Man presents with headache, ptosis and abnormal eye movements

A 49-year-old Brazilian man with no known medical history was admitted to the hospital for headache, ptosis of the right upper eyelid and abnormal eye movements. He had been discharged from the hospital recently with a working diagnosis of migraine, only to be admitted again with worsening symptoms. The admitting team ordered an MRI of the brain that showed a possible cavernous sinus thrombosis. At this point, Ophthalmology was urgently consulted. On review of systems, the patient complained of a bifrontal headache but denied any ocular pain or changes in his vision.Uncorrected visual acuity was 20/20 in both eyes. Both pupils were equally round, but the right pupil was sluggish to constriction while the left pupil constricted briskly. There was no afferent pupillary defect in either eye. IOP was within normal limits in both eyes. Confrontation visual fields were full. Extraocular motility was full in the left eye. However, the right eye had significantly limited motility; the patient had limited adduction, elevation and depression in the right eye. The anterior and posterior segments were completely unremarkable in both eyes.