Recurrent Unilateral Ophthalmoplegia in a 5-year-old

Case Presentation

A 5-year-old girl presents with sudden onset left-sided ptosis and outward and downward deviation of the left eye for 2 days before presentation. These symptoms are constant without any diurnal variation and no aggravating or relieving factor is identified. There is no change in vision, redness, watering, or swelling of the concerned eye or eyelid. The right eye is asymptomatic. There is no history of any facial droop or asymmetry, difficulty in swallowing, or regurgitation of feeds. There is no weakness in any limbs or elsewhere. There is no history of any sensory abnormalities or autonomic dysfunctions such as bowel or bladder incontinence reported. She does not complain of any early morning headaches, vomiting, photophobia, loss of consciousness, or seizures with the present episode or in the recent past. She also denies any constitutional symptoms of fever and weight loss. Two similar episodes are reported in the past 6 months, both of which were self-resolving within a span of 2 days. However, the 2 previous episodes were associated with a dull aching pain in the forehead lasting throughout the episode of the illness. The remainder of pertinent past medical history, developmental milestones, and social history are negative. Family history is significant for migraine in mother and maternal grandmother.

On physical examination, the patient is afebrile and has normal vitals. She is active and playful throughout the examination. A complete neurological examination reveals ptosis of the left eye with downward and outward deviation of the left eye. There is limited adduction and supraduction of the left eye. The pupillary examination is however normal. The findings are suggestive of oculomotor palsy …