Lumps and Bumps - Slides

History and Exam A 37 year-old man with no PMH presented with bilateral painful red eyes and progressive proptosis for several months. He noted the increasing protrusion of both eyes, but only complained of recent onset of pain in both eyes over the last four days. He also developed worsening blurry vision in both eyes with the left eye worse than right. Patient had no personal or family history of cancer. His initial examination showed right eye VA of 20/50 and left eye 20/100 at near and massive proptosis and lagophthalmos of both eyes with near complete corneal exposure bilaterally. On his external exam, the patient also had bilaterally enlarged lacrimal glands and submandibular lymph nodes as well as diffusely restricted extraocular movements. He presented with IOPs of 24 OD and 39 OS, reactive pupils, and a 1+ RAPD OS. Patient's ophthalmic exam showed diffusely dry corneal epithelium of both eyes and an inferior corneal ulcer of the left eye. Fundus exam was otherwise unremarkable. Initial CBC and CMP on presentation were only remarkable for mildly elevated WBC. CT orbit w/o contrast demonstrated massive enlargement of the bilateral lateral rectus, inferior oblique, and medial rectus muscles along with severe proptosis and straightening of the optic nerve. Patient was admitted to the hospital for inpatient evaluation.VBorbitalpathologyorbitalinflammation; KBDautoimmuneopticneuropath