PUBLICATION EXCLUSIVE: Man presents with diplopia and ptosis of left eye

A 36-year-old Hispanic man with no significant medical or ocular history was referred to the Tufts New England Eye Center with complaints of double vision and drooping of his left upper eyelid. Three months before presentation, he presented to an outside emergency department with complaints of sudden onset dizziness and double vision. He did not recall any other symptoms at that time. Workup was pursued at the outside hospital; Lyme titer, TSH, acetylcholine receptor antibodies, CT and MRI of the brain, and lumbar puncture were all normal or negative. His symptoms subsequently resolved within a few days, and no further investigation was pursued.Three months later, he again developed vertical binocular double vision and drooping of his left upper eyelid. He noted his symptoms fluctuated and worsened as the day progressed. He presented to a local optometrist who then referred him to the Tufts New England Eye Center.