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Revista Ecuatoriana de Neurología

On-line version ISSN 2631-2581Print version ISSN 1019-8113

Rev Ecuat Neurol vol.31 n.2 Guayaquil Jul./Sep. 2022

https://doi.org/10.46997/revecuatneurol31200128 

Imágenes en Neurología

A Watery Eye And An Enlarged Trigeminal Nerve.

Ojo Acuoso Y Ensanchamiento Del Nervio Trigémino.

Oscar H. Del Brutto1 

1Universidad de Especialidades Espíritu Santo, School of Medicine and Research Center. Samborondón, Ecuador. <oscardelbrutto@hotmail.com>


Key Words: Watery eye; trigeminal neuropathy; trigeminal enlargement.

Palabras clave: Ojo acuoso; neuropatía trigeminal; ensanchamiento del trigémino.

A 45-year-old man was evaluated one week after the acute onset of pain and numbness in the right side of the face. On examination, he had a right watery eye, which has been present for several weeks (Figure 1). The patient denied history of eye trauma or previous episodes of inflammatory or infected conditions affecting the lacrimal drainage complex. Neurological examination showed decrease of all sensations in the distribution of the three branches of the right trigeminal nerve. Function of the other cranial nerves was intact and there were no motor or sensory deficits in the limbs. Routine metabolic workup as well as CSF examination were within normal limits.

Figure 1 Right eye of the patient showing excessive tears production in the right eye. 

Watery eyes are the result of an imbalance between tear out-flow and production. This condition most commonly affects both eyes, being the dry eye syndrome its most frequent cause since dry eyes may enhance the production of tears. Sjögren’s syndrome is an autoimmune disorder often associated with dryness of the eyes and mouth (keratoconjunctivitis sicca and xerostomia) as well as with trigeminal or other cranial neuropathies, peripheral neuropathy and other mixed neurological deficits (1).

In our patient, unilaterality of watery eye and sensorial deficits confined to the ipsilateral side of the face, pointed the trigeminal nerve as the origin of the problem. While the facial nerve innervates the lacrimal glands, the sensory input of these glands is conducted through the trigeminal nerve, triggering the production of natural tears.

Findings of the neurological examination prompted the practice of a brain MRI, which showed marked enlargement and abnormal enhancement of the right trigeminal nerve including the Gasserian ganglion (Figure 2). While Sjögren’s syndrome-related trigeminal neuropathy may be unilateral in about 60% of cases (2), damage of the trigeminal nerve is often expressed on MRI as atrophy of the nerve and not as enlargement (3). Likewise, the patient did not meet internationally accepted criteria for Sjögren’s syndrome diagnosis (4).

Figure 2 Contract enhanced T1-weighted MRI showing diffuse enlargement of the risght trigeminal nerve that included the Gasserian ganglion. 

In this particular case, MRI findings were against the diagnosis of tumors of the trigeminal nerve that can cause abnormal and focal enlargement of the nerve (5), and favor the occurrence of idiopathic trigeminal neuropathy as the most likely cause of this syndrome.

REFERENCES

Mellgren SI, Göransson LG, Omdal R. Primary Sjögren’s syndrome associated neuropathy. Can J Neurol Sci 2007; 34: 280-287. https://doi.org/10.1017/s0317167100006697. [ Links ]

Mori K, Iijima M, Koike H, Hattori N, Tanaka F, Watanabe H, et al. The wide spectrum in Sjögren’s syndrome-associated neuropathy. Brain 2005; 128: 2518-2534. https://doi.org/10.1093/brain/awh605. [ Links ]

Domínguez J, Lobato RD, Madero S, Benito-León J, Rivas JJ, Gómez PA. Surgical findings in idiopathic trigeminal neuropathy mimicking a trigeminal neurinoma. Acta Neurochir (Wien) 1999; 141: 269-272. https://doi.org/10.1007/s007010050297. [ Links ]

Vitali C, Bombardieri S, Jonsson R, Moutsopoulos HM, Alexander EL, Carsons SE, et al. Classification criteria for Sjögren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis. 2002; 61: 554-558. https://doi.org/10.1136/ard.61.6.554. [ Links ]

Sevick RJ, Dillon WP, Engstrom J, Bergman WG, Harnsberger HR. Trigeminal neuropathy: Gd-DTPA enhanced MR imaging. J Comput Assist Tomogr. 1991; 15: 605-611. [ Links ]

Source of funding Universidad Espíritu Santo - Ecuador.

Received: April 02, 2022; Accepted: June 02, 2022

Conflicts of Interest

No conflicts of interest to disclose.

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License