Bilateral central ptosis in acquired immunodeficiency syndrome

The man who could not see what he could not eat

A 55-year-old Hispanic man born in New Mexico presented with progressively worsening bilateral upper eyelid ptosis and dysphagia. External levator advancement 5 years before did not improve his ptosis. A thorough systemic workup for myasthenia gravis was negative, but electromyography suggested a myopathic process. Molecular genetic testing was positive for oculopharyngeal muscular dystrophy.

Downgaze palsy and bilateral ptosis due to a thalamomesencephalic lesion

An unusual combination of downgaze palsy and bilateral ptosis occurred in a patient with central nervous system lymphoma involving bilateral thalamus and midbrain tegmentum. Following treatment with corticosteroids, the transition from total paralysis of downgaze to the supranuclear form was noted, along with alleviation of ptosis, followed by complete resolution of both. The results of serial magnetic resonance images were consistent with our interpretation that his initial eye signs were caused by the combined involvement of the bilateral rostral interstitial nucleus of the medial longitudinal fasciculus (supranuclear downgaze palsy) and the oculomotor subnuclei (nuclear palsy of the inferior recti and levator palpebrae muscles).