Allergic fungal rhinosinusitis presenting with epiphora and blurry vision

Abstract

In this clinical picture ophthalmic providers are alerted to the possibility of paranasal sinus disease in patients with symptoms of epiphora, proptosis, diplopia, ophthalmoplegia, ptosis, lagophthalmos, optic neuropathy, orbital or preseptal cellulitis, periorbital swelling or visual impairment. These patients typically have a history of allergic rhinitis, nasal polyposis, nasal obstruction or discharge, or sinus involvement. Allergic fungal rhinosinusitis (AFRS) is a subtype of chronic rhinosinusitis that results in mucus build-up affecting any of the paranasal sinuses – including the frontal, maxillary, ethmoid, and sphenoid sinuses. AFRS infection is most often caused by Aspergillus, and typically affects young immunocompetent patients who live in warm humid climates. Inhaled fungal spores cause an allergic response and chronic inflammation which can eventually lead to non-invasive nasal airway remodelling, polyp formation and bony demineralisation. Diagnosis requires clinical, laboratory, radiographic and histopathologic testing. Treatment for AFRS typically involves surgical and medical management. The most common ophthalmic features of AFRS are proptosis, diplopia and vision loss. Epiphora alone is an atypical presentation. A 33-year-old man presented with complaints of chronic epiphora in both eyes and blurry vision in the left eye. The patient had a six-year history of seasonal allergies and refractory rhinitis. Visual acuity was 6/4.8 in the right eye and 6/6 in the left. Anterior and posterior segment examinations were unremarkable. Artificial tears were prescribed. Five months later, the patient presented to the emergency department with complaints of worsening sinus congestion, sinus pain and blurred vision. Thick discharge was noted medially in both eyes. Imaging revealed complete opacification of all paranasal sinuses with hyperdense material. There was bony remodelling, thinning and dehiscence with destruction of the cribriform plate and extension into the cranial vault. A mass effect on each medial rectus was noted, causing proptosis with optic nerve compression (Figure 1). Flexible fibreoptic laryngoscopy found the nasal cavities filled with polyps. Nasal histopathology revealed mucin with eosinophils and lymphocytes. Cultures found abundant