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External Eye Disease

Middle-aged Woman With Atypical Upper Eyelid Retraction

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

1 Credit CME

JAMA Ophthalmology

Published Online: June 16, 2022

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Natalie A. Homer, MD¹;

Morgan Darrow, MD²

Author Affiliations

¹Division of Ophthalmic Plastic and Orbital Surgery, Department of Ophthalmology, University of California, Davis, Sacramento
²Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento

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A 42-year-old woman with history of a functional pituitary adenoma, breast cancer in remission for which she was undergoing tamoxifen therapy, and prior bilateral laser in situ keratomileusis surgery was referred for evaluation of right lagophthalmos. She reported 2 months of increasing right-sided blurry vision and a sensation of eye dryness. She was found to have incomplete eyelid closure by her primary care physician, who initiated artificial tear lubrication and bedtime eyelid taping with partial symptom improvement.

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A 42-year-old woman with history of a functional pituitary adenoma, breast cancer in remission for which she was undergoing tamoxifen therapy, and prior bilateral laser in situ keratomileusis surgery was referred for evaluation of right lagophthalmos. She reported 2 months of increasing right-sided blurry vision and a sensation of eye dryness. She was found to have incomplete eyelid closure by her primary care physician, who initiated artificial tear lubrication and bedtime eyelid taping with partial symptom improvement.

Clinical examination revealed 20/25 visual acuity OD with full extraocular motility and normal intraocular pressure. She was noted to have right upper eyelid retraction (Figure 1A) with substantial static upper eyelid lag on downgaze (Figure 1B). She had 1-mm right lagophthalmos with incomplete blink. Frontalis and orbicularis oculi strength were intact. She was measured to have a 2-mm relative right enophthalmos and no resistance to retropulsion. A review of patient photographs from 2 years prior showed symmetric bilateral eyelid appearance without retraction.

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Article Information

Corresponding Author: Natalie A. Homer, MD, UC Davis Health Eye Center, Division of Ophthalmic Plastic and Orbital Surgery, Department of Ophthalmology, University of California, Davis, 4860 Y St, Ste 2400, Sacramento, CA 95817 (natalie.a.homer@gmail.com).

Published Online: June 16, 2022. doi:10.1001/jamaophthalmol.2022.1532

Conflict of Interest Disclosures: Dr Homer reported personal fees as a consultant from Pulse Biosciences outside the submitted work. No other disclosures were reported.

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

References

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Uddin JM , Rose GE . Downgaze “hang-up” of the upper eyelid in patients with adult-onset ptosis. Ophthalmology. 2003;110(7):1433-1436. doi:10.1016/S0161-6420(03)00457-3 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.