Ptosis and Diplopia in a 74-Year-Old With History of Stroke

Rod Foroozan, MD


December 02, 2015

Clinical Presentation

A 74-year-old woman was evaluated for ptosis and diplopia. She had noted the sudden onset of ptosis 2 months earlier, initially in the right upper eyelid and then a few days later in the left upper eyelid. One month before she was examined, she noted intermittent binocular diplopia. No other systemic symptoms, such as headache, jaw claudication, and weakness or numbness in the extremities, were present at evaluation.

Five years before, the patient was hospitalized for diplopia and told she had a stroke. At that time, the diplopia slowly resolved over several weeks without treatment. She also had cataract surgery in each eye 4 years before examination.

The patient does not drink alcohol or smoke tobacco. There is no family history of vision loss in her mother or father. She is taking lisinopril for hypertension.

Visual acuity was 20/20 in each eye. Color vision with Ishihara pseudoisochromatic plates was 10/10 in each eye. Pupils were brisk in each eye, with no anisocoria and no relative afferent pupillary defect. Intraocular pressure was 16 mm Hg in each eye. Slit-lamp examination of the anterior segment showed posterior chamber intraocular lenses in each eye. Funduscopic examination was normal in each eye.

She had 2-3 mm of ptosis with each upper eyelid. There was no change after 1 minute of upgaze and good orbicularis oculi strength on each side. The ptosis remained unchanged after 2 minutes of ice packs placed over closed eyelids on each side. There was no eyelid twitch.

She had full ductions in each eye. There was a 4-prism diopter esodeviation noted in primary position and left gaze (where she became symptomatic with diplopia), and she was orthoptic in other positions of gaze.


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