A 46-year-old woman presented with a 3-year history of hand tremors and slow gait. On examination, blood pressure was normal without postural hypotension. Visual pursuit was normal, and saccades were hypometric. Motor strength and tendon reflexes were normal, but she had mild cogwheel rigidity, bradykinesia, rest tremor of both hands, and extensor plantar responses. Tandem gait was impaired. Iris atrophy (eFigure 1, links.lww.com/WNL/D83) was seen when evaluating pupillary reflexes, and the patient was sent for slit-lamp examination, which showed atrophy of both irises (Figure 1 and see eFigure 2, links.lww.com/WNL/D84 for normal iris of a matched control). We suspected that she had atypical parkinsonism. An MRI of the brain was unremarkable, and 18F-fluoro-dihydroxyphenylalanine PET scan was unavailable. She was started on levodopa but had no response.
