An 81-year-old male presented with a six-week history of painless, right-sided ptosis. He denied any diplopia or any other neurological symptoms. His ptosis was variable during the day and was better and worse on different days. Past medical history was significant for hypertension, and he had past ocular history of an epiretinal membrane with decreased visual acuity in the right eye (OD). The remainder of the surgical, social, and family history was unremarkable. On examination, the best-corrected vision was 20/50 in both eyes (OU). Pupils were isocoric in the light and dark and measured 3 mm and 2 mm, respectively. There was no relative afferent pupillary defect (RAPD). Extraocular movements demonstrated an intermittent exotropia of 3 prism-diopters in primary gaze. External exam demonstrated right lid ptosis with dermatochalasis OU (see Fig. 18.1). Marginal reflex distance 1 (MRD1) was zero OD and 4 mm in the left eye (OS) and MRD2 was 5 mm OU, with palpebral fissures of 6 mm OD and 9 mm OS, and lid crease measurements of 8 mm OU. Levator palpebrae superioris function measured 6 mm OD and 11 mm OS. On sustained upgaze there was fatigability and worsening of lid ptosis OD (Fig. 18.2) and bilateral orbicularis weakness. Enhancement of ptosis was noted with elevation of the left eyelid, as well as the Cogan’s lid twitch sign. Automated visual field (Humphrey 24-2) was normal OU. Intraocular pressure measurements, slit lamp biomicroscopy and dilated funduscopic examinations were normal except for a moderate nuclear sclerosis OD consistent with 20/50 vision OD, a posterior chamber intraocular lens (PCIOL) OS, and an epiretinal membrane OD. Combined ice test and rest test results are shown in Fig 18.3.

Original languageEnglish (US)
Title of host publicationQuestions and Answers in Neuro-Ophthalmology: A Case-Based Approach
PublisherWorld Scientific Publishing Co.
Number of pages12
ISBN (Electronic)9789814578783
ISBN (Print)9789814578769
StatePublished - Jan 1 2014

ASJC Scopus subject areas

  • Medicine(all)
  • Neuroscience(all)


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