SURVEY OF OPHTHALMOLOGY VOLUME 48 • NUMBER 5 • SEPTEMBER–OCTOBER 2003 CLINICAL CHALLENGES PETER J. SAVINO AND HELEN DANESH-MEYER, EDITORS A Lot of Clot Michael A. Grassi, MD, 1 Andrew G. Lee, MD, 1,2,3 Randy Kardon, MD, PhD, 1 and Jeffrey A. Nerad, MD 1,4 Departments of 1 Ophthalmology, 2 Neurology, 3 Neurosurgery and 4 Otolaryngology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA Comments by Jurij R. Bilyk, MD (In keeping with the format of a clinical pathological conference, the abstract and key words appear at the end of the article.) Case History. A 37-year-old man presented with a red and painful right eye (OD). He had long-standing classic migraine treated with amitriptyline and pro- panolol. He was using no other medications. He smoked one package of cigarettes per day over the last 15 years and admitted to occasional cocaine and marijuana use. He was not employed and lived next to a farm with cattle and chickens. Family history was significant for coronary artery disease in his mother who died at the age of 51 years. He was well until 1 week prior to admission when he developed a severe right sided, retro-orbital head- ache. There was associated left arm numbness and tingling. The patient was admitted to an outside hos- pital for pain control and further evaluation. Minimal relief was noted with analgesics and compazine. A computed tomography (CT) scan of the head dem- onstrated pansinusitis. Cephalexin 500 mg PO QID was begun. Lumbar puncture revealed a normal opening pressure, no red or white blood cells and normal cerebrospinal fluid chemistry. He denied an- tecedent trauma or prior ocular disease. The patient reported a “flu-like” illness associated with fever, cough, and rhinorrhea 3 weeks prior. 555  2003 by Elsevier Inc. 0039-6257/03/$–see front matter All rights reserved. doi:10.1016/S0039-6257(03)00088-2 He was afebrile with normal vital signs. There was no cervical, supraclavicular, axillary, or inguinal lymphadenopathy. The frontal and maxillary sinuses were tender to palpation. Extremely poor dentition with leukoplakia was noted. There was no cardiac murmur. Left upper lobe crackles were appreciated. The abdomen was soft and there was no hepato- splenomegaly. No focal neurologic abnormalities were noted. Visual acuity was 20/20 in both eyes (OU). Exter- nal examination revealed 4 mm of proptosis (OD) and 2 mm of ptosis of the right upper eyelid OD. There was moderate periorbital erythema and edema OD (Fig. 1). Extra-ocular motility testing showed moderate limitation of right abduction (Fig. 2). In- traocular pressures were normal OU and there was normal excursion of the tonometry mires (1–2 mm Hg) during the cardiac cycle during applanation to- nometry. The pupils were isocoric, normally reactive, and there was no relative afferent pupillary defect. Slit-lamp biomicroscopy revealed conjunctival che- mosis and a large inferior subconjunctival hemor- rhage OD, but the remainder of the anterior segment