrast revealed an enhancing mass extending along the course of the left oculomotor nerve suggestive of a schwannoma. Lumbar puncture was normal and neurosurgery advised against biopsy. He received fractionated radiation therapy (50Gy) and a shortcourse; of dexamethasone for a presumed left oculomotor nerve schwannoma and his ptosis and diplopia started to improve two weeks after treatment. Follow-up MRI six months after treatment showed further decrease in the size of the lesion and his diplopia in primary position resolved. Eighteen months after treatment, his double vision returned and repeat MRI demonstrated stability in the size of the cisternal portion, but an increase in the size of the cavernous and intra-orbital portion of the left oculomotor nerve mass. Due to the relatively prompt response to radiation and dexamethasone, the possibility of an inflammatory lesion was considered. An extensive workup including CT of the chest/abdomen/pelvis was normal. He was also started on mycophenolate mofetil as he did not tolerate corticosteroids well. One month later, he suddenly lost vision in his left eye and examination revealed hand motions vision with a left relative afferent pupillary defect, left ptosis and complete left ophthalmoplegia. The right eye had normal visual acuity and motility. Repeat MRI demonstrated interval enlargement of the mass with compression of the left optic nerve at the orbital apex. Repeat lumbar puncture was normal and after 5 days of high-dose intravenous methylprednisolone, his vision in the left eye worsened to no light perception. A diagnostic procedure was performed.
Date 2019-03
Language eng
Format application/pdf
Source 2019 North American Neuro-Ophthalmology Society Annual Meeting
Relation is Part of NANOS 2019: Frank B. Walsh Session 3
Collection Neuro-ophthalmology Virtual Education Library: NOVEL http://NOVEL.utah.edu
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Holding Institution North American Neuro-Ophthalmology Association. NANOS Executive Office 5841 Cedar Lake Road, Suite 204, Minneapolis, MN 55416
Rights Management Copyright 2019. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
ARK ark:/87278/s61z8nnw
Contributor Primary Jonathan A. Micieli, MD, CM
Setname ehsl_novel_fbw
ID 1431989
Reference URL https://collections.lib.utah.edu/ark:/87278/s61z8nnw
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