Idiopathic horner syndrome diagnosed remotely using telemedicine.

Idiopathic Horner Syndrome Diagnosed Remotely using Telemedicine. The novel Coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), pandemic has altered the field of ophthalmology in myriad ways. During the initial lockdown period in March, the use of telemedicine expanded to adhere to public health guidelines. The field of neuro-ophthalmology is an ophthalmic sub-specialty less prone to the use of telemedicine. We present a case of isolated idiopathic Horner syndrome in a 39 year old female diagnosed through telemedicine. Copyright:

Introduction

The global severe acute respiratory syndrome-coronavirus two beta coronavirus pandemic has impacted the health-care system in an unprecedented fashion. Social distancing to protect patients, providers, and ancillary staff has altered both inpatient and outpatient work environments. Ambulatory-based specialties such as ophthalmology have seen dramatic changes in practice patterns. The Center for Disease Control and Prevention has recommended telemedicine with the expectation of continued social distancing.[1] Here, we describe a case of Horner syndrome diagnosed through the implementation of telemedicine.

Case Report

A 39-year-old woman developed stable right upper eyelid ptosis 5 months before presentation. She endorsed an intermittent pounding sensation on the right side of her head lasting minutes to hours and intermittent injection of the right eye. She denied acute-onset vertigo, nystagmus, cough, unintended weight loss, hypothenar eminence numbness, recent trauma, and recent surgery.

Due to institutional changes initiated, she was seen through virtual visit through the AmWell software system (Boston, Massachusetts, USA). Before her consultation, she was prescribed 1.0% apraclonidine eye drops. She also E-mailed a digital photograph of her eyes [Figure 1a] showing right upper eyelid ptosis and right miosis. Forty-five minutes before the encounter she instilled the apraclonidine drops into both eyes. At the time of the visit, her margin reflex distance one was 4.5 mm bilaterally, and her right pupil was larger than her left exhibiting reversal of anisocoria [Figure 1b]. The patient consented to having her image used. Her pain and headache were concerning for a carotid artery dissection. Magnetic resonance imaging (MRI) extending into the chest and magnetic resonance angiogram (MRA) of the head and neck showed dilatation of the left internal carotid artery (ICA) in the cervical region, but there were no concerning findings on the right side [Figure 2]. The remainder of the MRI and MRA were normal, indicating an idiopathic etiology. A follow-up computed tomography angiography showed that there was no ICA dissection, but that there were findings consistent with fibromuscular dysplasia.

Figure 1

(a) External photograph in bright lighting demonstrating right pupillary miosis and right upper eyelid ptosis. (b) External photograph demonstrating reversal of anisocoria after instillation of apraclonidine drops

Figure 2

Magnetic resonance angiogram of the neck showing dilatation, as indicated by the arrows, of the left cervical internal carotid artery

Discussion

Horner syndrome results from a lesion along the oculosympathetic pathway. The pathway originates in the hypothalamus, descends into the superior thoracic spinal cord, and ascends into the orbit. Findings of Horner syndrome include partial ptosis, anhidrosis, and miosis. The most common cause of Horner syndrome is idiopathic. There are etiologies, which, if not diagnosed and treated promptly may represent significant morbidity and mortality including among other, ICA dissection, tumor of the lung apex, and brainstem stroke.

Apraclonidine has weak alpha1 activity which in normal eyes does not result in pupillary diameter change. However, a pupil affected by Horner syndrome will dilate in response to apraclonidine. Our patient experienced reversal of anisocoria after instillation of apraclonidine drops, diagnostic of Horner syndrome.[2] The pathophysiology is that denervation of the iris from sympathetic innervation results in upregulation of the alpha1 receptor, resulting in super sensitivity to apraclonidine. A prior report in the literature documented super sensitization within 36 h of the initial insult.[3]

Her workup was normal, indicating an idiopathic etiology. Horner syndrome represents a unique neuro-ophthalmic condition where a relatively straightforward diagnosis can be made through telemedicine and preappointment prescription of apraclonidine. As the medical profession transitions into a “new normal” there will very likely be increased use of telemedicine, particularly in the field of ophthalmology. Utilization of telemedicine to diagnose conditions with significant risk for devastating consequences should be expanded on during the Coronavirus pandemic and afterward as technology continues to improve. Herein, we demonstrate the feasibility of remotely diagnosing Horner syndrome using telemedicine.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors declare that there are no conflicts of interests of this paper.