Positive ice test in a patient with a lymphomatous infiltration of the levator palpebrae superioris.

The ice test is known to be specific for the diagnosis of ocular myasthenia gravis in patients with ptosis, with reported specificities of 97%-100%. We report a patient with diffuse large B-cell lymphoma who showed a positive result to the ice test. A 53-year-old woman presented with left eyelid ptosis of 3 weeks' duration. She had finished chemotherapy and radiotherapy for diffuse large B-cell lymphoma a year previously. On ophthalmological examination, her best-corrected visual acuity was 20/20 in each eye. Marginal reflex distances were +4 in the right eye and -1 in the left eye. Levator palpebrae superioris functions were 11 mm in the right eye and 8 mm in the left eye. Ptosis improved after 5 minutes' application of ice to both eyelids, after which marginal reflex distances were +4 in the right eye and +1 in the left eye. Thyroid function tests, anti-acetylcholine receptor antibody test, and the repetitive nerve stimulation test were all negative. Magnetic resonance imaging showed fusiform masslike enlargement of the left superior rectus muscle and left levator palpebrae superioris muscles, with enhancement suggesting metastatic infiltration.