Cicatricial upper eyelid retraction from metastatic breast carcinoma
D. Magnetic resonance imaging of the orbit
While upper eyelid retraction is most commonly seen in thyroid eye disease (choice A), coinciding globe proptosis, rather than enophthalmos, would be anticipated. Additionally, while a finding of slowed upper eyelid depression with downward globe rotation can be seen in thyroid disease (ie, Von Graefe sign), a static eyelid lag is more suggestive of levator muscle tethering or dysgenesis, such as in congenital ptosis or cicatricial disease.1 A facial (cranial nerve VII) palsy commonly presents with upper eyelid retraction from unopposed eyelid elevating forces and incomplete eyelid closure that could be addressed by gold weight implantation (choice B). Suspected idiopathic Bell palsy can be treated with systemic steroid and antiviral therapy when other etiologies are not suspected (choice C). However, ipsilateral orbicularis weakness should be present in cranial nerve VII palsy, and findings of globe enophthalmos and upper eyelid lag are not characteristic.