Crossed Signals: Double and Unsteady

A 45-year-old Egyptian man with history of hypertension, hyperlipidemia, and coronary artery disease presented with three days of severe holocephalic headache, fatigue, blurry vision, and difficulty forming full sentences, which evolved into binocular diplopia and left eyelid drooping. He had no history of trauma or systemic complaints. Examination showed mildly decreased central acuities in both eyes, ptosis OS, and anisocoria with a larger left pupil more notable in the light. He had -1.5 adduction, -0.5 abduction, and -3 infraduction in the left eye, and -3 supraduction OU (see pictures).