Pseudo double elevator palsy.

A 22-year-old male presented to the outpatient department of ophthalmology with complaints of binocular diplopia in upward gaze, pain, and proptosis of the right eye for 2 months. On examination, visual acuity of both eyes was 20/20. Axial proptosis of the right eye was observed (right eye 22 mm and left eye 20 mm). On palpation, no mass was felt and no local tenderness was noted. The ocular movements of the right eye were restricted in the upward and downward gaze. In the primary position, the right eye was hypotropic by 12 Δ [Figures 1 and 2]. Magnetic resonance imaging (MRI) of the orbit and brain revealed a well-defined oval lesion measuring 1.4 mm × 2.7 mm involving the posterior aspect of the right inferior rectus. Marked enlargement of the inferior rectus was observed [Figure 3]. Cystic areas were observed within the lesion. No signs of neurocysticercosis were observed. The patient was administered an oral dose (15 mg/kg body weight) of albendazole divided into two doses for 4 weeks combined with oral prednisolone acetate at a dose of 1 mg/kg body weight once daily for 3 weeks. The doses were then tapered over 2 weeks, following which the patient started showing signs of improvement. Within 2 months, the diplopia resolved and proptosis started resolving. MRI of the orbit after 4 months showed complete regression of the lesion.

Figure 1

Showing restriction of right eye movement in up gaze

Figure 2

Showing restriction of the right eye movement in down gaze

Figure 3

Magnetic resonance imaging of the orbit showing cyst in the posterior aspect of the inferior rectus (arrow)

Restricted ocular movements of the right eye in the upward gaze associated with diplopia gave an impression of double elevator palsy. Double elevator palsy usually presents with the paralysis of the two ocular elevators (superior rectus and inferior oblique), hypotropia, and pseudoptosis.[12] In our patient, the eye was hypotropic but not ptotic. Ocular movement was restricted in down gaze also. Therefore, we termed this condition pseudo double elevator palsy. We would like to add cysticercosis of the inferior rectus, as observed in our case, as the cause of pseudo double elevator palsy.

Cysticercosis of the inferior rectus is rare but should be considered a differential diagnosis in cases with restricted extraocular muscle motility and proptosis of recent onset with a high index of suspicion, particularly in the endemic areas.

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