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Chronic ocular pain may have many causes and can be a frustrating problem for both patient and doctor alike. We describe two patients who had similar symptoms and eye findings who had been unable to relieve their pain with conventional analgesia. We postulate a cause for their pain and describe our experience of a treatment strategy using a standard dose of botulinum toxin injection into an extraocular muscles.
Case 1
A 56 year old white woman presented with what was initially thought to be a right orbital cellulitis but investigations and clinical course subsequently suggested a non-infectious idiopathic inflammatory aetiology. Her history suggested orbital myositis and she described right sided facial weakness, nausea, and right sided ptosis. She had a 9 month course of oral steroids and despite this needed tramadol, paracetamol, and flurbiprofen to control her pain. Her symptoms and examination findings slowly stabilised until she was left with marked limitation of upgaze in her right eye. Her symptoms did not change over the next 3 years, at which point she was referred to our care. When she attempted to look up she described a juddering sensation and severe pain just above the eye. She rarely had pain …