A man in his 60s with a history of surgery to repair right upper eyelid ptosis 1 year prior presented to a neuro-ophthalmology clinic with limited movement of the right eye of 1 year's duration and worsening recurrent ptosis of the same eye. Results of previous single-fiber electromyography and serologic testing for acetylcholine receptor-binding antibodies were negative for myasthenia gravis. His ocular history included amblyopia and nonarteritic ischemic optic neuropathy of the left eye. His medical history included obstructive sleep apnea, coronary artery disease, coronary artery bypass surgery, and prostate cancer, the last in remission for the past 4 years.Visual acuities were 20/30 OD and hand motions OS. The patient had an Adie pupil in his right eye and a relative afferent pupillary defect in the left eye. The right eye demonstrated total ophthalmoplegia, and no deficit was found in the left (Figure 1). Exophthalmometer measurements demonstrated enophthalmos of the right eye associated with facial asymmetry. Margin reflex distance was 0 mm in the right eye and 4 mm in the left. In-office ice and sleep testing did not improve the ptosis or ophthalmoplegia in the right eye. The remainder of his examination was remarkable for punctate epithelial erosions of the right eye and optic atrophy of the left.