![]() The referring provider noted that the patient complained of pain in his right shoulder and adjacent to the right side of his neck. Right eyelid ptosis and ipsilateral pupil miosis were documented at this visit. The referring provider had seen him 5 months prior to the neuro-ophthalmology consult. He had an appropriate mood and was oriented to time, space, person and place. He was also a social drinker and denied any illicit drug usage. The patient smoked 10 cigarettes a day and had been doing so for at least 20 years. He had no significant family medical or ocular history. His medications included aspirin, atorvastatin and hydrochlorothiazide. The patient’s medical history was positive for hypertension and high cholesterol. ![]() He was not using any ocular medications and reported no drug allergies. In addition, the patient had undergone laser retinopexy to repair a retinal tear in the right eye, and glaucoma was suspected in both eyes. He also stated that a few months following that injury the eyelid droop may have started after bird waste got into his eye. He did not seek any care at that time and did not notice any changes in vision, eyelid appearance or pupil size following that injury. He reported a history of multiple mildly traumatic ocular events that included being poked in the right eye 2 years prior. He reported that these signs had been stable for more than a year. Depending on the etiology, a prompt diagnosis and appropriate treatment may significantly benefit the patient and could be be life-saving.Ī 60-year-old Black male was referred to the neuro-ophthalmology clinic for further evaluation of right eyelid ptosis and ipsilateral pupil miosis. Anisocoria and ptosis are two findings with varying etiologies that all optometrists encounter. Also provided are an overview of differential diagnoses and additional testing or imaging that may be appropriate in cases of ptosis and abnormal pupils. It demonstrates the importance of investigating all differential diagnoses, and it provides a guide for teaching third- and fourth-year optometry students and residents to manage cases of ptosis and abnormal pupillary findings. The following case report discusses the appropriate testing and diagnosis of a patient with ipsilateral ptosis and miosis.
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