Game 19
Solve
in
1
You patient or rather patients comes in presenting with a drooping eyelid and sweating on the opposite side of the face.
One seems to be a significant other, whilst your actual patient presents with a relatively small constricted pupil on the contralateral side.
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Your patient seems to be restless, like he's high or something.
Solve
in
2
History of the patient reveals that they have a history of drug abuse.
You suspect cocaine abuse to be a potential factor.
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Turning off the lights in your consultation room, the ipsilateral eye begins to slowly dilate, at a speed much less than the contralateral eye.
You also notice that the sweating only occurs on one side of the face.
last
chance
Your patient's significant other explains that the eyelid drooping and sweating makes him uncomfortable, despite being for the most part alright.
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"He always get's really mad after taking...you know...and pulls his eyelid up. He used to tape his eyelid up using duct tape which gave him blepharitis once."
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To disuade cocaine abuse, you decide to use apraclonidine to confirm your diagnosis.
The
answer
Horner's Syndrome (2nd order)
- Associated with the triad: ptosis, miosis and anhydrosis.
- Though a bit of a stretch, cocaine abuse may cause a series of defects which may potentially lead to damage, including carotid aneurysms
- 2nd order defects are identified through ipsilateral face anhydrosis, and can typically caused from pre-ganglionic lesions
- Cocaine is one of the ways to diagnose (10%), which would normally cause a dilation in the pupil, does not in Horner's syndrome
- 0.5-1% apraclonidine has a weak adrenergic agonist action, which reverses the anisocoria due to sensitivity of pupils to adrenergic reactions
- 1% hydroxyamphetamine is typically also used to confirm pre-ganglionic, as it will cause a dilation and reversal of miosis, which would not occur in post-ganglionic.