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Eye - Horner Syndrome

 

Thank you for asking me to examine Harry who presented with ___

 

The salient findings on examination were partial ptosis, miosis, anhidrosis (only if proximal to carotid bifurcation), and apparent enophthalmos (inset eye), which is consistent with Horner’s syndrome. The presence of ___ suggests the lesion is at the ___

 

In further detail...

 

There was partial ptosis (complete does not occur as III nerve controls levator palpebrae superioris, which controls upper eyelid), miosis and apparent enophthalmos on the right/left. There was not heterochromia of irides (only with congenital Horner’s).

 

There was/was not ipsilateral anhidrosis over the face and upper arms and trunk, which may suggest a central/pre-ganglionic/post-ganglionic lesion / I could not appreciate clear anhidrosis and was not able to localise the lesion based on this. 

  • Central lesion = face, arm and upper trunk

  • Peripheral pre-ganglionic = face only

  • Post-ganglionic distal to carotid bifurcation = sweating unaffected

 

Visual acuity was ___.

 

Visual fields were normal/other

 

Colour saturation was normal.

 

There were intact direct and consensual pupillary light and accommodation reflexes bilaterally

 

Eye movements were normal. The ptosis could be overcome by voluntary upward gaze.

 

On further examination to assess the underlying aetiology

  • In terms of central lesions, there were/were not features of lateral medullary syndrome (secondary to vertebral artery occlusion)

    • Nystagmus to side of the lesion

    • Ipsilateral fifth nerve (pain and temperature), ninth and tenth nerve lesions

    • Ipsilateral cerebellar signs

    • Contralateral pain and temperature loss over the trunk and limbs

  • In terms of pre-ganglionic lesions, there was/was not clubbing or finger abduction weakness or wasting to suggest a lower trunk brachial plexus (C8, T1) lesion

    • If so, proceed to examination for apical lung cancer

  • In terms of post-ganglionic lesions, there was/was not any neck masses, or lymphadenopathy.

    • There were/were not scars to indicate previous neck surgery

 

In summary, my findings suggest Horner’s syndrome. The pattern of anhidrosis suggests a central/pre-ganglionic/post-ganglionic lesion. The presence of ___ suggests ___.

 

I would proceed from here by:

  • MRI to assess for underlying aetiology

 

Differentials for ptosis are:

  • With constriction

    • Tabes dorsalis (late complication of neurosyphilis)

  • 3rd nerve palsy - but dilated

  • With normal pupils

    • Senile ptosis

    • MG

    • Dystrophies - myotonic, facioscapulohumeral

  • Bilateral:

    • MG

    • Myotonic dystrophy

    • Syringomyelia

    • Congenital

 

Differential for the underlying lesion include:

  • Central lesions

    • Hypothalamus - stroke, tumour

    • Brainstem lesions (lateral medulla), including vascular (lateral medullary) or tumours

    • Spinal cord lesions - including syringomyelia

  • Pre-ganglionic

    • Apical lung tumour

    • Mediastinal tumours

    • Cervical rib

    • Iatrogenic

    • Thyroid malignancy

  • Post-ganglionic

    • Trauma

    • Surgical neck dissection

    • Internal carotid artery dissection or aneurysm

    • Skull base - tumour (NP carcinoma, lymphoma)

    • Cavernous sinus lesion

 

What is the pathophysiology?

The sympathetic trunk is affected. This leads to the miosis, and partial ptosis through weakness of the superior tarsal muscle (complete does not occur as III nerve controls levator palpebrae superioris, which controls upper eyelid). Enophthalmos is an illusion caused by ptosis.

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