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JAMA Ophthalmology Clinical Challenge
March 21, 2019

An Elderly Woman With Progressive Diplopia

Author Affiliations
  • 1Department of Ophthalmology and Visual Sciences, University of Illinois, Chicago
JAMA Ophthalmol. 2019;137(6):714-715. doi:10.1001/jamaophthalmol.2019.0251

A 75-year-old woman was referred to the ophthalmology clinic for evaluation of double vision and a droopy left upper eyelid. Over the previous 5 months, the patient had experienced gradual onset of binocular, horizontal diplopia and ptosis of the left upper eyelid. There were no neurological deficits and no pain. Her symptoms were constant, without fluctuation during the day. There was no history of trauma or prior surgery of the eye. Her medical history was notable for hypertension and type 2 diabetes. Family history was positive for hypertension in her mother, prostate cancer in her father, and ductal carcinoma in situ in her daughter. She was a current daily smoker at presentation. An ophthalmologic examination revealed a visual acuity of 20/25 OD and 20/30 OS. Pupillary, intraocular pressure, and dilated fundus examinations were unremarkable. Abduction was severely restricted in the left eye, but it did not elicit pain, and extraocular muscle movements were otherwise full. There was substantial resistance to retropulsion of the left eye. Bilateral blepharoptosis, with more severity on the left side, was noted. The margin-to-reflex distance 1 was 2 mm on the right and 0 mm on the left. A 3.5-mm left enophthalmos was noted compared with the right side, and there was hollowing of the left superior sulcus. Testing of cranial nerves V and VII were unremarkable.

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