Red and Swollen Eye in a 61-Year-Old Man
Background
A 61-year-old man presents to the emergency department (ED) complaining of pain in his right eye that has persisted for 5 days, with associated redness and swelling.
The patient had been examined at another ED a few days before this presentation and was diagnosed with herpes zoster, for which he was given a prescription for acyclovir and hydrocodone and discharged home.
Since he started taking acyclovir, the patient has noticed that the pain and swelling in his eye has increased. He also reports binocular diplopia and decreased visual acuity. On the day of presentation, he is nauseous and vomiting, and he cannot open the affected eye.
On physical examination, the patient has normal and stable vital signs. Visual acuity in the unaffected left eye is normal at 20/25. In the right eye, he can only perceive bright light. In addition, the affected eye demonstrates ptosis of the upper eyelid, generalized proptosis, and mild periorbital erythema with associated edema (see Figure 1). Extraocular movements of the affected eye are as shown (see video clip). The right pupil is 8 mm in diameter and nonreactive to direct and indirect light. Intraocular pressure in both eyes, as measured by a handheld tonometer (Tono-Pen), is normal at 12 mm Hg.
What is the diagnosis?
Hint: The patient has diabetes mellitus and has been unable to control his blood glucose levels over the past 2 weeks.
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