A 56-year-old female patient was seen by live “virtual visit” telemedicine during the 2020 COVID-19 pandemic quarantine restrictions. She had a two-year history of gradual onset diplopia and had been seen by several eye care providers including an optometrist, an ophthalmologist and a neuro-ophthalmologist. Other than the diplopia, she denied any visual changes, but she had noticed variable ptosis of the left upper eyelid over the past 6 months. Past medical history was unremarkable with the exception of hypothyroidism for which she took levothyroxine replacement. Her review of systems was negative for any other abnormalities.
On physical examination, the patient was noted to have a near visual acuity (self-tested) of 20/30 in each eye while wearing her over the counter +1.25 D reading glasses. There was a right eye fixation preference and a large-angle exotropia, estimated to be 30 PD by Hirschberg light reflex. Ocular motility was notable for limited elevation of the left eye in both the adducted and abducted positions. Significant ptosis of the left upper eyelid was present, with a margin-to-reflex distance (MRD) of approximately zero millimeters compared to the right eye with an estimated MRD of 5mm. No obvious difference in pupillary size was noted but this was difficult to be certain of given the limited visibility with the teleconferencing system.