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Blepharitis With Facial Numbness and Ocular Pain

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man in his 60s presented to the emergency department with a 3-week history of numbness of the right side of the forehead and cheek and severe right-sided ocular discomfort that was relentless and kept him awake at night. He had been seen 2 weeks previously with similar symptoms and was diagnosed as having blepharitis and discharged with instructions for eyelid hygiene. His symptoms failed to improve, and he visited his family physician the following week. His physician prescribed a course of amoxicillin and clavulanate potassium, but the symptoms remained.

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Space-occupying lesion of the right Meckel cave

C. Order contrast-enhanced magnetic resonance imaging of the brain

The patient’s unilateral neurologic signs indicated a pathologic process centered on the right trigeminal nerve, and the involvement of the ophthalmic and maxillary nerves, but not the mandibular nerve, localized the lesion to the Meckel cave (MC). The MC is a mouth-shaped cavity at the anterior aspect of the middle cranial fossa. It houses the trigeminal nerve root ganglion and ophthalmic (V1), maxillary (V2), and mandibular (V3) branches until their exit at separate foramina.1 Lesions within the MC may present with pain, paresthesia, or motor dysfunction of the trigeminal nerve or its individual branches.2

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Article Information

Corresponding Author: Jennifer C. Fan Gaskin, MBChB, MD, FRANZCO, Royal Victorian Eye and Ear Hospital, 32 Gisborne St, East Melbourne, Victoria 3002, Australia (drjfan@gmail.com).

Published Online: September 7, 2017. doi:10.1001/jamaophthalmol.2017.2492

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

References
1.
Sabancı  PA, Batay  F, Civelek  E,  et al.  Meckel’s cave.  World Neurosurg. 2011;76(3-4):335-341.PubMedGoogle ScholarCrossref
2.
Soni  CR, Kumar  G, Sahota  P, Miller  DC, Litofsky  NS.  Metastases to Meckel’s cave: report of two cases and comparative analysis of malignant tumors with meningioma and schwannoma of Meckel’s cave.  Clin Neurol Neurosurg. 2010;112(10):927-932.PubMedGoogle ScholarCrossref
3.
Maggioni  F, Bellamio  M, Margoni  M, Zanchin  G, Manara  R.  Hematoma of Meckel’s cave: a rare possible symptomatic trigeminal neuralgia.  J Neurol. 2012;259(7):1481-1482.PubMedGoogle ScholarCrossref
4.
Braksick  S, Shah-Haque  S, El-Haddad  B, Moussa  R.  Neurosarcoidosis presenting as trigeminal nevralgia [sic]: a case report and review of the literature.  Sarcoidosis Vasc Diffuse Lung Dis. 2013;30(2):153-156.PubMedGoogle Scholar
5.
Alobaid  A, Schaeffer  T, Virojanapa  J, Dehdashti  AR.  Rare cause of trigeminal neuralgia: Meckel’s cave meningocele.  Acta Neurochir (Wien). 2015;157(7):1183-1186.PubMedGoogle ScholarCrossref
6.
Cerase  A, Brindisi  L, Lazzeretti  L, Pepponi  E, Venturi  C.  Lung cancer presenting with trigeminal neuropathy.  Neurol Sci. 2011;32(5):927-931.PubMedGoogle ScholarCrossref
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