A 64-year-old white man was seen in the neuro-ophthalmology clinic for 2 years of binocular vertical diplopia more noticeable at distance.
He had no decrease in vision, eye pain, flashes, floaters or ptosis. There was no recent history of trauma. Systemic review of systems was negative for dysphagia, dyspnea, muscle weakness or any other neurologic symptoms. Ocular history included cataracts and mild meibomian gland dysfunction. Medical history included low-grade transitional cell carcinoma of the bladder currently in remission, hypertension and hypercholesterolemia. Medications included