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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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