A 65-Year-Old Man With Diplopia and a Drooping Eyelid

Sumaira Nabi, MBBS; Sadaf Khattak, MBBS; Mazhar Badshah, MBBS, MD, FCPS


August 21, 2019

Physical Examination and Workup

Upon clinical examination, the patient is an alert, older male oriented in time, place, and person. His vital signs include an oral temperature of 98.6°F (37°C), a regular pulse rate of 70 beats/minute, and a blood pressure of 140/70 mm Hg. His respiratory rate is 14 breaths/min, and his Glasgow Coma Scale is 15/15.

Upon ocular examination, the patient has a right-sided, partial ptosis with restriction of horizontal and vertical eye movements. He has no lid swelling, proptosis, or chemosis. The pupillary size and reaction are normal, and visual acuity is intact in both eyes. Upon funduscopic examination, changes are consistent with a grade-1 hypertensive retinopathy. However, the disc margins are clear.

Facial sensory loss in the distribution of the first division of right cranial nerve V (CN V1) is also detected. The remaining cranial nerves are intact and symmetrical. No signs suggest meningeal irritation, pyramidal weakness, or cerebellar dysfunction. The patient’s abdomen is soft and nontender, and no clinical evidence suggests organomegaly or ascites. Bowel sounds are audible. The patient's precordial examination reveals normal heart sounds, and auscultation of the lung fields shows normal vesicular breathing.

The laboratory analysis demonstrates a normal complete blood count (CBC) and erythrocyte sedimentation rate (ESR). The patient’s liver function test results, renal function test results, serum glucose levels, ECG, and chest radiograph findings are unremarkable. Results for antinuclear antibodies (ANAs), extractable nuclear antigen (ENA) profile, HIV serology, hepatitis B surface antigen (HBsAg), and hepatitis C antibody (anti-HCV) are negative. Serum angiotensin-converting enzyme (ACE) levels are normal, as are the thyroid function tests and routine cerebrospinal fluid (CSF) examination.

MRI of the brain and orbit shows a normal cavernous sinus, as well as normal brain parenchyma and orbital contents. No orbital or intracranial mass lesion is seen (Figures 1-3). Repetitive nerve stimulation is normal, and anti-acetylcholinesterase antibodies are negative.

Figure 1.

Figure 2.

Figure 3.


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