A 42-year-old man was referred to the New England Eye Center for evaluation of binocular diplopia. Four months earlier, the patient developed acute-onset horizontal binocular diplopia that was present constantly but worsened later in the day. More recently, he began to notice left upper eyelid drooping. He otherwise felt well with no headache, weakness, difficulty swallowing, fever, fatigue or weight loss. He had been evaluated by an outside optometrist who prescribed prism glasses that were ineffective, so he was referred to the New England Eye Center for neuro-ophthalmologic evaluation.
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