#JAMAClinicalCase: Acute Ptosis in a Middle-aged Man With Hy
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A 56-year-old man with hypertension presented with 2 weeks of acute ptosis in the left upper eyelid. Three weeks prior, the patient had noted severe left-sided facial pain. He denied any diplopia, decreased vision, or recent trauma. The patient had previously been evaluated by his primary care physician and referred to a neuro-ophthalmologist. During the course of the workup, the patient had undergone computed tomography (CT) of the head and chest, magnetic resonance imaging (MRI) of the brain, and carotid duplex ultrasonography. Following a workup with unremarkable results, the patient presented to the Bascom Palmer emergency department for a second opinion. On initial examination, his best-corrected visual acuity was 20/20OU. Intraocular pressure, ocular motility, and confrontational visual fields were normal. There was no axial proptosis or enophthalmos by exophthalmometry. The pupil was 5 mm OD and 4 mm OS. No afferent pupillary defect was observed. External examination demonstrated a left-sided ptosis. Anterior and posterior examination, including the optic nerve head, had normal results in both eyes. The cranial nerve, gross motor, and gross sensory examination had otherwise unremarkable results. The patient’s blood pressure was 160/79 mm Hg.

Both MRI with magnetic resonance angiography (MRA) and CT angiography is highly sensitive and specific in detecting spontaneous carotid artery dissection. Computed tomography requires radiation and iodinated contrast but is faster and may better identify intraluminal thrombi. With MRA, the sensitivity of MRI for carotid dissection ranged from 50% to 100% across studies, while CT angiography sensitivity ranged from 64% to 100%.9 Generally, both MRI or MRA and CT angiography are acceptable imaging modalities for the evaluation of carotid dissection. While conventional angiography remains the gold standard test, it is associated with serious complications, including hemorrhage and infection. The patient was transferred to a nearby tertiary hospital. He was medically managed with oral anticoagulation and antihypertensive drugs.

Source: https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2768201