A 68-year-old male patient, presented to us with history of progressive loss of vision in the right eye and persistent right-sided retro-orbital pain and headache for 2 months which started immediately after the cataract surgery of the right eye (Phacoemulsification under topical anaesthesia using lignocaine 2% eye drops) with intra-ocular lens implantation. The pre-operative visual acuity was 6/60 in the right eye and 1/60 in the left eye. The patient reported initial improvement in vision, but it was followed by rapid deterioration, for which he attended his ophthalmologist, who diagnosed it as a case of optic neuritis, as a complication of cataract surgery. He was started on oral methyl-prednisolone. There was no improvement in the symptoms and then the patient attended our out-patient department clinic. He had no history of diplopia, redness, watering, proptosis or floaters. There was no history of trauma or symptoms suggestive of meningitis or encephalitis. There was no history of cough, dyspnoea or haemoptysis.\nOn examination, the patient was conscious and oriented, with non-tender paranasal sinuses and bilaterally palpable temporal arteries. Neurological examination revealed complete right-sided ophthalmoplegia with mydriasis, hypoalgesia and diminished right corneal reflex. Ophthalmological examination revealed right and left visual acuity of 3/60 and 1/60, respectively. Right pupil was dilated and fixed, whereas the left pupil was reactive to light. Fundoscopy revealed oedema and pallor of right disc, whereas the left disc was normal.\nLaboratory investigations revealed haemoglobin of 12 g/dl (Normal:12–16 g/dl) and fasting blood sugar of 105 mg/dl (normal: 60–100 mg/dl). Serum angiotensin-converting enzyme and thyroid function tests were within their normal limits. Serum immuno-inflammatory markers were within normal limits. He was negative for HIV, hepatitis B and C and had normal levels of cluster of differentiation (CD)-4 and CD-8.\nThe first T1-weighted axial magnetic resonance imaging (MRI) of brain (Fig. A) showed minimal soft tissue at the right orbital apex which was abutting the right-sided optic nerve suggestive of OAS. In view of clinical examination and MRI report, a presumptive diagnosis of pseudotumor (inflammatory versus infectious aetiology) was made and the patient was started on ceftriaxone and vancomycin in meningitis dosage with tapering course of dexamethasone. Even after 10 days of this treatment, there was no improvement in symptoms. Instead, the visual acuity in the right eye decreased to perception of light only with development of right-sided proptosis.\nRepeat T1-weighted axial MRI scan of head (Fig. B) revealed an increase in the size of the mass with bony erosion of sphenoid sinus which was suggestive of infectious aetiology. Biopsy of the lesion was deferred in view of the proximity of the mass to the major neuro-vascular bundle in the orbital apex and cavernous sinus and the major risk involved in the procedure relative to its yield. The patient was empirically started on liposomal amphotericin-B in view of possibility of fungal infection.\nEven after 21 days of liposomal amphotericin-B, there was further increase in proptosis and the visual acuity in right eye diminished to ‘No light perception’ with increased intensity of peri-orbital and retro-orbital pain. A repeat T1-weighted axial MRI of head (Fig. C) revealed further destruction of the local anatomic sites with increase in mass lesion to 19 × 16 × 14 mm. Serum galactomannan antigen level was 0.5 index (Borderline).\nBy virtue of its size and extension, the mass was now accessible for biopsy. Under general anaesthesia, endoscopic navigation-assisted biopsy was taken from seven different sites. Review of histological specimen from posterior ethmoid mucosa, posterior ethmoid tissue near optic nerve and sphenoid sinus mucosa (Fig. ) showed fungal hyphae (Fig. A and B) morphologically compatible with Aspergillus species.\nHe was subsequently started on injectible voriconazole which was continued for 10 days. Now the patient showed dramatic improvement in his headache which resolved completely in 5 more days. Right eye movements began. The patient was then discharged on oral voriconazole.\nThe patient was completely free of symptoms with completely resolved ophthalmoplegia with repeat T2-weighted axial MRI revealing decrease in the size of the mass (Fig. D), after 7 months of oral voriconazole. But unfortunately, the patient had no recovery of vision in his right eye.
A 50-year-old female was admitted with a paroxysmal boring pain in the left parietal and left frontal region for 9 months, accompanied by progressive vomiting and decreasing of visual acuity and proptosis in the left eye. Headache could be relieved by diclofenac sodium. Two months prior to presentation, her headache worsened extending to the whole left side of the face, accompanied by numbness. No light perception or reflex was detected in the left eye. Horizontal movement was limited in the left eye. Pre-operative CT showed a 29 × 20 mm isodense lesion with heterogeneously enhancement in the region of the left cavernous sinus, left orbital apex, left optic nerve canal, and sphenoid sinus. Bone destruction could be seen in the left wall of the sphenoid sinus. The optic nerve could not be distinguished from the lesion (Fig. a). MRI showed a 21 × 26 mm patchy lesion that was isointense on T1WI and hyperintense on T2WI in the left cavernous sinus region (Fig. b, c). Enhanced-MRI showed noticeable enhancement of the lesion. The lesion was closely related to the dura mater and extended to the sphenoid sinus and optic apex, partly surrounding the left internal carotid artery (Fig. d). MRA suggested stenosis in the cavernous segment of the left internal carotid artery and A1 segment of the left anterior cerebral artery. The patient underwent partial mass excision via a pterional craniotomy due to its close attachment to the ophthalmic branch and maxillary branch of the trigeminal nerve. The lesion was partly fibrotic and partly a milk-white viscous substance. A biopsy was performed immediately and histopathologic examination revealed Aspergillus species (Fig. e). The patient was administered voriconazole after surgery. Post-operative images indicated the resection of the mass (Fig. f). Examination after a follow-up of 15 months showed a complete resolution of the headache. Her vision of the left eye was not regained.