A 65-Year-Old Man Is Being Evaluated for New-Onset Ptosis

A 65-year-old man is being evaluated for new-onset ptosis.  Earlier in the day, the patient underwent right total knee arthroplasty for advanced osteoarthritis with no operative complications.  While in the postoperative recovery unit, he had difficulty opening his left eye and developed slurred speech.  The patient has never had these symptoms, and his preoperative neurologic examination was unremarkable.  He has no prior history of double vision, difficulty swallowing, or limb weakness.  Medical history includes ischemic stroke with no residual deficits, type 2 diabetes mellitus, hypertension, and a 20-pack-year smoking history.  Temperature is 36.7 C (98.1 F) , blood pressure is 150/90 mm Hg, pulse is 92/min, and respirations are 12/min.  Neurologic examination reveals bilateral ptosis, left greater than right.  Pupils are equal in size and reactive to light.  An ice pack is placed over the closed eyelids for 2 minutes, leading to improvement of the ptosis.  Which of the following is the most likely cause of this patient's current symptoms?

A) Acetylcholine receptor antibodies
B) Disruption of the oculosympathetic chain
C) Impaired presynaptic calcium channels
D) Inflammation and edema of the facial nerve
E) Ischemic oculomotor nerve palsy
F) Posterior communicating artery aneurysm

Correct Answer:

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