This Week's Eye-Openers

Jama Ophthalmology

When a drooping eyelid signals an aneurysm

Acute ptosis with a dilated pupil and headache requires urgent neuroimaging to exclude a compressive third-nerve palsy. A 25-year-old woman with periodontitis presented with two days of left eye pain, blurry vision, photophobia, headache, and new left upper-eyelid drooping. Three weeks earlier, she had undergone a left-sided root canal, tooth extraction, and bone graft, and subsequently experienced persistent headaches and neck stiffness. Oral antibiotics, corticosteroids, and naproxen provided no improvement.

Visual acuity was 20/25 OD and 20/50 OS. Intraocular pressure, color vision, and extraocular movements were normal. However, examination demonstrated left ptosis and anisocoria, with the left pupil larger than the right in both bright and dim conditions. There was no relative afferent pupillary defect.

The combination of unilateral headache, ptosis, and mydriasis raised concern for a pupil-involving oculomotor nerve palsy from an intracranial aneurysm. Urgent MRI and CT angiography identified a 6-mm left posterior communicating artery aneurysm and a 10-mm right internal carotid artery terminus aneurysm. She underwent neurosurgical clipping of both lesions, with complete resolution of ptosis and mydriasis by six weeks.

Posterior communicating artery aneurysms may compress cranial nerve III, causing ptosis, ophthalmoplegia, and pupillary dilation. Even with preserved extraocular motility, acute ptosis and mydriasis should prompt immediate neurovascular imaging.

By: Taha Mujahid

An 80-year-old man with a history of bilateral cataract surgery 15 years ago and mild nonproliferative diabetic retinopathy (NPDR) was referred for evaluation of abnormal pupils. He has not had an ophthalmic examination in approximately 15 years and reports no new visual symptoms. Visual acuity measures 20/25 OU. Pupillary examination is significant for bilateral small, irregular pupils that constrict minimally to bright light. However, both pupils constrict briskly and symmetrically during accommodation to a near target. Extraocular movements are full, with no evidence of ptosis or limitation of upgaze. Dilated fundus examination demonstrates mild NPDR OU without macular edema or other acute posterior segment abnormalities.

Which of the following is the most appropriate next step in the diagnostic evaluation?

A. Obtain serologic testing for syphilis

B. Perform dilute pilocarpine testing

C. Attribute the pupillary findings to prior cataract surgery and recommend routine follow-up

D. Obtain emergent MRI of the brain and orbits

E. Perform apraclonidine testing

By: Cristian Flores

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