Horner's syndrome
This 53 year-old man was referred by his optician because of dropping of the right eyelid. However, the patient was unaware of any aigns or symptoms. On examination, the right upper lid was ptotic with small pupil. The lower lid was also higher than that of the left giving the right eye an apparent enophthalmos. There was no heterochromia. Direct questioning did not reveal any signs or symptoms of asymmetrical facial sweating or flushing during exercise.
Clinically, the patient has a right Horner's syndrome.  Pharmacological test was performed to determine the site of the lesion. 1:1000 adrenaline was instilled into both eyes but there was no changes in the pupil sizes. The result suggested that the Horner's syndrome is of a preganglionic nature (Note: in the presence of post-ganglionic lesion, the affected pupil will dilate due to denervation hypersensitivity). A chest X-ray was requested but showed no signs of apical abnormalities. The patient was reviewed at regular interval for any new symptoms.
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