New-onset ptosis initially diagnosed as conjunctivitis.

Joe, 66 years of age, was referred with a 2-week history of a right upper eyelid abnormality. He complained of associated diplopia initially, but this subjectively improved after a few days as the eye became more difficult to open. He had a mild, intermittent headache for 4 weeks, relieved with oral paracetamol. There were no other neurological symptoms. He had no other symptoms of giant cell arteritis. His past medical history included hypercholesterolaemia for which he was taking regular statin therapy. He was an ex-smoker with a 40 pack-year history. Initially, Joe’s general practitioner (GP) diagnosed conjunctivitis and prescribed chloramphenicol drops four times daily. One week later the symptoms had not improved and Joe was referred to the eye clinic complaining of increasing right periocular pain. On examination, his visual acuity was 6/5 in each eye. There was near complete ptosis of the right eye. The right pupil was fixed and dilated, and there was no direct or consensual light reflex present. Cover testing revealed right exotropia and hypotropia, while extraocular movements showed limited right adduction and elevation. These findings were consistent with a right, partial, pupil-involving oculomotor nerve palsy.