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 69-year-old male was admitted with a progressive frontal paroxysmal headache accompanied with mild vomiting, diplopia, and visual disturbance for 1 month, without fever. Visual acuity was 0.6 in the left eye and 0.9 in the right eye without visual field loss. Other neurologic and clinical findings were normal. He was healthy other than a 10-year history of well-controlled hypertension and coronary heart disease. The patient reported no history of fungal infection or a history of contact with unusual infectious sources. CT scan showed a mass in the sphenoid sinus and clival region. Bone destruction was observed in both regions (Fig. a). MRI showed a hypointense signal on T2-weighted images (T2WI) in the lesions and an isointense signal on T1 weighted images (T2WI) with heterogeneous gadolinium-enhancement in the sphenoid sinus, both cavernous sinuses, bilateral ethmoid sinuses, and maxillary sinus (Fig. b–d). This patient underwent trans-sphenoidal lesion debridement. Purulence was observed during the operation. A biopsy was performed immediately and histopathology examination revealed Aspergillus species (Fig. e). The patient was administered fluconazole after surgery. Post-operative neurological examination showed obvious improvement of headache, vomiting, vision, and diplopia. Post-operative images indicated the resection of the mass (Fig. f). Examination after a follow-up period of 24 months showed no clinical symptoms, and no additional therapy was required.