Presentation

A 34-year-old female presented to Wills Eye Emergency Room complaining of worsening left eye pain and tearing. She noted a change in appearance that occurred nine months prior to presentation. She experienced mild left-eye pain and blurry vision that began six months prior. The symptoms progressed and patient sought medical care 1.5 months prior to the ER visit, but she was unable to obtain outpatient follow-up, and worsening pain ultimately brought her to the emergency room.

Medical History

Past medical history was significant for diabetes, hypertension, asthma and genital herpes, which were treated with lantus insulin 12 units once daily; amlodipine 10 mg once daily; valsartan 320 mg once daily; clonidine patch 0.1 mg applied weekly; albuterol inhaler when needed; and acyclovir 500 mg once daily. Her past surgical history included tonsillectomy, cholecystectomy, hysterectomy, tubal ligation and hernia repair. Family history was noncontributory. The patient was a current smoker, but denied alcohol or illicit drug use. She was allergic to latex.

Examination

The patient’s visual acuity was 20/40 in the right eye with pinhole improvement to 20/25, and count fingers in the left eye with pinhole improvement to 20/400. There was a trace relative afferent pupillary defect on the left. Confrontational visual fields were full and intraocular pressure was 16 in both eyes. Ishihara color plates were full in both eyes (patient held the plates close to her face for left eye testing). Extraocular movements were full on the right. The left eye displayed only 40 percent supraduction and 90 percent abduction.

External exam revealed left-eye proptosis and hypoglobus. Hertel exophthalmometry was 14 mm on the right and 20 mm on the left. Resistance to retropulsion of the left orbit was noted. Further examination revealed left upper eyelid fullness and inferior superficial punctate keratopathy on the left cornea. The slit-lamp exam was otherwise unremarkable. Dilated fundus exam was normal. The patient underwent a CT scan (See Figure 1).

Figure 1. CT coronal and axial images displaying a well-circumscribed left lacrimal mass producing a mass effect on the globe and scalloping of the frontal bone.