The patient, similar to this woman, had pain around her right eye upon upgaze.

Diagnostic Data
Her best-uncorrected visual acuity was 20/20 O.U. at distance and near. External examination was normal with no afferent defect. Goldmann intraocular pressures measured 14mm Hg in both eyes. The dilated fundus examination was normal.

Your Diagnosis
How would you approach this case? Does this patient require additional tests? What is your diagnosis? How would you manage this patient? What is the likely prognosis? 

Discussion
Additional history might include asking questions about blurred vision, dizziness, tinnitus, episodes of visual loss and history of sinus disease.

The diagnosis in this issue is trochlear tendonitis. When a patient presents with the chief complaint of acute unilateral pain in the region of the superonasal orbital rim, suspect idiopathic trochleitis.^1-3

Trochleitis is characterized by a local inflammatory process affecting the trochlear tendon of the superior oblique muscle called the trochlea.^1-3 In most cases, the cause is unknown. Typically, the patient will describe an aching around the eye, which has persisted over a few days and is also sometimes accompanied by a sharper pain. The patient usually describes that the pain worsens with eye movement, especially in superior gaze and supraduction.^1-3 Upon palpatation of the globe and adnexa, the patient will localize tenderness to the superonasal orbital rim. Occasionally, slight swelling of the muscle and tissue are present in that area.

Most patients that present with idiopathic trochleitis are in good health and experience relief of their pain after a week"s regimen of oral nonsteroidal anti-inflammatory medication.¹ Patients have a 25% chance of relapse within one year of the initial presenting episode.¹

Trochleitis has also been considered to be a trigger for migraine headaches.^2-3 Relief of the condition may also bring about the side effect of relief of migrainous events.

Although most cases of trochleitis are acute in nature and can be diagnosed by their constellation of signs and symptoms, be sure to consider other, more serious causes as well as potential underlying etiologies. Trochleitis has been known to occur secondary to rheumatoid arthritis, systemic lupus erythematosus, scleritis, Brown"s syndrome and orbital myositis.^1,2 In cases of recurring trochleitis with or without systemic symptoms, these conditions should be ruled out with appropriate laboratory tests.

Inspecting the conjunctiva for injection and discharge will eliminate local infection and cellulitis as a cause. Orbital complications can be dismissed when there is an absence of proptosis. If a patient is proptotic, a thyroid investigation along with consideration of neuroimaging is indicated to rule out space-occupying lesions, myosistis, mucocele, and orbital cellulites.

If diplopia is present, investigate for binocular problems and noncomitant muscle paralyses. Patients with orbital myositis are typically diplopic, having restricted eye movements and positive forced ductions.¹ In cases occurring secondary to Brown"s syndrome, the trochleitis may be congenital or acquired. In the congenital form, a click syndrome impairs movement of the superior oblique tendon through the trochlea. Characteristics of the syndrome are limited elevation in adduction with minimal or no superior oblique overaction. There will also be a positive forced duction test upon elevating the globe while adducting.^1-2

1. Tychsen L, Tse DT, Ossoinig K, Anderson RL. Trochleitis with superior oblique myositis. Ophthalmology 1984 Sep;91(9):1075-9.
2. Yanguela J, Pareja JA, Lopez N, Sanchez Del Rio M. Trochleitis and migraine headache. Neurology 2002 Mar 12;58(5):802-5.
3. Yanguela J, Sanchez-del-Rio M, Bueno A, et al. Primary trochlear headache: a new cephalgia generated and modulated on the trochlear region. Neurology 2004 Apr 13;62(7):1134-40.

Thanks to Justin Greczek, B.Sc., for contributing to this case.