一名右眼嚴重疼痛伴隨眼肌麻痺罕見案例的鑑別診斷思維與照護

A rare case of severe painful right eye ophthalmoplegia: differential diagnosis, clinical reasoning, and care

頭痛是常見的症狀，但眼眶疼痛合併眼肌麻痺卻非常罕見，許多原因會造成疼痛性眼肌麻痺，如腫瘤、血管、發炎和感染等嚴重病因，以臨床推理快速鑑別排除嚴重的疾病。本篇描述照護一位因右眼窩後側嚴重疼痛持續二個月，伴隨眼球活動度降低、上眼瞼下垂而入院診療的女性個案，其住院期間鑑別診斷護理經驗。經由神經學檢查發現個案右側第III、IV、V腦神經功能缺損，腦部磁振造影發現右側海綿竇周邊區域顯示有肉芽腫樣的發炎，而血液檢驗及腦脊髓液檢查皆正常。在排除因腫瘤、血管、感染、代謝及免疫等疾病導致的疼痛性眼肌麻痺後，判定為罕見疾病Tolosa-Hunt症候群，經由口服類固醇，48小時後眼球後疼痛明顯解除，眼瞼下垂與眼肌麻痺部分改善。筆者為病房專科護理師，藉由會談、病史詢問，系統性的身體評估、實驗室檢驗與影像學檢查，識別個案的健康問題及介入措施，以幫助個案儘早回歸正常生活。

Headache is a common condition, but orbital pain accompanied by ophthalmoplegia is extremely rare. Painful ophthalmoplegia can result from various serious causes, including tumors, vascular abnormalities, inflammation, infections, and other systemic conditions. Prompt identification of lifethreatening conditions and thorough clinical reasoning for differential diagnosis are essential. This case involves a 71-year-old woman hospitalized with severe right retro-orbital pain persisting for two months, along with restricted eye movement and ptosis of the right upper eyelid. Neurological examination revealed functional impairments of the right cranial nerves III, IV, and V. Blood and cerebrospinal fluid tests were unremarkable, while brain MRI showed granuloma-like inflammation around the right cavernous sinus. After ruling out tumors, vascular lesions, infections, metabolic, and autoimmune diseases, the diagnosis of Tolosa-Hunt syndrome—a rare inflammatory disorder—was made. Oral corticosteroid treatment led to significant pain relief within 48 hours and partial improvement in ptosis and ophthalmoplegia. This case highlights the importance of thorough medical history-taking, systematic physical assessment, laboratory investigations, and imaging studies in identifying complex conditions and facilitating timely treatment to support recovery and restore quality of life.