C10019330 / invoice 10000

 Eye is droopy with third lid staying over part of eye

HX:
sunken LEFT eye with raised 3rd eyelid first noticed on sunday 3 days ago
flushed with saline, next day seemed better less droopy and third eyelid less raised
now worsened again 
not trying to paw at eye, no signs of discomfort
no ocular discharge
otherwise welll
also due 4th zydax

CE:
BAR 
RIGHT Eye:
small darkpigmented mass on eyelid margin~2mm circular - concistent w mebomian gland
corneal surface 
4mm x 4mm circular area of corneal opacity - scarring from healed corneal ulcer, see hx
mydriatic pupil relative to L eye
no episcleral injection, no bleparospasm, no ocular discharge

LEFT eye:
sunken globe - enopthalmos
raised third eyelid
miotic pupil relative to R eye 
no episcleral injection, no bleparospasm, no ocular discharge
distant direct - normal tapetal reflection, jerking head around too much to perform close direct 
oxybupre instilled, movement of third eyelid with cotton tip- no fb

HR 80bpm, no murmur, regular rhythm, hr readily audible on both L+Rhs 
RR and effort wnl, no wheezes or crackles ausc
MM pk, moist, CRT <2s
Normal gait no circling, no head tilt, no nystagmus

Tonometer:
20-21mmhg L eye, 20mmhg R eye --> both wnl

LEFT eye fluorescein negative

Assessment:
L eye findings consistent with horner's syndrome
DDX underlying cause of horners: 
- 1st order; intracranial (e.g. mass - neoplasia), spinal disease, thoracic disease (cranial mediastinal mass), other
- 2nd order; cervical soft tissue disease (e.g. mass, neoplasia, trauma), other
- 3rd order; middle ear mass or neoplasia, otitis media/interna, retrobulbar injury/mass/neoplasia, iatrogenic (bulla osteotomy), other
- idiopathic

Plan:
DWO options for further workup incl:
- sedation and xrays skull, cervical, thoracic here
- refer for CT 

Client elect monitor only for now. Adv to revisit if symptoms worsen, incl but not limited to; head tilt, circling, nystagmus, head pressing, neuroligcal events, changes in demeanour/behaviour, changes in eddu, depression/lethargy. 

TX:
Zydax 1.1ml SC dorsal inj