(Accepted 30 September 1983)

Basilar aneurysm
An unusual cause of pain in a blind eye
SUSAN LIGHTMAN, ANTHONY TYERS and PETER LEAVER*
Department of Clinical Ophthalniology, Moor-elds Eye Hospital, Cirv Road,
London ECI V ZPD, U K

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Kc.1. word.s: brain aneurysm: painful blind eye

IN TKO DU CTlON
Pain in a blind eye is usually associated with
either raised intraocular pressure or
impending phthisis. Aneurysms of the internal carotid artery and circle of Willis are
a well known cause of pain and neurological
signs in and around the eye (Ross-Russell,
1980). unlike vertebro-basilar aneurysms
which are uncommon (Locksley, 1966;
Drake, 1965: Nijensohn et ul., 1974). The
latter d o not have such classic modes of
presentation, often presenting with nonspecific symptoms before the aneurysm
ruptures (Drake. 1965: Cogan & Mount,
1963). Hence, they are difficult to diagnose
and with an enucleated eye localizing
neurological signs may be absent and the
diagnosis only made when neurological
signs develop elsewhere.
CASE REPORT
A 63-year-old male whose left eye was
blind fi-om ti screwdriver injury 40 years
previously. presented with a six-month history of pain around the left eye. The pain
radiated from the eye to the brow. temple

* Reprint r e y w r t r l o : Dr. Susan Lightman. Moorfieldc
Eye Hospital. C i l j Road. London EC I V ZPD. U K

and vertex and was aching in type. I t occurred several times a week. had no precipitating factors and was partially relieved by
aspirin. He had also noticed occasional
slight drooping of the left eyelid. The
patient was a known hypertensive. on treatment with Methyl Dopa.
On examination. the left eye was
divergent with no perception of light. There
were signs of an old penetrating ocular injury. The intraocular pressure was raised at
75 mmHg and there was no view of intraocular structures posteriorly. An ultrasonic B scan showed a total fixed retinal
detachment with cyst formation.
He was treated initially with oral Diamox
250 mg qds and then with a retrobulbar
injection of 2 ml of 70%alcohol but without
effect. Left enucleation was performed four
months after presentation. A partial left
ptosis was noted at the pre-operative
examination and attributed to the retrobulbar alcohol. Histology of the enucleated
globe revealed no other disease process.
After an apparent improvement lasting
about two weeks. recurrent bouts of pain
returned and persisted. There were no other
symptoms and the ptosis remained unchanged. Ten months later, the pain increased and a complete left ptosis developed
over a period of four weeks. He now also
complained of a feeling of numbness

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S. Lightman et al.

Fig. 1. Vertebral angiogram showing large saccular
aneurysm arising from trunk of basilar artery.

around the left eye and cheek and mild
weakness of the right arm and leg. He had
signs of pyramidal weakness of the limbs
and facial weakness on the right side, but
there were n o sensory signs. His BP was
190/ 110.
CT scans showed a large density mass
enhancing strongly after Conray. Carotid
angiography was normal but vertebral
angiography showed a large saccular aneurysm arising from the trunk of the basilar
artery at the origin of the left superior
cerebellar artery, projecting superiorly and
to the left behind and medial to the posterior cerebral artery (Fig. I ) .
Surgery was considered but refused at
that time by the patient. His blood pressure
was controlled and the pain and
hemiparesis improved. Two months later he
developed a dense right hemiplegia. He was
readmitted and after further discussion surgery was undertaken.
At surgery the aneurysm was found to be
indenting the brain stem medial to the tentorium just inferior to the oculomotor nerve.

which was atrophic, either as a result of injury from the screwdriver 40 years
previously or from compression by the
aneurysm. The aneurysm was 30 mm in
diameter with a 7-8 mm neck arising from
the basilar artery proximal to the bifurcation at the origin of the left superior
cerebellar artery. A Surgita aneurysm clip
was placed across the neck, the aneurysm
was aspirated and fleshy clot removed via
an incision into the fundus.
The patient had a stormy post-operative
course but was eventually discharged with a
residual hemiparesis and facial weakness
which has continued to improve.

COMMENT
Initially this patient seemed to have a
straightforward problem of a painful blind
eye with a markedly raised intraocular
pressure. He had minimal intermittent
ptosis at that time without other signs suggestive of IIIrd nerve involvement, which

Basilar aneurysm

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was considered to be the result of a retrobulbar alcohol injection. He had experienced facial numbness but had no objective
sensory loss. The eye was enucleated as
other measures had failed to control the
pain, ~~~~h~~clues suggesting another disease process were not found
ten
months later when he developed a complete

(L) ptosis and (L) pyramidal and facial
weakness soon after.
ACKNOWLEDGEMENT
The authors would like to thank Professor W.I.
McDonald and Mr. David Thomas for their help in
preparing this paper. S.L. is supported by a grant from
the Wellcome Trust.

REFERENCES
COGAN. D. E. & MOUNT. H . T. J.: lntracranial aneurysms causing ophthalmoplegia. Arch. Ophthol.
70:757-771. 1963
DRAKE. C. G.: Surgical treatment of ruptured aneurysms of the basilar artery. J. Neurowrg. -73:457-473. 1965
LOCKSLEY, H. 6.: Natural history of subarachnoid haemorrhage. lntracranial aneurysms and arteriovenous
malformations.J. Neurosurg. _'5:321-368, 1966
NIJENSOHN: D. E.. RUBEN. J. S. & REAGAN, T. J.: Clinical significance of basilar artery aneurvsmh,.
Neurulogv 301-305. 1974
ROSS-RUSSELL. R. W.: Vascular causes ofocular pain. Trans. ophrhul. Soe. U K 1'00:251-252. 1980

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