Tolosa-Hunt Syndrome Presenting as Painful Unilateral Ophthalmoplegia in a 65-Year-Old Woman: A Case Report

A 65-year-old woman presented to a tertiary care center with a classical clinical scenario-3 months of persistent, right-sided frontal headache. Over the course of 20 days, a right-sided frontal headache developed into ptosis of the right upper eyelid. The headache was associated with throbbing pain in front of her skull along with periocular pain but without any systemic or neurological red flags. She had longstanding total blindness in the right eye which was diagnosed by complete absence of Perception of Light (PL). On examination, she was awake and afebrile, with unilateral right-sided ptosis and periocular tenderness. Diagnostic workup, including complete blood count, revealed no significant abnormalities, but MRI characterized by non-specific white matter hyperintensities with post-contrast enhancement of the cavernous sinus, indicative of THS. The patient showed a dramatic response to methylprednisolone, with significant ptosis improvement within 48 h, suggesting an underlying inflammatory etiology. This case highlights the importance of early diagnosis by clinical features, radiological evidence & utility of steroid trials in atypical neuro-ophthalmological presentations with inflammatory markers.