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Horner syndrome poses a challenge for the physician. Confusion in the diagnostic process may arise because some patients with Horner syndrome do not exhibit the classic findings of simultaneously occurring miosis and mild ptosis. When that is the case, the diagnosis may be missed and essential life-saving treatment not rendered.
In classic Horner syndrome findings, the physician observes mild ptosis and miosis. The less common secondary symptoms of anhydrosis and inverse ptosis of the ipsilateral lower eyelid may also be present. In Horner syndrome that is congenital or has occurred very early in life, one may see heterochromia of the iris with the lighter colored iris on the side of the Horner syndrome. The physician must not eliminate the possibility of Horner syndrome when only miosis or only mild ptosis is seen. Subsequently, both symptoms may occur at the same time, elucidating the diagnosis of Horner syndrome.
Pollard ZF, Greenberg MF, Bordenca M, Lange J. Atypical Acquired Pediatric Horner Syndrome. Arch Ophthalmol. 2010;128(7):937–940. doi:10.1001/archophthalmol.2010.119
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