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JAMA Ophthalmology Clinical Challenge
August 2016

Ptosis, Miosis, and Intermittent Esotropia Following Pituitary Adenoma Resection

Author Affiliations
  • 1USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles
JAMA Ophthalmol. 2016;134(8):941-942. doi:10.1001/jamaophthalmol.2016.0787

An Asian woman in her 50s with diabetes, hypertension, and hyperlipidemia presented with ptosis and intermittent esotropia of the right eye. Fourteen years earlier, the patient underwent a pituitary adenoma resection and external beam radiation. Immediately after the resection, she developed slight ptosis and an adduction deficit of the right eye, presumed to be secondary to partial oculomotor nerve III (CNIII) damage. Four years earlier, she developed intermittent esotropia of the right eye, presumed secondary to cranial nerve VI palsy. At the present clinic visit, the patient reported the persistence of intermittent diplopia, which had remained unchanged for years, and denied other ocular or systemic complaints. Visual acuity measured 20/20 OU. We noted 3 mm of relative right upper eyelid ptosis and anisocoria (3 mm OD and 4.5 mm OS in ambient lighting). Pupils were round and reactive with no afferent pupillary defect. The degree of anisocoria was the same in ambient and dim lighting. Extraocular movements were initially intact; however, a few minutes later, the patient developed an intermittent esotropia of the right eye, with episodes of sustained adduction lasting up to 30 seconds followed by normalization of ductions and alignment (Video; Figure, A). These episodes occurred more commonly following voluntary adduction. On infraduction, the right upper eyelid simultaneously retracted, exposing 3 mm of superior sclera (Figure, B). On adduction, the right pupil constricted slightly. The remainder of the examination was within normal limits. A magnetic resonance imaging (MRI) from 1 year prior showed a small amount of residual tumor within the right cavernous sinus, stable over years (Figure, C).