Caroline Bredthauer, BA
Medical Student
New York Medical College
New York, New York, United States
Nathan Michalak, MD
Resident
New York Medical College (Metropolitan)
New York, New York, United States
Petra Aboulhosn, MD
Attending Physician
Montefiore Hospital
Bronx, New York, United States
Eric L. Altschuler, MD, PhD
Associate Chief, Director of Clinical Research
Metropolitan Hospital
New York, New York, United States
A 79-year-old F with PMHx of HTN, HLD, dementia, presented with AMS, left hemiparesis, and aphasia. CTA significant for basilar artery occlusion; TPA administered. EKG showed new-onset AFib—the likely etiology of CVA. MRI 3 days after presentation was significant for infarctions of right medial thalamus and midbrain. She was noted with bilateral ptosis managed with artificial tears and eyelid taping. On admission to acute inpatient rehabilitation (AIR), assessment of degree of ophthalmoplegia was not possible as patient did not participate in exam. Ptosis did not improve after 10 days of AIR. Patient and her family continued taping the eyelids and using eyedrops and reported that this was a very effective solution despite no physiologic improvement. Patient was discharged to SAR with improvements in bed transfers, ambulation, and navigating stairs. At SAR, eyelid taping during the day and lubrication with eyedrops was continued.
Discussions:
Ophthalmoplegia, including ptosis, may result from infarctions involving the thalamus or midbrain, commonly seen after basilar artery occlusion. Ophthalmoplegia is typically seen on the side of the infarction; bilateral ophthalmoplegia is more common in bilateral thalamic/midbrain infarctions. Our patient, with a unilateral thalamic/midbrain infarction but bilateral ptosis, represents an extremely rare presentation of this condition. Prognosis of ptosis following a thalamic/midbrain infarction is usually poor, with surgical correction previously identified as one of few treatment modalities for this issue. Patients may have functional improvement elsewhere, such as our patient whose hemiparesis improved during AIR stay.
Conclusions:
Bilateral ptosis in a patient with unilateral infarction is uncommon presentation of this condition. By taping open the eyelids and using eyedrops, our patient was able to participate well in therapy and be discharged safely to SAR. Further research regarding laterality of infarction, resultant location and degree of ophthalmoplegia, and functional outcomes is warranted.
