Help I'm seeing double vision and have ptosis

[Ryan_eyeball]

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S: A 62 year old gentleman presented a month ago, with a chief complaint of double vision and ptosis of the left eye only. He said that at the beginning of the day he would see fine (no diplopia), but towards mid day and afternoon the symptoms would manifest themselves (and this cycle would happen every day). The patient stated that this has occured for the past week, and never experienced this before. He denies pain, itch, redness, trauma, or previous surgeries. His medical history includes: arthritis, and hypertension for the past ten years. His ocular history includes cataracts OU and has had PCIOL's implanted. The patient figured this would go away but hasn't. NKDA, or NKMA's. Medications: Atenolol, and Viagra (and one happy wife, I didn't ask).

Entering Rx plano +2.50 Add OU 20/20

O: Pupils: PERRLA (-) APD
EOM's: FROM OU
CT: Left Hypotropia in all gazes.
CF: FULL to FC OU

K's : 43.00x180 and 43.50 x 90 OU
SLex: Ptosis of the left eyelid, trace injection OU.
PCIOL's, Open Posterior Capsule OU
DFE: ONH's: 0.3 flat OU, Macula's mild Rpe changes
Periphery No holes, Tears, Detachments OU

What's your differential diagnosis? What tests would you do now? How would you proceed from this point forward? Remember no cheating, or looking this up. Patients don't have to A,B,C, or D marked on their forwards, they want to know what's wrong. I'll reveal more information if people suggest additional tests.

I'll give ya a hint "chill out"

 

[Ben Chudner]

I won't give away the answer as I assume this is for the students, but I think this is a great idea. A lot of other forums post grand rounds type cases for people to test their knowledge. May I suggest changing the title to "Grand Rounds", or "Case Presentation" and let the students have at it. Great hint by the way.

 

[Tokey]

My first impression is possible ocular myasthenia gravis...

 

[cpw]

that is a good hint 🙂

 

[Ryan_eyeball]

I don't mind making up cases to present on here. Especially CL or BV ideas to bounce off other people would be benefical to me and I hope others.

 

[Ben Chudner]

I don't mind making up cases to present on here. Especially CL or BV ideas to bounce off other people would be benefical to me and I hope others.

If you need help, I am sure a lot of us have cases that we can share. I have a ton of slides we used to quiz our students when I was a resident.