## 2 Case Report  
A 45-year-old female patient with a medical history of beta-thalassemia under iron chelation therapy, insulin-dependent diabetes mellitus, and glaucoma presented to the Eye Clinic at the University Hospital of Cagliari. She reported an acute onset of right eye pain and diplopia. On a scale from 1 to 10, the patient rated the pain as 6. During the physical examination, the patient was fully alert and oriented, able to ambulate independently, and demonstrated no global or segmental muscle weakness. Sensory function remained intact. Ocular motility testing revealed deficits in right eye adduction, infraduction, and elevation, accompanied by ptosis. The other cranial nerves were unaffected, and there was no evidence of pupillary light reflex abnormalities. Notably, the patient exhibited protosis in the right eye. Both visual acuity and color sensitivity were preserved, and intraocular pressure remained normal, with the patient continuing her prescribed hypotensive eye drops. Urgent blood tests and a computed tomography (CT) scan were performed, both of which showed no significant abnormalities. Infectious, autoimmune, and neoplastic causes, as well as thyroid disorders and IgG4-related disease, were ruled out. Given the clinical presentation of ocular pain and ophthalmoplegia, which raised the suspicion of Tolosa-Hunt Syndrome, the patient was initially treated with corticosteroid therapy (prednisone 100 mg/day) during hospitalization. However, no significant improvement was observed in either symptoms or neurological findings. Additionally, during corticosteroid therapy, the patient reported significant difficulty in maintaining glycemic control, with more prolonged and insulin-resistant postprandial hyperglycemia than usual. Subsequent Magnetic Resonance Imaging (MRI) was conducted using a 1.5 Tesla machine (Philips S.p.A, Amsterdam, Netherlands). Spectral Pre-Saturation with Inversion Recovery (SPIR) sequences (T2-weighted), Short Tau Inversion Recovery (STIR) long-echo time (TE) sequences, and Turbo Spin Echo (TSE) sequences (T1 and T2-weighted) were acquired in axial, coronal, and sagittal planes, with a section thickness of 1 mm and a field of view ranging from 149 \(\times\) 149 mm to 151 \(\times\) 151 mm. Following the administration of the paramagnetic contrast agent Gadovist (Bayer S.p.A., Leverkusen, Germany), additional T1-weighted images were obtained, targeting the orbit. The TSE sequences (T2-weighted) showed hyperintense signals in the right medial rectus, inferior rectus, and superior oblique muscles (Figures 1-3). Post-contrast T1-weighted images revealed moderate enhancement in the medial rectus muscles, particularly on the left side, along with peripheral enhancement involving the superior oblique muscles bilaterally and the left inferior rectus muscle (Figure 4). Despite these findings, the extraocular muscle thickness remained within normal limits [12]. Additionally, a marked glycemic imbalance was detected, with fructosamine levels exceeding 305 umol/L [13]. A subcutaneous glucose sensor was applied under the guidance of a diabetologist, allowing the patient to monitor her blood glucose levels multiple times a day without the need for frequent finger picks. This led to a substantial improvement in her blood glucose control. In the following months, the patient experienced a gradual resolution of the ocular motility deficits and pain, alongside improved glycemic control. The clinical follow-up at one year confirms that the signs and symptoms had completely resolved and had not reoccurred.  
Figure 1: Image acquired with T2-weighted Turbo Spin Echo (TSE) sequences on the axial plane show a hyperintense signal in the medial rectus of the right eye (orange arrow).  
Figure 2: Image acquired with T2-weighted Turbo Spin Echo (TSE) sequences on the coronal plane show a hyperintense signal in the medial rectus (orange arrow) and inferior rectus (blue arrow) muscles of the right eye.