Pictorial case study: Horner's syndrome

An 80-year-old man was brought in by his daughter after she noticed his left eyelid was dropping.

She was not sure how long it had been going on for. He had also complained that his left hand was getting progressively weaker. On examination the man was frail and had a cough. He had a partial left ptosis with normal eye movements. His left pupil was noticed to be smaller than on the right. What is the diagnosis, management and differential diagnoses?

Diagnosis and management

This man has a left Horner’s syndrome, the features of which are a partial ptosis, meiosis, enophthalmos and, depending on the level of the lesion, adhydrosis.

Acquired Horner’s syndrome occurs when the sympathetic nerve supply to the eye is interrupted. Causes include brainstem disease such as infarction, MS, tumours, syringomyelia, lesions that affect the pre-sympathetic ganglion including trauma, iatrogenic (central venous pressure lines), and Pancoast’s tumour. Causes of post-cervial ganglia lesion include dissection of the internal carotid.

This man was found to have a Pancoast’s tumour which has also affected the nerve supply to the intrinsic muscles of the hand. Initial management is focused on finding and treating the cause.

Possible different diagnoses of ptosis

  • P     Ageing.
  • P     Third nerve palsy.
  • P     Myasthenia gravis.
  • P     Blepharophimosis.

Differential diagnosis

Third nerve palsy

  • Severe ptosis.
  • Pupil enlarged (unless there is a medical cause).
  • Eye facing down and out in complete third nerve palsy.
  • Sudden onset of double vision.
  • If the pupil is affected, refer to a specialist for an MRI scan and central angiography to exclude a central aneurysm.
  • Check fourth and fifth nerve function.
  • Check for diabetes and hypertension.
  • Exclude giant cell arthritis.

Contributed by Dr Raj Thakkar, a GP in Wooburn Green, Buckinghamshire

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