Diagnosing Horner Syndrome can be difficult in the setting of an incomplete triad. A 27-year-old man presented with unilateral eyelid droop and intermittent ipsilateral headaches, having already seen 7 physicians. Physical examination revealed unilateral ptosis but no pupillary miosis or facial anhidrosis. Inspection of his clinical photographs revealed elevation of the ipsilateral lower eyelid, suggesting sympathetic dysfunction. On further questioning, he admitted to naphazoline dependence. Reexamination after ceasing the naphazoline unveiled the anisocoria. Vascular imaging subsequently revealed carotid dissection, and the patient was started on anticoagulant and antiplatelet therapy. The ptosis persisted after conjunctival Müllerectomy. External levator resection was recommended, but patient declined. This case underscores the importance of clinical photography, meticulous medical record review, and complete medication history including over-the-counter preparations. Clinicians should meticulously inspect the lower eyelid in cases of atypical blepharoptosis and consider the effects of eye drops when inspecting pupils for miosis.
A 57-year-old man with a past medical history of coronary artery disease, chronic sinusitis, allergic rhinitis, and history of sinus surgery on intranasal steroids presented to an outside emergency room with worsening sinusitis symptoms of 4-5 days’ duration. On arrival, labs revealed a leukocytosis, and computed tomography (CT) of the maxillofacial region revealed significant sphenoid sinus disease, with mild mucosal thickening in the right ethmoid and frontal sinuses. He was admitted for treatment with antibiotics. The following day, the patient felt his swelling and pain had improved but noted acutely decreased vision in his right eye. CT angiography of the head on this day revealed right periorbital edema and cellulitis, with occlusion versus thrombus of the right superior ophthalmic vein and engorgement of the medial and inferior rectus muscles. There was also opacification of the right sphenoid and maxillary sinus (Figure 1). He was started on heparin by Neurology. Two days after admission, he experienced increasing right periorbital swelling, redness, and ptosis. He was transferred to University of Florida, Gainesville, for ophthalmological examination.
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