1-9 The first originates in the dorsolateral hypothalamus. Sympathetic innervation to the eye consists of a three-neuron arc. 1-3 Old photographs can aide the clinician in distinguishing congenital Horner’s by documenting heterochromia present at birth. 1-5,9 Iris pigmentation (which is under sympathetic control during development) is completed by the age of two, making heterochromia an uncommon finding in Horner’s syndrome acquired later in life. When it’s of congenital origin, it presents around the age of two years with heterochromia and absence of a horizontal eyelid fold or crease in the ptotic eye. Horner’s syndrome has no predilection for age, race, gender or geographic location. 1-9 The classic clinical findings associated with Horner’s are ptosis, pupillary miosis, facial anhidrosis, apparent enophthalmos, increased amplitude of accommodation, heterochromia of the irides (if before age two or congenital), paradoxical contralateral eyelid retraction, transient decrease in intraocular pressure and changes in tear viscosity. Horner’s syndrome is characterized by an interruption of the oculosympathetic nerve supply somewhere between its origin in the hypothalamus and the eye. The diagnosis in this issue is Horner’s syndrome due to acute carotid artery dissection. What would be your diagnosis in this case? What is the patient’s likely prognosis? Tracing Neuro-Ophthalmic Pathways A diluted topical adrenergic drop instillation test was completed to provoke suspected denervation hypersensitivity on the suspected side and observe its effect on the ptotic eyelid. Inspecting old photographs was completed to ensure that the ptotic eyelid position on the suspected side was new. How might this presentation connect with the symptom of facial pain on the right side? Click image to enlarge.Īdditional studies included measuring the pupils in both bright and dim illumination to confirm a pathologic anisocoria. Dilated fundus examination revealed no significant posterior pole or peripheral retina findings: the nerves were distinct with cup-to-disc ratios of 0.3/0.35 OD and OS. Her biomicroscopic examination was normal and Goldmann applanation tonometry was measured at 17mm Hg in both eyes. The pertinent external and pupillary observations are demonstrated in the photographs below. Her extraocular motilities were normal and her confrontation fields were full OU. Her best-corrected entering visual acuities were 20/20 OD and 20/20 OS at distance and near. She was taking only the oral antibiotic prescribed by the doctor and denied allergies of any kind. She had no previous medical or ocular history. She explained she was diagnosed with a sinus infection by her medical doctor and started on an oral antibiotic but was not improving. Gurwood thanks Nick Karbach, OD, for his contributions to this case.Ī 47-year-old female presented to the office emergently with a chief complaint of right-side facial pain of two weeks’ duration.
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