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Acute Ptosis in a Middle-aged Man With Hypertension

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 56-year-old man with hypertension presented with 2 weeks of acute ptosis in the left upper eyelid. Three weeks prior, the patient had noted severe left-sided facial pain. He denied any diplopia, decreased vision, or recent trauma. The patient had previously been evaluated by his primary care physician and referred to a neuroophthalmologist. During the course of the workup, the patient had undergone computed tomography (CT) of the head and chest, magnetic resonance imaging (MRI) of the brain, and carotid duplex ultrasonography. Following a workup with unremarkable results, the patient presented to the Bascom Palmer emergency department for a second opinion.

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Horner syndrome

C. Magnetic resonance angiography of the brain and neck

There is a broad differential diagnosis for symptoms of headache, anisocoria, and ptosis. An edrophonium test (choice A) aids in diagnosing myasthenia gravis, while sumatriptan injections (choice D) can treat cluster headache. Although myasthenia gravis and cluster headache may present with acute ptosis, a patient with this constellation of symptoms must first be evaluated for life-threatening causative mechanisms. Myasthenia gravis typically does not present with a headache and anisocoria, while new migraines1 or cluster headaches2 in a 56-year-old patient are atypical. Lastly, a diagnosis of blepharoptosis and referral for surgical repair (choice B) should be made only after more lethal diagnoses have been excluded.

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Article Information

Corresponding Author: Hasenin Al-khersan, MD, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL 33136 (haseninrh@gmail.com).

Published Online: July 16, 2020. doi:10.1001/jamaophthalmol.2020.1320

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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