Abstract Details

Title Acute Bilateral Ophthalmoparesis due to Bacterial Meningitis in the Setting of Sphenoid Sinusitis

Topic Neuro-ophthalmology/Neuro-otology

Presentation(s) P1 - Poster Session 1 (5:30 PM-6:30 PM)

Poster/Presentation
Number 4-023

Objective We present a novel case of a patient in whom bilateral bacterial sphenoid sinusitis and meningitis manifested as acute bilateral ophthalmoparesis.

Background A 67-year-old man with a two-week history of bifrontal headaches, posterior neck pain and binocular diplopia presented with markedly limited eye movements in all directions of gaze. There were 215 x 10⁶ white blood cells per litre of CSF, of which 98% were neutrophils; however, CSF was culture negative. Magnetic resonance imaging of the brain demonstrated bilateral sphenoid sinusitis and skull base osteomyelitis. The patient underwent bilateral endoscopic sphenoidectomy. Intraoperative bone swab and culture of the right sphenoid mucosa grew Moraxella catarrhalis, while one mucosal specimen also grew Staphylococcus lugdenesis from broth culture only; meningitic doses of ceftriaxone and metronidazole were administered.

Design/Methods Not applicable.

Results By ruling out brainstem, neuromuscular junction and extraocular muscle localization, we concluded that all six ocular motor cranial nerves were damaged in the subarachnoid space by meningitis. Following meningitic doses of ceftriaxone and metronidazole, the patient’s eye movements improved after two months; his headaches and neck pain fully resolved over this timeframe.

Conclusions Acute bilateral ophthalmoparesis is a very uncommon occurrence with multiple possible causes, which should prompt consideration of brainstem, cavernous sinus, meningeal, myoneural and orbital localization. Focused imaging is required, and when clinical features point to infection or neoplasia, lumbar puncture should also be carried out. The clinical spectrum of Moraxella catarrhalis and Staphylococcus lugdenesis infections may now be extended in an adult population to acute bilateral ophthalmoparesis due to sphenoid sinusitis and meningitis. There are multiple possible mechanisms by which acute bacterial meningitis could injure the ocular motor cranial nerves including direct nerve infiltration by inflammation and infection, compression, and ischemia; however, it is still unclear why acute complete bilateral ophthalmoparesis so rarely occurs.

Authors/Disclosures
Austin Pereira PRESENTER	No disclosure on file
Felix J. Tyndel, MD	Dr. Tyndel has nothing to disclose.

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