At times, painful diplopia is present. Usually the patient has a preceding history of cancer. Occasionally, cavernous sinus syndrome is the first manifestation of a systemic neoplasm. Exophthalmos can be seen. If the tumor is a pituitary adenoma, endocrine symptoms and visual loss may be present.
Patients frequently are elderly and present with subacute or chronic ophthalmoplegia.
Rarely, they may have pain similar to that of trigeminal neuralgia. This results in acute onset of massive exophthalmos with orbital, ocular, and conjunctival chemosis, binocular diplopia, and visual loss. Direct fistulas present with prominent acute symptoms. Conversely, indirect fistulas are characterized by mild proptosis, chronic diplopia, drooping of the lid, a red eye, and visual loss. This is infrequent in the postantibiotic era.