Unilateral Ptosis

5-year-old boy presented with left sided retro-orbital

and frontal headache that started 2 days prior to presentation. He could not open his left lid and complained of diplopia a day later. On examination, he had
complete ptosis and restriction of all eye movements in the
left eye except for lateral gaze (Figure, A and Video; Video
available at www.jpeds.com). His pupils were equal in size
and reactive to light bilaterally and the rest of his
neurologic examination was normal.
Unilateral ptosis can be the result of weakness of the
M
uller muscle, which is innervated by the sympathetic
nervous system (Horner syndrome) or the levator palpebrae superioris muscle, which is supplied by cranial nerve
III (ie, the oculomotor nerve).1 In Horner syndrome, ptosis is not accompanied by diplopia. Disorders of the oculomotor nerve can occur anywhere from its origin in the
brainstem to its peripheral innervations of the muscles
within the orbit. Compressive lesions, such as posterior
communicating artery aneurysms, classically involve the
superficially located pupillary fibers and, therefore, cause
a dilated pupil. However, when the pupil is spared, etiological considerations range from trauma to tumors, vasculopathy, demyelination, and infectious processes
involving the oculomotor nerve. Neuromuscular causes

such as in myasthenia gravis can, on occasion, cause unilateral ptosis as can botulinum toxin injections for
cosmetic purposes.2
Magnetic resonance imaging of the brain demonstrated
thickening and enhancement of the left third cranial nerve,
which was highly suggestive of an infectious or inflammatory
disorder (Figure, B). Because serologic and cerebrospinal
fluid assays were normal, a presumptive diagnosis of
ophthalmoplegic migraine was entertained. Symptoms
resolved after steroid treatment. The pathophysiology of
ophthalmoplegic migraine is not well understood. However
some evidence suggests that it may be a demyelinating
process.3 n

Riddhiben Patel, MD
Meghan Harper-Shankie, MD
Ekta Patel, MD
Lalitha Sivaswamy, MD
Childrens Hospital of Michigan
Wayne State University School of Medicine
Detroit, Michigan

References available at www.jpeds.com

Figure. A, Child with unilateral ptosis. B, Magnetic resonance imaging of the brain, in coronal section, following administration
of gadolinium. Arrow indicates thickening and enhancement of the left third cranial nerve as it courses between the posterior
cerebral and superior cerebellar arteries.

J Pediatr 2015;167:1160.
0022-3476/$ - see front matter. Copyright 2015 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jpeds.2015.07.022

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References
1. Brazis PW, Biller JM. Localization in Clinical Neurology. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2011.

2. Akkaya S, Kokcen HK, Atakan T. Unilateral transient mydriasis and ptosis

after botulinum toxin injection for a cosmetic procedure. Clin Ophthalmol 2015;9:313-5.
3. Lance JW, Zagami AS. Ophthalmoplegic migraine: a recurrent demyelinating neuropathy? Cephalalgia 2001;21:84-9.

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