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Diplopia and Ptosis in an Older Woman

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

A 75-year-old woman presented with horizontal binocular diplopia, right-sided ptosis, and a new headache that was progressive over 3 days. She reported difficulty opening her jaw, pain when chewing, and a 2.3-kg weight loss. The week prior, she experienced left-sided ptosis that persisted for 2 days and subsequently resolved. She denied vision changes, eye pain, scalp tenderness, and myalgias. Past medical history included schizophrenia, hypothyroidism, and supraventricular tachycardia.

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A. Giant cell arteritis

Facial and extraocular muscles are typically spared by the myositis associated with aminoacyl transfer RNA synthetase antibodies, and the lack of other features of antisynthetase syndrome (interstitial lung disease, nonerosive arthritis, Raynaud phenomenon) makes this diagnosis less likely. Immunoglobulin G4–related disease can cause enlargement of the extraocular muscles, creating a restrictive pattern of motility but may also be accompanied by hypertrophic pachymeningitis and sclerosing lesions of the abdomen and lungs. Lastly, although the history of transient contralateral ptosis may be reminiscent of myasthenia gravis, the lack of fatiguability, normal ice-pack test results, and soft tissue changes on magnetic resonance imaging suggest an alternate etiology.

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Article Information

Corresponding Author: Jeannette Y. Stallworth, MD, Department of Ophthalmology, University of California, San Francisco, 490 Illinois St, 5th Floor, Room 5X8, San Francisco, CA 94143 (jeannette.stallworth@ucsf.edu).

Published Online: July 25, 2022. doi:10.1001/jamaneurol.2022.1982

Conflict of Interest Disclosures: None reported.

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

References
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Jennette  JC , Falk  RJ , Bacon  PA ,  et al.  2012 Revised international Chapel Hill consensus conference nomenclature of vasculitides.   Arthritis Rheum. 2013;65(1):1-11. doi:10.1002/art.37715PubMedGoogle ScholarCrossref
2.
De Smit  E , O’Sullivan  E , Mackey  DA , Hewitt  AW .  Giant cell arteritis: ophthalmic manifestations of a systemic disease.   Graefes Arch Clin Exp Ophthalmol. 2016;254(12):2291-2306. doi:10.1007/s00417-016-3434-7PubMedGoogle ScholarCrossref
3.
González-Gay  MA , García-Porrúa  C , Llorca  J ,  et al.  Visual manifestations of giant cell arteritis—trends and clinical spectrum in 161 patients.   Medicine (Baltimore). 2000;79(5):283-292. doi:10.1097/00005792-200009000-00001PubMedGoogle ScholarCrossref
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Dimant  J , Grob  D , Brunner  NG .  Ophthalmoplegia, ptosis, and miosis in temporal arteritis.   Neurology. 1980;30(10):1054-1058. doi:10.1212/WNL.30.10.1054PubMedGoogle ScholarCrossref
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Barricks  ME , Traviesa  DB , Glaser  JS , Levy  IS .  Ophthalmoplegia in cranial arteritis.   Brain. 1977;100(2):209-221. doi:10.1093/brain/100.2.209PubMedGoogle ScholarCrossref
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Bromfield  EB , Slakter  JS .  Horner syndrome in temporal arteritis.   Arch Neurol. 1988;45(6):604. doi:10.1001/archneur.1988.00520300018011PubMedGoogle ScholarCrossref
7.
Arunagiri  G , Santhi  S , Harrington  T .  Horner syndrome and ipsilateral abduction deficit attributed to giant cell arteritis.   J Neuroophthalmol. 2006;26(3):231-232. doi:10.1097/01.wno.0000235562.42894.33PubMedGoogle ScholarCrossref
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.

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