Unilateral ptosis secondary to mantle cell lymphoma of the left lacrimal gland
D. Obtain orbital imaging with intravenous contrast
The etiologies for unilateral ptosis in adults include involutional, traumatic, myogenic (eg, muscular dystrophy), neurogenic (eg, myasthenia gravis), and mechanical (eg, eyelid or orbital mass). While the most common cause of ptosis in adults is involutional ptosis related to levator dehiscence, other diagnoses should be considered in patients with abnormal clinical findings in addition to ptosis. In such patients, an appropriate workup should be completed prior to surgical repair, making choice A incorrect.
Although ptosis that is more notable at night and with fatigue is classically seen with myasthenia gravis, patients with ptosis of other etiologies may report similar symptoms owing to reduced compensatory frontalis action by the end of the day. This patient did not have any neurologic signs or fatiguability on examination, and antiacetylcholine receptor serology findings were negative, making myasthenia gravis less likely and choice B incorrect. Similarly, the patient had normal levator function and extraocular motility, making myogenic ptosis less likely and choice C also incorrect. However, unilateral findings of superior sulcus fullness and increased resistance to retropulsion were concerning for an orbital process, making choice D the most appropriate next step. In this case, orbital imaging revealed a well-demarcated tumor involving the left lacrimal gland, with mass effect on the superior rectus-levator complex (Figure 2). Subsequent biopsy and workup demonstrated mantle cell lymphoma without systemic involvement.