E–Pearl of the Week: Plus-minus lid syndrome

November 20, 2012


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November 20, 2012

Plus-minus lid syndrome

Plus-minus lid syndrome is a rare median mesencephalic lesional syndrome characterized by ipsilateral ptosis and contralateral superior eyelid retraction. These features are explained by involvement of ipsilateral levator palpebrae fascicles as they exit the central caudal oculomotor subnucleus as well as the contralateral inhibitory levator palpebrae pathway prior to entering the same subnucleus. Distinction from pseudo plus-minus lid syndrome is seen when manual elevation of the ptotic lid has no effect on contralateral lid retraction.  Contralateral downward gaze deviation with ipsilateral pupil-sparing oculomotor palsy can also be seen and indicates contralateral superior rectus subnucleus involvement near the medial margin of the ipsilateral oculomotor nucleus.


  1. B Gaymard, C Lafitte, A Gelot, et al. Plus-minus syndrome. J Neurol Neurosurg Psychiatry 1992; 55: 846-848.

  2. F. Bandini. Pseudo Plus-minus Syndrome. Arch Neurol 2009; 66:668-669.

Submitted by Jonathan Beary, D.O., Neurology Resident, Cleveland Clinic.

Disclosure: Dr. Beary reports no disclosures.

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