A 38-year-old man had a 6-year history of painless progressive left eyelid drooping, impaired near vision, and horizontal diplopia.

Our patient had a 6-year history of progressive painless left upper eyelid ptosis and binocular horizontal diplopia, worse on gaze to the right. He also noticed a larger left pupil and had blurred vision of his left eye when looking at near objects.

On examination, visual acuity was 20/20 on the right eye (OD) and 20/25 on the left eye (OS). Confrontation visual fields were normal. On funduscopy, the appearance of the discs, maculae, vessels, and periphery was normal. On center gaze, there was a slight exotropia (lateral deviation) and hypotropia (downward deviation) of the left eye. The range of eye movements was normal on the right eye. There was left upper eyelid ptosis.