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PubMed2006

Refractive surgery in patients with high myopic anisometropia.

PURPOSE: To assess the efficacy and safety of LASIK in patients with high myopic anisometropia and to provide specific screening guidelines for anisometropic patients undergoing refractive surgery. METHODS: Twenty-six eyes of 16 patients with high myopic anisometropia (>3.0 diopters) were enrolled in this study. Complete pre- and postoperative ophthalmologic and orthoptic examinations were performed. The preoperative orthoptic examination was done with glasses and contact lenses. Twenty-two eyes of 13 patients underwent uncomplicated LASIK; the second eye was treated 2 weeks after the first eye. Patients were examined 1 day, 7 days, and 1, 3, 6, and 12 months after surgery. RESULTS: Thirteen patients obtaining good results at red glass bar test (RGB) underwent LASIK without postoperative diplopia; four showed an improvement of the sensorial assessment. Three patients were excluded from surgery because of diplopia with RGB values <4 to 5. LASIK temporarily induced diplopia in the suppressed eye of one patient; however, the diplopia disappeared after surgery of the fixating eye. CONCLUSIONS: Patients with high myopic anisometropia and a weak sensorial state who undergo refractive surgery may be at risk for postoperative diplopia. We suggest clinical guidelines to reduce the occurrence of this complication.

Adult↗
PubMed2004

Endonasal endoscopic orbital decompression in patients with Graves' ophthalmopathy.

AIM: To present the results of endonasal endoscopic orbital decompression in patients with Graves' ophthalmopathy. METHODS: Endonasal endoscopic orbital decompression was performed in 32 orbits of 21 patients with Graves' ophthalmopathy. In 17 patients the surgery was performed because of active ophthalmopathy non-responsive to conservative treatment, and in 4 patients for esthetic reasons. Preoperative and postoperative examination included visual acuity, examination of the eyelids and cornea, ocular motility, cover testing, Hertel exophthalmometry, and applanation tonometry. RESULTS: Visual acuity improved from preoperative 0.81+/-0.28 (mean +/- standard deviation) to postoperative 0.92+/-0.21 (p=0.0032, Student t-test). Retraction of upper and lower eyelids, as well as exposure keratitis, was reduced after operation (p<0.001). Mean proptosis reduction in all orbits was 4.6+/-1.7 mm (p<0.001). An average reduction of intraocular pressure was 3.4+/-3.0 mmHg (p<0.001). New-onset diplopia developed in 8 patients. Diplopia persisted in 9 out of 11 patients who had preoperative diplopia. Two patients experienced postoperative relief of diplopia. Ocular motility was subsequently corrected by eye muscle surgery in 13 eyes, whereas prisms were used in other 5 manifestly strabic eyes. CONCLUSIONS: Endonasal endoscopic orbital decompression procedure improved visual acuity, decreased proptosis and intraocular pressure, and also had favorable cosmetic results in most patients. Post decompression diplopia and strabismus were successfully managed by either eye muscle surgery or application of prisms.

Adult↗
PubMed2004

Could visual neglect induce amblyopia?

Oculomotor nerve disease is a common cause of diplopia. When strabismus is present, absence of diplopia has to induce the research of either uncovering of visual fields or monocular suppression, amblyopia or blindness. We describe the case of a 41-year-old woman presenting with right oculomotor paresis and left object-centred visual neglect due to a right fronto-parietal haemorrhage expanding to the right peri-mesencephalic cisterna caused by the rupture of a right middle cerebral artery aneurysm. She never complained of diplopia despite binocular vision and progressive recovery of strabismus, excluding uncovering of visual fields. Since all other causes were excluded in this case, we hypothesise that the absence of diplopia was due to the object-centred visual neglect. Partial internal right oculomotor paresis causes an ocular deviation in abduction; the image being perceived deviated contralaterally to the left. Thus, in our case, the neglect of the left image is equivalent to a right monocular functional blindness. However, bell cancellation test clearly worsened when assessed in left monocular vision confirming that eye patching can worsen attentional visual neglect. In conclusion, our case argues for the possibility of a functional monocular blindness induced by visual neglect. We think that in presence of strabismus, absence of diplopia should induce the search for hemispatial visual neglect when supratentorial lesions are suspected.

Adult↗
PubMed1977

Blunt trauma to the eye.

1. Blunt trauma to the orbital region may result in a blowout fracture, characteristically found in the orbital floor, which may contain herniated orbital contents including both inferior muscles of the eye. Persistent diplopia continues as a problem in a significant number of patients following the surgical management of a blowout fracture of the orbit. 2. Prompt recognition and treatment of blowout fractures exhibiting diplopia is usually successful. Inferior rectus and inferior oblique muscles incarcerated in a blowout fracture site for periods varying from two months to nine years may fail to function properly even following successful release of the entrapped muscles. There is some presumptive evidence to suggest a myogenic or neurogenic cause for such dysfunction. 3. Vertical diplopia that persists beyond three months following release of entrapped muscle tissue requires surgical correction, depending on the degree of vertical dissociation. 4. Motility surgery was required in 18 of 20 cases of persistent diplopia. Multiple muscle combinations are frequently required to achieve success. The criterion for a successful result was elimination of vertical diplopia in the primary and reading positions.

Eye Injuries↗
PubMed1990

Botulinum treatment of strabismus following retinal detachment surgery.

Twenty patients with strabismus and diplopia following surgery for retinal detachment were treated by botulinum toxin injection of the eye muscles. Twelve patients had regained fusion with elimination of diplopia in the primary position at the time of examination, 5 to 96 months after treatment (mean, 24 months). Three patients had partial diplopia elimination, and five patients continued to have diplopia.

Adult↗
PubMed1995

Ocular neuromyotonia: clinical features, physiological mechanisms, and response to therapy.

Ocular neuromyotonia (ONM) is a rare disorder characterized by episodic diplopia, occurring either spontaneously or following sustained eccentric gaze. Most patients have had prior radiation therapy to the sellar and parasellar region. ONM is thought to reflect impaired muscle relaxation due to inappropriate discharges from oculomotor, trochlear, or abducens neurons or axons with unstable cell membranes. Patients with ONM often benefit from membrane stabilizing agents such as carbamazepine. Here we describe a 71-year-old man, with no history of radiation therapy, who for 18 months had had transient episodic diplopia that occurred after down gaze. Clinical examination indicated ONM in muscles supplied by the right oculomotor nerve. Binocular scleral search coil eye movement recordings revealed a defect not only of muscle relaxation but also of maximal muscle contraction. The patient was treated with carbamazepine 200 mg per day with complete resolution of his symptoms. ONM may be more common than previously recognized, and patients with unexplained transient episodic diplopia should be specifically tested for diplopia and ocular misalignment following sustained eccentric gaze.

Aged↗
PubMed2004

Bilateral sixth cranial nerve palsy after unintentional dural puncture.

PURPOSE: Bilateral sixth nerve palsy is a known though uncommon complication following dural puncture. The recommended treatment consists of hydration and alternate monocular occlusion. The value and the timing of an epidural blood patch (EBP) for sixth nerve palsy remains controversial as some authors have demonstrated benefits in performing an EBP early in course of the nerve palsy whereas others have not found any advantage when an EBP was performed later. CLINICAL FEATURES: A 40-yr-old woman developed bilateral sixth nerve palsy ten days after an unintentional dural puncture. An EBP was done within 24 hr after the onset of the symptoms and immediate improvement of the diplopia was noted by the patient and confirmed by an ophthalmologist. Complete resolution of the diplopia occurred 36 days after the dural puncture. CONCLUSION: Blood patching within 24 hr of the onset of diplopia may be a reasonable treatment for ocular nerve palsy as it relieved the postdural puncture headache and produced partial improvement of the diplopia.

Abdominal Pain↗
PubMed1995

Reversals of the colour-depth illusion explained by ocular chromatic aberration.

Although many colour-depth phenomena are predictable from the interocular difference in monocular chromatic diplopia caused by the eye's transverse chromatic aberration (TCA), several reports in the literature suggest that other factors may also be involved. To test the adequacy of the optical model under a variety of conditions, we have determined experimentally the effects of background colour on perceived monocular chromatic diplopia and perceived depth (chromostereopsis). A Macintosh colour monitor was used to present red, blue, and green test stimuli which were viewed monocularly or binocularly (haploscopically) through 1.78 mm artificial pupils. These apertures were displaced nasally and temporally from the visual axis under controlled conditions to induce a variable degree of TCA. Monocular chromatic diplopia and binocular chromostereopsis were measured for red and blue targets, and also for red and green targets, presented on either a black background or on a background which was composed of the sum of the targets' spectral composition (e.g. red and blue presented on magenta; red and green presented on yellow). In all cases, chromatic diplopia and chromostereopsis were found experimentally to reverse in sign with this change in background. Furthermore, we found that a given coloured target could be located in different depth planes within the same display when located on different background colours. These seemingly paradoxical results could nevertheless be explained by a simple model of optical TCA without the need to postulate additional factors or mechanisms.

Adult↗
PubMed2006

Correlation between ocular motility and evaluation of computed tomography in orbital blowout fracture.

PURPOSE: To investigate outcomes of management of blowout fracture patients evaluating computed tomography (CT) findings and diplopia. DESIGN: Single-center retrospective interventional consecutive case series. METHODS: This study included 113 cases of pure blowout orbital fracture with diplopia. We investigated patients' satisfaction based on percentage of Hess area ratio (HAR%) on the Hess chart, evaluating fracture type and number of points of contact of extraocular muscles to the fracture edge (points of muscle contact) based on CT. RESULTS: Of the patients with HAR% > 85%, most experienced no diplopia. Sixty-two (55%) of 113 patients underwent surgical repair to improve diplopia, and 31 (50%) of 62 patients had surgery within three days after injury. A favorable outcome with HAR% > 85% was seen in 81 (72%) of 113 patients. Of 32 patients with two points of muscle contact at one extraocular muscle, 15 patients (47%) improved with a final HAR% > 85%. None of the four patients with medial wall fracture and two points of muscle contact had improved in their final HAR% > 85%. Thirty (97%) of 31 patients with either floor or medial wall fracture and no muscle involvement had a favorable outcome regardless of fracture type. Initial CT findings of the rectus muscle was strongly correlated with a mean initial HAR% (r = -0.94) and a mean final HAR% (r = -0.87). CONCLUSIONS: The clinical manifestations and prognosis of patients were approximately predicted through the analysis of CT on fracture type and number of points of contact of an extraocular muscle to the fracture edge.

Adolescent↗
PubMed2005

Extraocular muscle surgery for extorsion after macular translocation surgery new surgical technique and clinical management.

PURPOSE: To report a new extraocular muscle surgery procedure for large-angle extorsion, and clinical management of subjective tilt and diplopia after full macular translocation (MT360). DESIGN: Consecutive retrospective case series. PARTICIPANTS: Seven patients with downward MT360 were evaluated after MT360, both before (preoperative) and after (postoperative) extraocular muscle surgery, with at least 6 months' follow-up. METHODS: Information gathered included demographics, visual acuity, ocular motility, torsion by Maddox rod, ocular history, and symptoms of visual disturbance. Surgery on extraocular muscles was performed based on the magnitude of torsion measured after MT360 surgery. MAIN OUTCOMES MEASURES: Maddox rod testing of torsion after MT360, and both preoperative and postoperative extraocular muscle surgery. RESULTS: Mean preoperative torsion was reduced from 45.4+/-11.3 degrees to 8.3+/-4.8 degrees (at 6 months after MT360) (P = 0.03). Extraocular muscle surgery slightly reduced the mean hypertropia of the operated eye (preoperative, 20+/-10 prism diopters [PD], vs. postoperative, 11+/-6 PD) (P = 0.06). Mean exotropia was affected minimally by extraocular muscle surgery (preoperative, 22+/-31 PD, vs. postoperative, 20+/-24 PD). Three patients required a second extraocular muscle surgery (performed on the fellow eye) to correct residual extorsion and diplopia. Overall, 85% (6/7) of patients were free of both diplopia and tilt after 1 or 2 extraocular muscle surgeries. CONCLUSIONS: Although our patients continued to have significant horizontal/vertical strabismus postoperatively, the extraocular muscle surgery performed was successful in reducing the torsional misalignment enough such that the remaining diplopia could be successfully ignored or suppressed.

Aged↗
PubMed2006

Early versus late orbital decompression in Graves' orbitopathy: a retrospective study in 125 patients.

PURPOSE: To determine if early rehabilitative orbital decompression in Graves' orbitopathy (GO) leads to a more effective postoperative outcome than the same intervention performed at a later, more likely, fibrotic stage. DESIGN: Retrospective comparative case series. PARTICIPANTS: The medical records of all GO patients treated with a 3-wall orbital decompression at our institution between 1990 and 2000 were reviewed retrospectively. Only patients operated bilaterally for aesthetic rehabilitation, without preoperative diplopia, were included. They were divided into group 1 (duration of GO < 4 years) and group 2 (duration > or = 4 years). METHODS AND MAIN OUTCOME MEASURES: The 2 groups were compared for demographics, smoking habits, preoperative characteristics (immunosuppressive treatments, Hertel values, score in NOSPECS [no signs or symptoms, only signs, soft tissue involvement with symptoms and signs, proptosis, extraocular muscle involvement, corneal involvement, sight involvement] class 2, degree of extraocular muscle enlargement), and surgical outcome (mean reduction of exophthalmos, symmetry of exophthalmos reduction, reduction in upper and lower lid retraction, any persistent periorbital swelling requiring cosmetic eyelid surgery, postdecompression diplopia). RESULTS: The medical records of 125 of 376 patients were selected for this study. There were no differences between group 1 (n = 70) mean GO duration (2.2+/-0.8 years) and group 2 (n = 55) mean GO duration (9.0+/-5.4 years) with respect to demographics, smoking habits, and preoperative characteristics except for the degree of extraocular muscle enlargement, which was significantly greater in group 1 (P = 0.039). There was no difference in surgical outcomes between the 2 groups, with the exception of postdecompression diplopia, which was significantly more frequent in group 1 than in group 2 (29% vs. 13%, P = 0.033). CONCLUSIONS: In GO, early rehabilitative orbital decompression does not improve surgical outcome and is associated with a higher risk of postdecompression diplopia.

Adult↗
PubMed2006

Evaluation of the National Eye Institute visual function questionnaire in Graves' ophthalmopathy.

PURPOSE: To determine the potential suitability of the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) for measuring health-related quality of life (HRQL) in patients with Graves' ophthalmopathy. DESIGN: Cross-sectional study. PARTICIPANTS: Thirty adult patients with mild to severe Graves' ophthalmopathy. METHODS: Participants self-administered the NEI VFQ-25 and completed a semistructured interview to provide feedback about the questionnaire. The percentage of responses at the maximum and minimum value was calculated to assess ceiling and floor effects, respectively, for the 12 subscales of the NEI VFQ-25. The NEI VFQ-25 scores were compared for Graves' ophthalmopathy patients who reported symptomatic diplopia and those who did not report diplopia using univariate and multivariate linear regression models. MAIN OUTCOME MEASURES: The NEI VFQ-25 subscale and composite scores. RESULTS: Health-related quality of life in those with Graves' ophthalmopathy was moderately impaired, with median composite score of 69. The greatest impairment was measured in the Mental Health (median, 50) and the Role Difficulties (median, 50) subscales. Significant ceiling effects were seen in 7 of the 12 subscales. More than two thirds of Graves' ophthalmopathy patients perceived that the NEI VFQ-25 lacked items relevant to their disease. The NEI VFQ-25 scores were lower for those with diplopia symptoms (composite score, 61) compared with those without diplopia (composite score, 90). Comparing these 2 groups, the largest differences were measured in the Driving and Peripheral Vision subscales. CONCLUSIONS: The NEI VFQ-25 includes many items that are applicable to Graves' ophthalmopathy patients. However, it shows significant ceiling effects in more than half of the subscales and it lacks items on issues that are important to Graves' ophthalmopathy patients, such as altered appearance and ocular discomfort. Efforts to develop an HRQL instrument that adds Graves' ophthalmopathy-specific items to relevant aspects of the NEI VFQ-25 are warranted.

Adult↗
PubMed2001

Skew deviation as a complication of cardiac catheterization.

PURPOSE: To report three patients who developed diplopia and skew deviation after cardiac catheterization. DESIGN: Interventional case series. METHODS: Three patients complained of diplopia after cardiac catheterization for myocardial infarction (two male patients) or aortic dissection (one female patient). Examination demonstrated skew deviation in each patient. RESULTS: Diplopia and skew deviation were mild and resolved completely in 4 months (case 1), 16 months (case 2), and 1.5 months (case 3). Sensitive signs of minor ischemic damage to the brain stem that cause such disorders are not detectable by neuroimaging. CONCLUSION: Rarely, cardiac catheterization may be complicated by diplopia and skew deviation.

Aged↗
PubMed1993

Neuro-ophthalmologic findings in chordoma and chondrosarcoma of the skull base.

Review of the clinical features of 48 patients with chordoma and 49 patients with low-grade chondrosarcoma of the skull base disclosed overlapping clinical profiles but distinctive features. Both tumors occurred at all ages but chondrosarcoma tended to occur in the third and fourth decades. Twenty-five (52%) of the patients with chordoma and 24 (49%) of the patients with chondrosarcoma had ocular symptoms (diplopia or visual impairment) as the initial manifestation of the disease. Of the 59 patients (both groups) with diplopia, the diplopia was initially intermittent in 25 (42%). Headache and diplopia from an insidious abducens nerve palsy was most common in both groups. Abducens nerve palsy occurred in 22 (46%) of the patients with chordoma and 23 (47%) of the patients with chondrosarcoma. Normal examination results were more common in patients with chordoma, whereas visual loss, facial numbness, and multiple cranial neuropathies were more common in patients with chondrosarcoma. The similarities in the clinical features of these tumors reflect their common origin at the central skull base and the vulnerability of the abducens nerves at that site. The differences reflect the tendency of chordomas to originate from the clivus and chondrosarcomas to originate from the temporal bone.

Adolescent↗
PubMed2005

[Transient trochlear nerve palsy as the presenting neurological sign of panarteritis nodosa].

INTRODUCTION: Panarteritis nodosa (PAN) is a systemic vasculitis affecting small and medium-sized arteries. Neuro-ophthalmological complications of PAN are rare but numerous, and may affect the eye, the visual and the oculomotor pathways. Such complications occur mainly in patients previously diagnosed with PAN. OBSERVATION: A 51-year-old woman presented with an isolated right trochlear (IV) palsy, in the setting of headaches and fluctuating fever of unknown etiology. Erythrocyte sedimentation rate was 13 mm and full blood cell count was normal. Previous chest X-ray and blood studies were negative for an infection or inflammation. Orbital and cerebral CT scan was normal. Spontaneous recovery of diplopia ensued over four days. Two days later, paresthesia and sensory paresis of the dorsal portion of the left foot were present. Lumbar puncture revealed 14 leucocytes (76 percent lymphocytes) with elevated proteins, but blood studies and serologies were negative. A diagnosis of undetermined meningo-myelo-radiculoneuritis was made. Because of a possible tick bite six weeks previously the patient was empirically treated with 2 g intravenous ceftriaxone for 3 weeks. Fever rapidly dropped. Six weeks after the onset of diplopia, acute onset of blindness in her right eye, diffuse arthralgias and fever motivated a new hospitalization. There was a central retinal artery occlusion of the right eye. Blood studies now revealed signs of systemic inflammation (ESR 30 mm, CRP 12 mg/L, ANA 1/80, pANCA 1/40, leucocytosis 12.4 G/L, Hb 111 g/L, Ht 33 percent). Biopsy of the left sural nerve revealed arterial fibrinoid necrosis. A diagnosis of PAN was made. CONCLUSIONS: Transient diplopia can be the heralding symptom of a systemic vasculitis such as PAN, giant cell arteritis and Wegener granulomatosis. In this patient the presence of accompanying systemic symptoms raised a suspicion of systemic inflammation, but the absence of serologic and imaging abnormalities precluded a specific diagnosis initially. A few weeks later, the presence of a second ischemic event (retinal) and positive blood studies led to a further diagnostic procedure. Oculomotor and abducens palsies have rarely been reported in association with PAN. We report the first case of trochlear nerve paresis as the inaugural neurological sign of PAN. This case highlights the importance of considering inflammatory systemic disorders in patients with acute diplopia particularly when they are young, lack vascular risk factors or cause, and complain of associated systemic symptoms.

Diplopia↗
PubMed2002

Prognosis of ischemic internuclear ophthalmoplegia.

OBJECTIVES: To determine the prognosis of internuclear ophthalmoplegia (INO) caused by infarction. DESIGN: Multicenter, retrospective observational case series. PARTICIPANTS: Thirty three patients with ischemic-related INO. METHODS: Chart review of clinical details. MAIN OUTCOME MEASURE: Resolution of diplopia in primary position. RESULTS: Of the group, 78.8% demonstrated resolution of diplopia in primary position with an average time to resolution of 2.25 months. The presence of associated neurologic symptoms (vertigo, ataxia, dysarthria, facial palsy, pyramidal tract signs) correlated with a worse prognosis for resolution of diplopia. When performed magnetic resonance imaging (MRI) demonstrated the causative infarct in only 52% of cases; the presence of an MRI-demonstrable lesion was not significantly associated with prognosis for resolution. CONCLUSIONS: Similar to ischemic ocular motor palsies, most ischemic-based INO become asymptomatic in primary position over 2 to 3 months. The presence of associated features correlated with persistent diplopia. MRI has limited yield in demonstrating the causative infarct.

Aged↗
PubMed1987

Use of a modified binocular visual field to assess cyclodiplopia.

The patient who notes binocular diplopia may indicate that horizontal, vertical, or cyclorotary components are present. Although the single binocular visual field provides an indication of the area which is free of horizontal and vertical diplopia, it does not assess cyclorotary diplopia. A simple modification of the single binocular visual field which allows determination of the clinical significance of the cyclorotary component of diplopia is presented. Reproducible information is easily obtained, assisting in patient follow-up and management.

Adolescent↗
PubMed1991

Double vision as a presenting symptom in an ophthalmic casualty department.

All patients presenting with double vision as a principal symptom who presented to the Casualty Department of Moorfields Eye Hospital over a nine month period were prospectively investigated. Two hundred and seventy five patients were identified accounting for 1.4% of all casualties. Monocular diplopia was commoner than expected accounting for 69 cases (25.1%) and was almost always a genuine symptom attributable to uniocular pathology, most commonly lenticular or corneal pathology. Two hundred and six patients (74.9%) had binocular diplopia and in most cases an aetiology was established. Cranial nerve palsies were the commonest cause of binocular diplopia accounting for 81 cases. Other causes were classified as convergence or accommodation problems, decompensating phorias, traumatic, muscular, orbital lesions, supranuclear lesions, and other miscellaneous conditions. In eight cases of monocular and 23 cases of binocular diplopia no cause for the symptoms could be identified.

Corneal Diseases↗