Question of the Week # 240

240) A 55 year old woman is evaluated in the emergency room for acute development of double vision and droopy right eyelid. She also reports pain in her right eye. She denies any fever.  She has no significant past medical history. On physical examination, she is afebrile and her blood pressure 132/88 mm Hg. Head and neck examination reveals ptosis of the right eyelid. Pupillary light reflex is lost. She can not adduct her right eye past the midline. The right eye is deviated downwards and laterally as shown in the picture below. There is no sensory loss on her face and the function of her other facial muscles are intact. Power is normal in all her extremities and deep tendon reflexes are intact.

The  most appropriate next step in management?

A)     Temporal artery biopsy

B)     Obtain Erythrocyte Sedimentation Rate

C)     Observation

D)     Magenetic Resonance Angiography (MRA)

E)     Ptosis Surgery

8 Responses

  1. B

  2. d

  3. Internuclear ophtalmoplegia likely in patient with Multiple Sclerosis
    Needs to have an MRI but why MRA???

    could be ESR??

    Anybody know…

    • ms is bilateral

  4. pca aneurysm affecting 3rd nerve and pupils
    hence diagnostic test is MRA

    MS cause no drooping eyelid
    temporal arteritis does not cause drooping eyelid

  5. D

  6. This question is genius .

    ansr : MRA

    isolated painful oculomotor nerve palsy + ptosis should alert us for Posterior cerebral artery aneurysm .

    No history of headache or jaw claudication rule our temporal arteritis .

  7. D)

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