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JAMA Clinical Challenge
Clinician's Corner
June 12, 2013

Ptosis, Erythema, and Rapidly Decreasing Vision

Author Affiliations

JAMA Clinical Challenge Section Editor: Huan J. Chang, MD, Contributing Editor. We encourage authors to submit papers for consideration as a JAMA Clinical Challenge. Please contact Dr Chang at tina.chang@jamanetwork.org

Author Affiliations: Departments of Otolaryngology/Head and Neck Surgery (Dr Zanation) and Ophthalmology (Drs Fleischman and Chavala), University of North Carolina School of Medicine, Chapel Hill.

JAMA. 2013;309(22):2382-2383. doi:10.1001/jama.2013.5517

A previously healthy 63-year-old white man presents to the emergency department with a swollen right eye and complete ptosis. Three weeks prior, the patient was evaluated for sinusitis by a local otolaryngologist. Cultures were performed on sinonasal aspirates and empirical ciprofloxacin and oral prednisone were initiated. The patient's symptoms, however, worsened. Cultures revealed Enterobacter aerogenes. On the morning of presentation, a complete ptosis of the right eye had developed (Figure, A). Vital signs were stable, but visual acuity was 20/200 in the right eye and 20/25 in the left. Examination was remarkable for limited ocular motility (Figure, B; Video) and a right relative afferent pupillary defect (Figure, C). Within an hour, vision had deteriorated to light perception. Serum glucose level was measured at 690 mg/dL (38.3 mmol/L) without an anion gap, and hemoglobin A1c level was 8.9%. Maxillofacial computed tomography imaging revealed sinusitis and orbital stranding. The patient was transferred to our institution. On arrival he had lost light perception. An area of ocular adnexal tissue necrosis had developed.