Oculosympathetic palsy or Horner's syndrome is the triad of meiosis, ptosis, and anhidrosis that results from disruption of the sympathetic pathways between the brain and the eye. Numerous aetiologies underlay Horner's syndrome and although the individual signs of the syndrome do not constitute an emergency, their presence makes any Horner's syndrome a potential vascular emergency due to the proximity of the internal carotid artery to the sympathetic ganglia. A progressive case of Horner's syndrome following blunt injury to the neck in an amateur snowboarder is presented.
A 39-year-old male fell during snowboarding. He landed on his back and right thumb and was treated for a Bennett's fracture. Two days later, he presented to Emergency Department for follow up of his fracture. His wife had noted his unequal pupil size prompting referral to the ophthalmic department (Figure 1).
He complained of a mild left sided periocular headache and a heavy feeling on the left side of his face. On examination, he was alert and systemically well. Snellen visual acuity was 6/6 bilaterally. He had partial leftsided eyelid ptosis with apparent enophthalmos of the left globe. The right pupil was larger than the left by 1mm. Both pupils were reactive to light. There was possible left sided anhidrosis, but this finding could not be ascertained firmly. The remainder of the ocular and neurological examination was normal. Both carotid arteries were palpable, and no thrill or bruits were noted. He had no prior ocular or vascular history.
The diagnosis of Horner's syndrome was made on the constellation of signs noted on examination. Of particular note was the presence of periocular and neck pain. The diagnosis was pharmacologically confirmed using 4% Cocaine drops to both eyes. The left pupil was not dilated compared to the contralateral side 30 minutes later. The presence of a painful Horner's syndrome prompted urgent liaison with the radiologist, and Computerised tomography (CT) scans of his head and neck were normal. Due to strong clinical suspicion, magnetic resonance imaging (MRI) with magnetic resonance angiography (MRA) was requested and demonstrated a dissection of the left internal carotid artery in the neck without occlusion of the lumen. The vertebral arteries were normal and no other intracranial abnormalities were noted. Warfarin anticoagulation was initiated, and the patient had no neurological sequelae. No complications were noted at four months review and the patient was subsequently maintained on antiplatelet therapy....