Third Nerve Palsy: A Case of Bilateral Eyelid Ptosis, Normal Pupils, and Vertical Diplopia With Multiple Intracranial Lesions

TL;DR

A 68-year-old woman with bilateral eyelid drooping and brain lesions shows how clinical and imaging findings can pinpoint midbrain issues.

Contribution

This case emphasizes the value of combining clinical signs with neuroimaging for accurate localization in complex cranial nerve disorders.

Findings

Bilateral ptosis without pupillary involvement suggested a midbrain lesion.

Imaging identified dorsal midbrain and frontal lobe abnormalities.

Symptoms and imaging together helped rule out cortical causes.

Abstract

Bilateral eyelid ptosis presents a rare and diagnostically challenging clinical scenario, particularly when accompanied by multiple intracranial lesions. We present the case of a 68-year-old woman with bilateral ptosis, vertical diplopia, and progressive confusion. Imaging revealed a dorsal midbrain lesion and bilateral frontal lobe masses. Clinical examination ruled out common causes of ptosis, such as myasthenia gravis and muscular dystrophies. The patient’s constellation of symptoms, bilateral ptosis without pupillary involvement and vertical diplopia, localized the lesion to the midbrain rather than the cortex. This case highlights the importance of integrating clinical examination with neuroimaging to refine localization in challenging presentations of cranial nerve pathology.

Figures