Isolated complete unilateral ptosis with intact extraocular eye movements

An 88-year-old woman presented with a 2-day history of inability to open her left eye with no ocular discomfort or blurred vision. She had a long-standing history of diabetes mellitus, hypertension and stroke disease. Examination revealed an isolated complete left eye ptosis with no pupillary involvement and intact extraocular movements. There were no other neurological deficits and fatigability was not elicited. Magnetic resonance imaging of the brain showed an acute infarct of the left red nucleus. Oculomotor nerve fascicles are widely separated in the midbrain before they exit at the interpeduncular fossa. A discrete lesion involving the most caudal fibres of the levator palpebrae is the most likely explanation. Although uncommon, this should be considered in patients with underlying cardiovascular risk factors.