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Editor,—We present a patient who possesses two aspects of Horner’s syndrome worth re-emphasising: (1) heterochromia iridis with Horner’s syndrome does not always signify a congenital origin,1-3 and (2) sympathomimetics, such as 2.5% phenylephrine, may be used to elevate the lid when desired as a measure to defer surgery.4-6
A nurse brought her 7½ year old daughter for evaluation of the right pupil, which was noted to be larger than that on the left in the dark. Review of systems and past medical history were unremarkable. An isolated deficiency of the dilator muscle in her left pupil without heterochromia iridis or ptosis was diagnosed. Two years later, mild ptosis and mild heterochromia were present. Because of the progression to a Horner’s syndrome, now also demonstrating left facial anhidrosis and acquired heterochromia, magnetic resonance imaging (MRI) of the neck and chest was performed. A large left apical lung ganglioneuroma was diagnosed. This was surgically excised and the patient had an uncomplicated recovery. In response to concerns regarding her asymmetric pupillary sizes, 2.5% phenylephrine was prescribed for use up to four times a day to help equalise her pupils when going on photographic shoots for modelling purposes.
Three years later, at age 12½, the patient shows marked heterochromia. She uses the 2.5% phenylephrine solution, but describes its true value to be for the near immediate relief of her ptosis after placing one drop in her affected eye, and two drops in the contralateral eye (Fig 1). She explains that contralateral drop placement serves to improve and maintain symmetry in the two lid fissures and that the effect lasts approximately 15 minutes with pupillary dilatation lagging 10–15 minutes behind.
Even in an otherwise asymptomatic child, the presence of heterochromia iridis with Horner’s syndrome can be the result of an undetected, progressive condition, and does not establish a definite congenital aetiology. Our patient appears to be a well adjusted and happy preteen, who, given a sense of control over her ptotic lid with topical drops, freely declines surgical correction for her ptosis at the moment. Coloured contact lenses were proposed as an option to mask her acquired heterochromia. The best effect of these lenses was obtained when matched to the colour of her darker iris, although the patient’s initial desire had been to match the colour of the eye affected by Horner’s syndrome.