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PubMedDate not supplied

Vertical diplopia following peribulbar anesthesia: the role of hyaluronidase.

PURPOSE: To estimate the incidence of vertical diplopia following peribulbar anesthesia in otherwise uncomplicated cataract surgery and to establish whether the use of hyaluronidase in the peribulbar injection mixture affected the likelihood of this complication. METHODS: Nine hundred forty consecutive phacoemulsification procedures using peribulbar anesthesia were retrospectively reviewed to identify cases of postoperative vertical diplopia. Case notes were reviewed to establish the nature and timing of the onset of diplopia, the anesthetic technique, and whether hyaluronidase was used. The patterns of progression as demonstrated by serial Hess charts were compared. RESULTS: There were 6 cases of vertical diplopia (incidence, 0.64%). All showed an immediate postoperative hypertropia in the injected eye changing during a 4- to 6-week period to hypotropia with restriction of upgaze. All applications of anesthesia were administered by consultant anesthetists, associate specialists, or residents under their direct supervision using 25-mm, 25-gauge needles with 2% lidocaine. Hyaluronidase was included in the injection mixture for 435 (46%) of the cases and was not included for 505 (54%) of the cases. All 6 cases of vertical diplopia occurred in the group in which hyaluronidase was not used, which has a significant association (chi-square test, 5.22; P = .023). CONCLUSION: Hyaluronidase should be included in peribulbar anesthetics to reduce the risk of postoperative vertical diplopia.

Aged↗
PubMed2005

[Four cases of diplopia following spinal anesthesia].

Many complications after spinal anesthesia have been reported, but diplopia is rare. We had four cases of diplopia in 794 cases of spinal anesthesia in three years at Nara Medical University Hospital. These 4 cases were not characterized by any major factors including gender, age, or anesthetic choice. However, two of them were accompanied with post-spinal headache. Diplopia in three cases improved spontaneously, but one finally required epidural blood patch for the persistent diplopia. Lack of concern regarding the possibility of post-spinal diplopia among medical staffs might be common because this incidence is really rare. However, we need to know the possibility of this neurological sequel after spinal anesthesia. We would like to propose that the informed consent regarding spinal anesthesia should include the possibility of this complication and anesthesiologists should perform intensive neurological examinations after spinal anesthesia concerning post-spinal diplopia.

Adult↗
PubMed1993

[Treatment and prognosis of diplopia].

The case notes of 341 patients who had consulted the Ocular Motility Clinic of Hyogo College of Medicine between 1986 to 1992 with a chief complaint of diplopia were studied. The recovery rates of diplopia from major causes were as follows: 72% of patients recovered from diplopia in oculomotor nerve palsy, 70% in trochlear nerve palsy and 71% in abducens nerve palsy. Various treatments were effective to eliminate the diplopia in 69% of patients with myasthenia gravis, 60% in Graves' ophthalmopathy, 78% in blowout fractures and orbital tumors. Pharmaceutical therapy was applied in 236 cases. In ocular motor nerve palsy oral prednisone gave a higher recovery rate than other medicines. The recovery rate of diplopia in medicinal therapy was 60% and it increased to 69% when combined with surgical treatment. We concluded that it is better to select the surgical treatment if the patient complains of diplopia after more than 6 months of conservative therapy.

Adolescent↗
PubMed1999

Nonsurgical management of binocular diplopia induced by macular pathology.

OBJECTIVE: To treat binocular diplopia secondary to macular pathology. METHODS: Seven patients underwent evaluation and treatment. All had constant vertical diplopia caused by various maculopathies, including subretinal neovascularization, epiretinal membrane, and central serous retinopathy. Visual acuity ranged from 20/20 to 20/30 in the affected eye. All except 1 patient had a small-angle, comitant hyperdeviation with no muscle paresis. Sensory evaluation demonstrated peripheral fusion and reduced stereoacuity. Neither prism correction nor manipulation of the refractive errors corrected the diplopia. A partially occlusive foil (Bangerter) of density ranging from 0.4 to 1.0 was placed in front of the affected eye to restore stable, single vision. RESULTS: The Bangerter foil eliminated the diplopia in all patients. Two patients elected not to wear the foil; 1 patient was afraid of becoming dependent, and the other was bothered by the visual blur. Visual acuity in the affected eye was reduced on average by 3 lines. All patients maintained the same level of sensory fusion, with only 2 having reduced stereoacuity. Symptoms returned when the foil was removed or its density was reduced. CONCLUSION: Low-density Bangerter foils provide an effective, inexpensive, and aesthetically acceptable management for refractory binocular diplopia induced by macular pathology, allowing peripheral fusion to be maintained.

Adult↗
PubMed2001

Recently acquired diplopia in adults with long-standing strabismus.

BACKGROUND: The evaluation and management of recent-onset diplopia in an adult with a history of long-standing strabismus can be perplexing and challenging. No guidelines exist, to my knowledge, for the examination of such patients. DESIGN: A retrospective medical record review. SUBJECTS: Patients seen in my practice with a history of recently acquired diplopia and a history of strabismus dating back to childhood. RESULTS: One hundred fifty-two patients who met the enrollment criteria were identified. Using the treatment approach outlined herein, 132 patients were relieved of their symptoms of diplopia. In most cases, the onset of the diplopia could be correlated with a change in the patient's ocular alignment, refractive needs, or refractive management. Returning patients to their motor status before the onset of symptoms or addressing the change in refractive needs or management usually resulted in relief of symptoms. CONCLUSION: In most cases, adult patients with a history of long-standing strabismus and a recent onset of diplopia can be effectively treated.

Adolescent↗
PubMed2003

Diplopia after refractive surgery: occurrence and prevention.

OBJECTIVES: To report the occurrence of persistent diplopia manifesting after refractive surgery, to describe the different causes of this complication, to provide risk stratification for its occurrence, and to outline minimal screening techniques for its prevention. METHODS: A retrospective medical record review of patients seen in 2 private strabismus practices who experienced persistent diplopia after refractive surgery. RESULTS: A total of 28 patients were identified who met the inclusion criteria. The causes of postoperative diplopia could be traced to 1 of 5 mechanisms. These included technical problems, prior need of prisms, aniseikonia, iatrogenic monovision, and improper control of accommodation in patients with strabismus. The recommended screening techniques would have identified all patients in this series as being at risk for postoperative diplopia with the exception of those in whom technical problems were responsible. CONCLUSIONS: Diplopia can become manifest after refractive surgery. With proper attention paid to risk stratification and recommended screening criteria, the incidence of this complication can be minimized.

Adult↗
PubMed2005

Monocular diplopia after neodymium: YAG laser capsulotomy.

PURPOSE: To present an unusual complication of posterior capsulotomy such as monocular diplopia and to discuss the importance of capsulotomy size. METHODS CASE REPORT: A 57-year old man came to our clinic complaining of horizontal monocular diplopia in his right eye for the past 3 days. The patient had undergone a Nd:YAG capsulotomy in this eye 3 weeks before. Slit-lamp biomicroscopy under pupil dilation revealed a small capsulotomy and a considerable Elschnig pearl as the presumable cause of the diplopia. The rest of the examination was completely normal. RESULTS: After repeat Nd:YAG capsulotomy treatment, the diplopia disappeared. CONCLUSION: Capsulotomy size is a significant factor to consider when treating a posterior capsular opacification. A capsulotomy that is larger than the pupil diameter under scotopic conditions may avoid disturbances of vision such as monocular diplopia.

Cataract Extraction↗
PubMed1991

Diplopia following midfacial fractures.

Over a period of 2 years, 363 patients who had sustained a total of 438 midfacial fractures due to blunt trauma received a full ophthalmological examination within 1 week of injury. Of these, 72 patients (19.8%) developed diplopia. Diplopia was most common following road traffic accidents (31%) and least common with simple falls (10%). Blow-out fractures of the orbit led to double vision in 58% of cases. Eighty two percent of patients recovered from diplopia within 6 months of injury; only 1 patient required squint surgery for double vision. The principal risk factors for diplopia comprise road traffic accidents, blow-out fractures and comminuted malar fractures. Early surgical reconstruction of midfacial fractures with conservative management of concomitant motility disorders has, in our series, resulted in very few patients having diplopia in the long term.

Accidents, Occupational↗
PubMed2005

The removal of the deep lateral wall in orbital decompression: its contribution to exophthalmos reduction and influence on consecutive diplopia.

PURPOSE: To evaluate the contribution of maximal removal of the deep lateral wall of the orbit to exophthalmos reduction in Graves' orbitopathy and its influence on the onset of consecutive diplopia. DESIGN: Case-control study. METHODS: The medical records of two cohorts of patients affected by Graves' orbitopathy with exophthalmos > or = 23 mm, without preoperative diplopia, were retrieved at random from the pool of patients decompressed for rehabilitative reasons at our institution (01/1990 to 12/2003), and retrospectively reviewed. They had been treated with an extended (cases, group 1, n = 15) or conservative (controls, group 2, n = 15) 3-wall orbital decompression performed through a coronal approach. The deep portion of the lateral wall had been removed in the extended decompression group while preserved in the conservative decompression group. Demographics, preoperative characteristics, and surgical outcome were compared. The difference in mean exophthalmos reduction between groups 1 and 2 was considered to be the contribution of the deep lateral wall to reduction of exophthalmos. RESULTS: Groups 1 and 2 were drawn from a pool of 37 and 335 patients, respectively. Demographics and preoperative characteristics of the two groups were not significantly different. The mean contribution of the deep lateral wall to exophthalmos reduction was 2.3 mm. The onset of consecutive diplopia was not significantly different between the two groups (case n = 2/15, controls n = 5/15; P = .203). Diplopia resolved spontaneously in all the patients of group 1, while all the patients of group 2 required surgery. CONCLUSIONS: Removal of the deep lateral orbital wall as part of a coronal-approach, 3-wall decompression, enhances the degree of exophthalmos reduction without increasing the risk of consecutive diplopia.

Adult↗
PubMed2006

Wavefront analysis of eye with monocular diplopia and cortical cataract.

PURPOSE: To determine whether higher-order aberrations can explain the monocular diplopia reported by a patient. DESIGN: Observational case report. METHODS: A patient complaining of monocular diplopia was examined with the Hartmann-Shack aberrometer to determine if the higher-order wavefront aberrations could account for the diplopia. The patient had a mild cortical cataract, and measurements were made before and after lensectomy. In addition, the retinal image was simulated using Zernike polynomials. RESULTS: Spherical aberration (0.20 microm for 4-mm pupil) and secondary astigmatism (-0.12 microm) were increased in the eye. The simulated retinal image had a double configuration that was approximately the same as the subjective image reported by the patient. After cataract surgery, the diplopia disappeared, and the spherical aberrations and secondary astigmatism were considerably decreased. CONCLUSIONS: The monocular diplopia probably stemmed from the combined effects of spherical aberration and secondary astigmatism caused by the cortical cataract.

Adult↗
PubMed2004

Persistent diplopia after retrobulbar anesthesia.

PURPOSE: To determine the causative factors of persistent diplopia after retrobulbar anesthesia. SETTING: Strabismus Section, Department of Ophthalmology, Seoul National University, Seoul, South Korea. METHODS: Prism and alternate cover tests in the diagnostic positions of gaze and ductions/versions were performed in 28 patients with persistent diplopia 6 months after retrobulbar anesthesia. The Lancaster test, Bielshowsky head tilt test, double Maddox rod test, fundoscopic examination for torsion, forced duction test, force generation test, tensilon test, thyroid function test, and/or orbit computed tomography were performed when necessary. RESULTS: Most of the patients (26 patients, 93%) did not have diplopia before retrobulbar anesthesia. Of the 14 patients with extraocular muscles imbalance, 12 patients showed vertical rectus overaction (11 superior recti, 1 inferior rectus) and 2 patients, mild vertical rectus underaction. Nine patients were presumed to have a sensory strabismus related to the preoperative poor vision, but this went unnoticed preoperatively. Three patients showed a small vertical deviation without any specific causative factors. CONCLUSIONS: Fifty percent of the cases of diplopia were associated with either direct trauma or anesthetic myotoxicity to the extraocular muscles, in which overactions were more common than underactions. Thirty-two percent of the patients were presumed to have sensory strabismus, which suggested the importance of preoperative examination for strabismus as well as providing an explanation about the risk of postoperative diplopia before surgery.

Adult↗
PubMed2004

Diplopia after cataract surgery: comparative results after topical or regional injection anesthesia.

OBJECTIVE: To compare the incidence of diplopia after topical or regional injection anesthesia in cataract surgery. STUDY DESIGN: Retrospective, noncomparative interventional case series. PARTICIPANTS AND METHODS: Three thousand five hundred forty-two consecutive cataract surgeries, performed from March 1998 to December 2001, were studied. MAIN OUTCOME MEASURES: Incidence and mechanisms of diplopia. RESULTS: Two thousand one hundred twenty-two patients were operated under regional and 1420 under topical anesthesia. Twenty-four cases of diplopia were observed, 21 (87.5%) in the regional group and 3 (12.5%) after topical anesthesia (P = 0.005). Eleven cases (45.8%) were secondary to motility problems, all in the regional anesthesia group (P = 0.006). Eight cases (33.3%) were secondary to refractive errors or intraocular lens luxation, 5 after regional and 3 after topical anesthesia (P = 0.88). Five cases (20.8%) were secondary to fusion loss, all in the regional anesthesia group (P = 0.06). CONCLUSIONS: In our study, topical anesthesia was associated with a lower incidence of diplopia relative to regional injection anesthesia. No cases of diplopia secondary to fusion loss or muscle damage were found after topical anesthesia surgery.

Administration, Topical↗
PubMed2005

Idiopathic orbital hemorrhage related to the inferior rectus muscle: a rare cause for acute-onset diplopia and unilateral proptosis.

PURPOSE: To report 6 patients with spontaneous orbital hemorrhage in relation to the inferior rectus muscle. DESIGN: Retrospective observational case series. PARTICIPANTS: Six patients with acute onset orbital pain, diplopia, and proptosis referred to the orbital clinic at the Royal Victorian Eye and Ear Hospital, January 1995 through December 2004. METHODS: Review of clinical history, imaging studies, and follow-up. MAIN OUTCOME MEASURES: Resolution of proptosis and diplopia and imaging studies of the orbit, including computed tomography (CT), magnetic resonance imaging (MRI), or both. RESULTS: Six patients (4 men, 2 women; mean age, 68 years) were referred with acute onset of unilateral proptosis and diplopia. None of the patients had a history of bleeding disorder. Visual acuity and intraocular pressure were normal; 3 patients showed marked limitation in upgaze on the affected side. Imaging studies of the orbit by CT, MRI, or both showed inferior orbital hemorrhage either within (4 patients) or adjacent to (2 patients) the inferior rectus muscle, possibly within the muscular sheath. Symptoms resolved completely in all but 1 patient, who had persistent diplopia in extreme upgaze. Follow-up CT, MRI, or both showed complete resolution in 3 patients and mild persistent inferior rectus muscle thickening in 2 patients. CONCLUSIONS: Acute onset proptosis and diplopia may be secondary to spontaneous orbital hemorrhage within the inferior rectus muscle or its sheath with no other orbital or systemic pathologic features. Symptoms resolved spontaneously over the course of days to weeks, and orbital imaging showed complete resolution or mild persistent enlargement of the muscle without significant symptoms.

Acute Disease↗
PubMed2005

[Intermittent diplopia after prolonged downward gaze to the right: what is the differential diagnosis?].

In general, intermittent diplopia evokes suspicion of ocular myasthenia gravis. However, other etiologies such as Brown syndrome or myokymia of the superior oblique may provoke intermittent diplopia. We present a case of intermittent diplopia due to a tumor in the cavernous sinus. A 59-year-old patient reported intermittent diplopia after prolonged downward gaze to the right. All other gaze directions failed to provoke symptoms. In 1992, the diagnosis of inactive macroadenoma of the pituitary gland was established and the patient underwent surgery and radiation therapy. At physical examination, prolonged downward gaze to the right of about 2 minutes provoked paresis of abduction, slight ptosis, and restriction of elevation on the left side, corresponding to sixth nerve palsy and palsy of the superior branch of the third nerve on the left side. MRI showed a relapse of the macroadenoma with infiltration of the cavernous sinus on the left side. The patient underwent surgery then focal radiation (gamma-knife). The clinical course was favourable and at the follow-up examination six months later, no diplopia was reported.

Abducens Nerve Diseases↗
PubMed2000

Vertical diplopia.

The diagnosis of an acquired vertical strabismus is not always straightforward. There is no one specific test that will diagnose a vertical deviation. The clinical presentation, signs, and symptoms are the driving forces that will help lead to the correct diagnosis. Patients with binocular vertical diplopia may have symptoms of recent onset or that have been long-standing. Others may not even be completely aware that their ocular symptoms are attributable to a doubled vertical image. The differential diagnosis for vertical diplopia includes oculomotor nerve palsy, superior oblique palsy, restrictive ophthalmopathies, myasthenia gravis, and skew deviation. This differential diagnosis is best used to sort out signs and symptoms in a patient with a vertical misalignment and diplopia. Because most clinicians feel more comfortable addressing the patient with complaints of horizontal diplopia, this paper will discuss the causes of vertical diplopia so that recognition will be easier, thus leading to more accurate diagnoses.

Diplopia↗
PubMed2002

A case of paradoxical diplopia in large-angle consecutive exotropia.

PURPOSE: To describe the investigation and subsequent management of paradoxical diplopia in unsightly exotropia. A 32-year-old lady requested surgical correction of a large manifest consecutive exotropia which, on initial correction with any base-in prism, was accompanied by paradoxical diplopia. METHODS: Botulinum toxin to the right lateral rectus reduced the deviation to 30 delta over a one-week period. The residual deviation was corrected with base-in Fresnel prisms which the patient wore constantly for another two weeks. Although there was demonstrable diplopia initially, it disappeared after 3-4 days of prism wear. Surgery was carried out comprising right lateral rectus recession (6 mm) and right medial rectus advancement from 12 mm to 6 mm posterior to the limbus. RESULTS: There was no diplopia following the surgery and the residual exodeviation measured 6 delta for near and 16 delta for distance (fixing OD). The patient remains symptom-free and cosmetically excellent. CONCLUSION: A gradual progressive reduction in the deviation using a combination of Botulinum toxin and prisms allowed a more informative conclusion to be made regarding the potential post-operative sensory status in this patient, by allowing her to slowly adjust to an altered ocular alignment. In patients with non-functional strabismus who may be at risk from post-operative diplopia, a trial with prisms over a few weeks with or without the addition of Botulinum toxin is advocated.

Adult↗
PubMed2001

Botulinum toxin to the lateral rectus for the treatment of esotropia with paradoxical diplopia.

A retrospective review of six patients with paradoxical diplopia in the presence of esotropia was carried out. All patients were treated with botulinum toxin to the lateral rectus of the affected side. Five patients had no diplopia post toxin and the remaining patient had diplopia which could be ignored. The number of injections per patient ranged between 3 and 34. Three patients went on to have surgery to increase the angle of esotropia, with relief of diplopia. We conclude that botulinum toxin has a role in the treatment of esotropic patients with paradoxical diplopia.

Adolescent↗
PubMed1996

Diplopia after surgical repair of orbital floor fractures.

Blowout fractures of the orbit are common sequelae to blunt facial trauma. Many aspects of this injury have been studied, in particular, the timing of and indications for surgical intervention. Although diplopia is often an indication for surgery and is presented to patients as a potential postoperative complication, the incidence of diplopia after surgical repair of orbital blowout fractures has not been well studied. We retrospectively studied 54 patients who underwent repair of an orbital blowout fracture. A minimum of 6 months follow-up was available for all patients included in the study. A total of 47 of 54 (86%) patients had clinically significant diplopia preoperatively, and 20 of 54 (37%) remained diplopic. A total of 17 of 54 (31%) fractures involved the medial wall and orbital floor, and 13 of these 17 patients (86%) had postoperative diplopia. Patients with combined orbital floor and medial wall fractures appear to be at higher risk for clinically significant diplopia postoperatively than those with fractures of the orbital floor only. The explanation for this observation may be related to a greater difficulty in restoring the preoperative contour of orbits with combined fractures.

Adolescent↗