A 45-year-old female patient presented as a walk-in to our clinic with the chief complaint a swollen and painful right eye. She reported dizziness but denied diplopia, fever, and history of any trauma. She stated that her symptoms had been going on for over 3 months and that she had been to multiple doctors with no relief. Her husband reported they went to another practice and she was given “shots in the eye” in February 2016 and November 2015; these provided no relief. The patient was uncertain if it was a steroid or an anti-VEG-f type medication. She denied ever being prescribed oral steroids or antibiotics. Her husband reported going to a local hospital emergency room in April 2016. He stated a CT was done but was normal. He was unsure if the scan was exclusive to the brain or if it also included the orbits.

Upon examination, unaided visual acuity was 20/60-1 OD, 20/40-2 OS, not improved with pinhole. Pressures by applanation were 15 and 14. General inspection revealed significant proptosis OD with heavy eyelid edema and engorgement of both the upper and lower right eyelids. Ocular motility was mildly limited, but there was no pain with eye movements. Pupils were normal with no afferent defect. Confrontation fields were full OD and OS.  Dilated fundus exam showed healthy optic nerve, macula, and vasculature.

My diagnosis was orbital inflammatory pseudotumor. The key findings with orbital inflammatory pseudotumor include pain, redness, diplopia, and decreased visual acuity, together with proptosis, chemosis, and possible restriction of ocular motility. CT imagining of the orbits generally shows thickening of the sclera posteriorly. These findings may mimic orbital cellulitis; a key differentiating factor is absence of fever (for adult patients) and absence of optic disc edema.

I advised the patient to return the ER for more specific imaging and labs. I provided them with a detailed summary of the examination findings and my diagnosis, as well as a few differential diagnoses to consider. We discussed in detail that she needed orbital CT, axial and coronal sections, with thin cuts, in order to make a definitive diagnosis. I also wrote recommendations for labs including ESR, CRP, CBC with diff, metabolic panel, ANA, BUN, and ANCA to evaluate for systemic conditions such as Wegener’s granulomatosis and polyarteritis nodosa, systemic vasculitis, or even lymphoma.

Around one week later, I got a surprise visit from the patient and her husband. She was smiling from ear to ear and had no pain, swelling, or proptosis at all! At the ER the diagnosis of orbital inflammatory pseudotumor was confirmed via orbital CT. She was provided a steroid dose pack and was cured in less than a week! We hugged and celebrated the joyous moment that she was now back to normal. In this case, a comprehensive case history is what ultimately lead to an accurate diagnosis.