Incomplete TNP is often microvascular in origin and requires evaluation for diabetes and hypertension. Microvascular TNP is frequently painful but usually self-resolves after 2 to 4 months.2 Giant cell arteritis may also cause an isolated, painful TNP.2
A varied differential diagnosis and a TNP link to COVID-19
The differential diagnosis for TNP includes the following:
Orbital apex injury is usually seen after high-energy craniofacial trauma.4 Orbital apex fractures present with different signs and symptoms, depending on the degree of injury to neural and vascular structures. Various syndromes come into play, the most common being superior orbital fissure syndrome, which is characterized by dysfunction of cranial nerves III, IV, V, and VI.4 Features include ophthalmoplegia, upper eyelid ptosis, a nonreactive dilated pupil, anesthesia over the ipsilateral forehead, loss of corneal reflex, orbital pain, and proptosis.4
In patients with suspected orbital apex fractures, it’s important to assess for the presence of an optic neuropathy, an evolving orbital compartment syndrome, or a ruptured globe, because these 3 things may demand acute intervention.4
Chronic progressive external ophthalmoplegia (CPEO) is a mitochondrial disorder characterized by a slow, progressive paralysis of the extraocular muscles.5 Patients usually experience bilateral, symmetrical, progressive ptosis, followed by ophthalmoparesis months to years later. Ciliary and iris muscles are not involved. CPEO often occurs with other systemic features of mitochondrial dysfunction that can cause significant morbidity and mortality.5
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