A 72-year old woman presents with a complaint of headache and that her right eye "just isn't working right." She is generally healthy, with only an idiopathic anemia, and no associated symptoms other than some fatigue and poor appetite. She characterizes the headache as being a sinus headache, and notes that it has been occurring on and off for a month or so, though she has never had any fever or nasal congestion/drainage. She has had "eye problems" related to this headache in the past, but today it is more severe than before.
When the patient looks at you, this is what you see:
She cannot voluntarily retract the right eyelid. It is nontender, and when you retract it for her, she complains of diplopia. You see this:
The right pupil is dilated and fixed; the left is 3 mm and reactive. Note that with level gaze the eyes do not seem quite conjugate. The right eye is deviated mildly down and out. When you ask the patient to look to her left:
There is no movement of the right eye at all. And when you ask her to look up:
Again the right eye does not move. Same with downwards gaze. On attempted right gaze you see this:
Uploaded with Skitch!
But on right gaze the patient still complains of diplopia. Vision in the right eye is grossly intact to confrontation. The right pupil reacts neither to light or attempted accommodation (on a very limited exam). Neurological exam is otherwise entirely normal, including as many cranial nerves as an ER doctor remembers how to test.
So -- what is the clinical finding here, and where is the lesion most likely to be based on the information you have?
Answer and discussion tomorrow.
(Photographs taken/published with patient permission.)