HPI - Slight temporal pain and discomfort. No loss of vision or diplopia reported.
Physicial Exam. Best vision is OD -2.75 Sph 20/25- and OS -2.50 20/25. Confrontation fields and extraocular muscles are full (if the RUL is held up). The pupils were dilated before my examination but were noted to be APD minus.
IOP 14 OU, CD 0.40 OU ONH diameters ~2.0mm, with no visible atrophy of the beta zone. Good disc color and sharp margins. The eye is quiet and the internal exam is negative.
After 30 seconds of upgaze, the patient does have a worsening ptosis but the LUL is intact and unaffected.
What are your thoughts? next steps?