Ptosis With Fluctuating Diplopia

Abstract

A patient in their 60s with a medical history of hypertension was referred for new-onset fluctuating diplopia and worsening right upper eyelid ptosis. The patient underwent rightsided ptosis repair at another hospital less than 1 year earlier without improvement. Bestcorrected visual acuity was 20/30 OU, and pupil examination revealed no anisocoria or afferent pupillary defect. Color vision was full in both eyes. External examination revealed a margin reflex distance 1 (MRD1) of 0 mm OD, 4 mm OS without fatigability in extended upgaze (Figure 1A). The patient had a small exotropia in primary gaze with a −2 supraduction deficit. No proptosis was observed. An ice pack was applied in the clinic to the ptotic eyelid for 2 minutes, which led to a 1.5-mm improvement (Figure 1B) in ptosis and no appreciable change in strabismus. The patient reported no associated headache, weakness, or difficulty swallowing.