Graves ophthalmopathy arises from soft-tissue enlargement in the orbit, leading to increased pressure within the bony cavity.6 Approximately 40% of patients with Graves ophthalmopathy present with restrictive extraocular myopathy; however > 90% have eyelid retraction, as opposed to ptosis.7
Guillain-Barré syndrome (GBS) is an acute, demyelinating immune-mediated polyneuropathy involving the spinal roots, peripheral nerves, and often the cranial nerves.8 The Miller Fisher variant of GBS is characterized by bilateral ophthalmoparesis, areflexia, and ataxia.8 At the early stage of illness, the presentation may be similar to TNP.8 Brain imaging is normal in patients with GBS; the diagnosis is established via characteristic electromyography and cerebrospinal fluid findings.8
Myasthenia gravis often manifests with variable ptosis associated with diplopia.9 Symptoms may be unilateral or bilateral. The ice-pack test has been identified as a simple, preliminary test for ocular myasthenia. The test involves the application of an ice-pack over the lids for 5 minutes. A 50% reduction in at least 1 component of ocular deviation is considered a positive response.10 Its specificity reportedly reaches 100%, with a sensitivity of 80%.10
COVID-19 infection may also include neurologic manifestations. There are an increasing number of case reports of central nervous system abnormalities including TNP.11,12
Trauma, tumors, or an aneurysm could be at work in TNP
TNP associated with trauma usually develops secondary to compression from an expanding hematoma, although it may also be a result of irritation of the nerve from blood in the subarachnoid space.13 Estimates of the incidence of TNP due to trauma range from 12% to 26% of cases.1,14 Vehicle-related injury is the most frequent cause of trauma-related TNP.14
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