Presentation

Figure 1: External photograph of nasal displacement with soft tissue swelling, left upper and lower eyelid erythema and edema.

A 25-year-old Hispanic male complained of redness and swelling of the left eyelids for two weeks. The patient had initially presented to an outside ophthalmologist five days prior, and was prescribed oral cephalexin 500 mg four times daily for treatment of presumed preseptal cellulitis, without progression or improvement in his symptoms. He reported ongoing pain in the left eye with movement, most notably in up-gaze, but denied concurrent diplopia, photophobia, recent illness or trauma. Systemic review was only significant for left nasal congestion over the preceding few weeks.

Medical History
Past medical, surgical and ocular history were noncontributory. The patient’s social history was notable for recent immigration to the United States from El Salvador eight weeks prior to presentation. The patient denied tobacco or illicit drug use and drank alcohol socially. He had no known drug allergies.

Figure 2: Extraocular motility montage disclosing limited up-gaze with mild hypoglobus of the left eye.

Examination
On examination, axillary temperature was 101.7 degrees Fahrenheit; the remaining vital signs were within normal limits. Ocular examination showed uncorrected visual acuity of 20/25 in both eyes. Pupils were equal and briskly reactive, without an afferent pupillary defect. Confrontation visual fields and Ishihara color plates were full bilaterally. External examination disclosed displacement of the nasal bridge to the right with moderate left upper and lower eyelid erythema and mild edema (Figure 1). Extraocular motility was full OD but limited OS, most notably in up-gaze (Figure 2).

Slit lamp examination of both eyes was unremarkable. Intraocular pressure by Goldmann tonometry was 14 mmHg OD and 17 mmHg OS. Hertel exophthalmometry disclosed 3 mm of relative left-sided proptosis. Dilated fundus exam in both eyes was unremarkable. 

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