62-year-old man developed a left red eye with lacrimation the day after his
coronary artery bypass graft. He was referred to the eye clinic where he was
treated for infective conjunctivitis with topical chlormaphenicol. Despite
treatment, his red eye and lacrimation persisted. Culture and sensitivity of
the conjunctival swab was negative for bacteria and virus. At the 3 months
review, his red eye had improved but he still complained of lacrimation and
problem in opening his eye. Syringing of the left punctum was patent.
a. What is the diagnosis?
Horner's syndrome. The man has a left partial ptosis and miosis. The
temporal relation suggests that the sympathetic pathway (see diagram below)
was damaged during insertion of a central venous pressure line or during
features1 of Horner's syndrome include:
apparent enophthalmos (less eye is seen because of the ptosis and the
updrawing of the lower lid),
ocular hypotony (the IOP of the affected eye typically has an IOP 5mmHg
less than the fellow eye),
increase in accommodation (due to changes in the tone of the ciliary
muscle and may amount to 0.5 to 1.5 dioptres),
anhidrosis (ipsilateral loss of sweating is seen in lesion of the first
and second order neurones) and
heterochromia (this occurs in congenital Horner's syndrome with the
affected eye being lighter in colour and this occurs because sympathetic
innervation is involved in melanocytes migration).
From the Atlas of
Ophthalmology by the Bascoe Palmer Institute.
b. How can you
confirm the diagnosis?
syndrome can be confirmed with the cocaine test and damage to the second
order neuron is supported with the hydroxyamphetamine test.
cocaine test, 4% (not 10% as some advocated) cocaine is instilled into both eyes. Horner's pupil
dilates little or none at all. Reuptake of the norepinephrine occurs
normally in the synaptic cleft. Cocaine blocks the reuptake, causing rapid
accumulation within the synaptic cleft resulting in dilation of a normal
pupil. The presynaptic nerve endings in Horner's syndrome have impaired
sympathetic tone and therefore respond poorly or none at all to the effect
Hydroxyamphetamine stimulates the release of norepinephrine from the
presynaptic nerve endings resulting in dilatation of the pupil. If the nerve
is damage, the nerve will not release norepinephrine as is the case with
third order neurone lesion. In the case of first and second order neurone
lesion, the pupil will dilate as the third order neurones are intact.
How do you explain the initial presentation?
conjunctival vessels and the lacrimal glands are innervated by the
sympathetic nerves. Reduced sympathetic input results in dilatation of the
conjunctival vessels and increased lacrimation. This may be mistaken for
conjunctivitis if the possibility of Horner's syndrome is not considered.
Romano et al studied the ocular manifestations after upper dorsal
sympathectomy for palmar hyperhidrosis in 50 patients. Postoperative
examination was done during the first week, at 3 to 4 weeks and at 6 to 12
months after the operation. Immediately after surgery there were 18 patients
with ptosis (6 severe) and 23 with miosis (12 severe). There were 19
patients with excessive lacrimation and some degree of congestion of
conjunctival blood vessels was present in almost all patients. Uniocular
decrease in tears was present in 2 patients. Most of these manifestations
decreased with passage of time.
1. Walsh TJ. Chapter
3: Pupillary abnormalities. Neuro-ophthalmology: Signs and symptoms. Third
Edition. 1992 Lea and Febiger.
Romano A, Kurchin A, Rudich R, Adar R. Ocular manifestations after upper
dorsal sympathectomy. Ann Ophthalmol. 1979 Jul;11(7):1083-6.