PUBLICATION EXCLUSIVE: Man presents with diplopia and ptosis of left eye

A 36-year-old Hispanic man with no significant medical or ocular history was referred to the Tufts New England Eye Center with complaints of double vision and drooping of his left upper eyelid. Three months before presentation, he presented to an outside emergency department with complaints of sudden onset dizziness and double vision. He did not recall any other symptoms at that time. Workup was pursued at the outside hospital; Lyme titer, TSH, acetylcholine receptor antibodies, CT and MRI of the brain, and lumbar puncture were all normal or negative. His symptoms subsequently resolved within a few days, and no further investigation was pursued.

Three months later, he again developed vertical binocular double vision and drooping of his left upper eyelid. He noted his symptoms fluctuated and worsened as the day progressed. He presented to a local optometrist who then referred him to the Tufts New England Eye Center.

Examination

Upon examination at Tufts, the patient’s best corrected visual acuity was 20/20 bilaterally. Pupils were equally round and reactive with no relative afferent pupillary defect in either eye. IOP was within normal limits. Cranial nerves V, VII, VIII, X, XI and XII were intact bilaterally. Partial ptosis of the left upper eyelid was noted (Figure 1), and when the eyelid was lifted manually, ptosis of the right upper eyelid became apparent (Figure 2), demonstrating Hering’s law. Extraocular muscle motility exam revealed abduction and adduction deficits in the right eye (Figures 3 and 4) as well as an elevation deficit of the left eye (Figure 5). Saccadic intrusions were noted in the left eye. Exam was negative for lagophthalmos or lid lag. Slit lamp and dilated funduscopic examinations were otherwise normal bilaterally.

Click here to read the full publication exclusive, Grand Rounds at the New England Eye Center, published in Ocular Surgery News U.S. Edition, February 10, 2017.