Intended for healthcare professionals

Endgames Picture Quiz

Sudden onset of pain in the eye and blurring of vision

BMJ 2009; 338 doi: (Published 22 January 2009) Cite this as: BMJ 2009;338:a3111
  1. Neha R Chopra, foundation year 2, medicine,
  2. Daniel A Jones, specialist trainee 3, cardiology,
  3. Narasinha Gadi, trust senior house officer, medicine,
  4. Farhad Huwez, consultant physician
  1. 1Basildon Hospital, Basildon and Thurrock NHS Trust, Nethermayne, Basildon Essex SS16 5NL
  1. Correspondence to: D A Jones danieljones{at}

    A 64 year old man was admitted with sudden onset of pain in his right eye, blurred vision, and double vision on looking to the right. His medical history included hypertension, myocardial infarction, and a stroke from which there was no residual deficit.

    Neurological examination identified intention tremor in both arms, horizontal nystagmus, and diplopia on looking to the right. He had no motor weakness, but the left plantar was extended. Examination of his face provided clues to the diagnosis (figure).


    • 1 What does the figure show and what is the likely diagnosis?

    • 2 What is the differential diagnosis?

    • 3 How would you localise the lesion in this patient?


    Short answers:

    • 1 The figure shows a unilateral partial ptosis, miosis, and apparent enophthalmos of the patient’s right eye, consistent with Horner’s syndrome. The sudden onset of the symptoms, the vascular risk factors, and the findings of the examination make Wallenberg (lateral medullary) syndrome the most likely diagnosis.

    • 2 Horner’s syndrome is caused by interruption of the sympathetic nervous system and it can originate anywhere along the pathway. Lesions can be central: (brainstem stroke, demyelination, syringomyelia, or spinal cord tumour), preganglionic (Pancoast’s tumour, cervical rib, mediastinal mass, thyroid mass, or surgery), or postganglionic (carotid artery aneurysm or carotid dissection).

    • 3 A thorough history (checking for weight loss, neck pain, and vascular risk factors) and examination (for example, checking the neck for masses and scars, examining the supraclavicular area for evidence of consolidation, and performing a thorough neurological examination for associated signs) may help localise the lesion. Investigations depend on the likely underlying cause but include magnetic resonance imaging (MRI) of the brain or spine and computed tomography of the chest.

    Long answer 1: Likely diagnosis

    The figure shows a unilateral partial ptosis, miosis and apparent enophthalmos. Causes of unilateral ptosis include lesions of the third cranial …

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