Abstract Title A Cavernous Sinus Mass Resection Develops Into An Eye-Opening Complication

Background Brain tumors are a rare disease in the general population, with a reported incidence of 5 – 13 out of 100,000. Cavernous sinus tumors are a subset of brain tumors and are also rare. Cavernous sinus tumors may impact internal carotid artery, cranial nerves 3 and 4, and the ophthalmic or maxillary branches of the trigeminal nerve. When tumors are located within this structure, ophthalmoplegia, proptosis, and paresthesias may develop. Management is affected by their involvement of surrounding structures and their mass effect which may cause significant pain.

Case Presentation This is a case of a 35-year-old male with no past medical history but three months of constant headaches associated with left facial numbness and progressive diplopia. His diplopia progressed to persistent binocular diplopia in upgaze, right gaze, and down gaze. Physical exam was remarkable for left cranial nerve 3 palsy and decreased sensation to the left face. Labs were only remarkable for a cortisol of 0.5. During workup, magnetic resonance imaging of the brain demonstrated an extra-axial mass in the left Meckel’s cave, left cavernous sinus, and left middle cranial fossa. The differential diagnosis at that time included schwannoma, spindle cell tumor, lymphoma, meningioma, pituitary adenoma, and metastases. His biopsy was inconclusive. For his palsy, the patient was given a pirate patch. Upon progression of symptoms, he presented to the emergency department. He underwent transsphenoidal biopsy that demonstrated a spindle cell tumor. He was then discharged, and later saw neurosurgery in clinic, who scheduled him for an elective left craniotomy with mass resection. He underwent this procedure with a postoperative course complicated by a pseudomeningocele, complete ophthalmoplegia along with proptosis, inferior displacement and lagophthalmos, with severe exposure keratopathy. Ophthalmology recommended lubricant, steroid eye drops, moxifloxacin eye drops and completed a tarsorrhaphy. The patient lost vision in his left eye due to the significant exposure keratitis due to postoperative swelling of the cavernous sinus.

Discussion Traditionally, management of ophthalmoplegia is achieved through use of lubricant eye drops and ointments. Surgical intervention can be considered depending on the severity and duration of lagophthalmos, in which a temporary vs permeant tarsorrhaphy is considered. Mild exposure keratopathy has a very good prognosis, while more severe disease can lead to permeant corneal scarring, perforation, and vision loss. Timely consultation and treatment for cavernous sinus masses are needed to prevent progression of these symptoms.