A tale of ptosis, pharmacological tests, and Pancoast tumour

Abstract

Horner syndrome (HS) classically presents with ipsilateral blepharoptosis, pupillary miosis, and facial anhidrosis and caused by a lesion along the oculosympathetic pathway from the hypothalamus to eye. The diagnosis of HS in a patient presenting with partial ptosis may be easily missed in the Asian patient. This is mainly due to the dark irides, making detection of anisocoria on direct visualization difficult. Index of suspicion must be high, especially in the absence of any extraocular motility or lid abnormalities. We present a case where a healthy asymptomatic patient presented with partial ptosis and diagnosis of HS was eventually confirmed through pharmacological tests. Non-targeted imaging with a simple chest X-ray revealed an apical lung lesion which eventually turned out to be malignant. Although it is a typical textbook description, this case highlights the importance of careful history and examination in an otherwise healthy patient presenting with mild ptosis.