PubMed · 14186866
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E F FINCHAM. 1963. MONOCULAR DIPLOPIA.. https://doi.org/10.1136/bjo.47.12.705
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A transient, decompensated vertical phoria in an individual with infantile nystagmus syndrome (INS) resulted in two images that oscillated vertically-a diplopic oscillopsia. Ocular motor studies during the vertical oscillopsia recreated by vertical prisms, led to the identification of a sub-clinical see-saw nystagmus (SSN), present under the prism-induced diplopic condition. Retrospective analysis of ocular motor recordings made prior to the above episode of vertical diplopia revealed the presence of that same sub-clinical SSN. The SSN had not been detected previously despite extensive observations and recordings of this subject's pendular IN over a period of forty years. Three- dimensional search-coil data from fourteen additional INS subjects (with pendular and jerk waveforms) confirmed the existence of sub-clinical SSN embedded within the clinically detectable horizontal-torsional IN in seven of the fifteen and a sub-clinical, conjugate, vertical component in the remaining eight. Unlike the clinically visible SSN found in achiasma, the cause of this sub-clinical SSN is hypothesized to be due to a failure of the forces of the oblique muscles (responsible for the torsional component of the IN) to balance out the associated forces of the vertical recti; the net result is a small, sub-clinical SSN. Thus, so-called "horizontal" IN is actually a horizontal-torsional oscillation with a secondary, sub-clinical SSN or conjugate vertical component. The suppression of oscillopsia by efference copy in INS appears to be accomplished for each eye individually, even in a binocular individual. However, failure to fuse the two images results in oscillopsia of one of them.
A 47-year-old man sustained fractures of the left orbita and zygomatic bone after a fall. He was advised to visit an oral and maxillofacial department for more detailed evaluation and treatment, but ignored the advice. Four days later, after sneezing and blowing his nose, he presented severe exophthalmos, diplopia, and reduction of vision. Two days after the symptoms presented he asked for oral and maxillofacial surgery consultation. He refused any surgical intervention and was treated conservatively. The recovery was slow and 1 week later he was discharged with slight esthetic problems.
BACKGROUND: Asymmetrical folding of the anterior portion of the superior oblique muscle is a simplified variant of the Harada-Ito procedure that is supposed to selectively correct ocular torsion. PATIENTS AND METHODS: This surgical technique was applied to 22 patients suffering from bilateral acquired IV nerve palsy. Ocular torsion was evaluated with the Harms tangent screen. Pre- and post-operative torsional values were compared. Post-operative follow-up was 12 months. RESULTS: Pre-operatively, mean excyclotropia was 8.8 degrees in primary position and 15.9 degrees in downgaze. Post-operatively, these values decreased to 1.5 degrees and 4.1 degrees, respectively. An enlarged field of binocular single vision, extending beyond 10 degrees inferiorly, was obtained in 17/22 patients. CONCLUSIONS: The selective technique of superior oblique muscle anterior tendon tucking allows one to efficiently correct the ocular torsion induced by acquired bilateral IV nerve palsy.