By Michael S. Vaphiades, DO
    Subspecialty Day 2011: Neuro-Ophthalmology

    In this case discussion from Neuro-Ophthalmology Subspecialty Day 2011, a patient is diagnosed with episodic pupillary dilation associated with migraine, and mechanical ptosis in the contralateral eye. In a Horner syndrome, the clinical features on the affected side include 1-2 mm of miosis, with greater anisocoria in dim illumination and a dilation lag; mild upper lid ptosis measuring 1-2 mm; and anhidrosis if the lesion is proximal to the carotid bifurcation. There are serious causes of both anisocoria and ptosis that may not be a Horner syndrome. A systematic approach, including the use of topical cocaine or apraclonidine, is essential when confronted with a patient with ipsilateral ptosis and miosis.