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Fifty-one patients with diplopia were investigated prospectively to assess the correlation between their subjective impression of disability from diplopia and an objective measurement obtained using a method of assessing the field of binocular single vision (BSV). The objective score generally exceeded the patient's own assessment and the scoring method has been modified to improve the correlation.
The authors present a new method for plotting and quantitating the field of binocular single vision (BSV). They modified a Goldmann perimeter to project a fusion target in the form of a cross (+). Unlike previous methods that used a spot, which is a poor fusion target that cannot detect cyclotorsion, the authors' method permits a single tester to plot BSV fields in patients who have any combination of horizontal, vertical, and cyclotorsional diplopia. The BSV fields were plotted in 23 patients with acquired diplopia using both the fusion target and the spot. Scoring was performed using a new scoring template weighted to the functionally important areas around primary and reading positions. Nine patients (39%) had scores for the two targets that differed by more than 10%. The authors' method yields BSV scores that are reproducible and easy to perform and that can be used for preoperative and postoperative assessments, serial monitoring of changes over time, and disability evaluations.
PURPOSE: To compare anesthesia methods with resultant strabismus patterns in patients with vertical diplopia after cataract surgery. METHODS: The authors analyzed 28 consecutive patients with acquired vertical diplopia after cataract surgery to identify the strabismus pattern. The method of anesthesia administration was available in 21 patients. Three orbital dissections with simulated retrobulbar blocks were performed on cadavers to ascertain the possibility of injuring the vertical rectus muscles at the time of injection. RESULTS: Fifty percent of the involved muscles were overactive, 39 percent were restricted, and 11 percent were paretic. Eleven patients received retrobulbar, and ten received peribulbar anesthesia. The inferior rectus in 17 patients and the superior rectus muscle in 11 were involved. The odds of damaging the inferior rectus, as opposed to the superior rectus muscle, with peribulbar anesthesia was 4.8 times higher than with retrobulbar blocks. Cadaveric dissections showed the likelihood of direct needle injury to either vertical recti with retrobulbar blocks. CONCLUSIONS: In this patient population, permanent vertical strabismus after cataract surgery results more often from overacting or restricted muscles than from primary muscle paresis. Both the superior and inferior recti can be injured with retrobulbar anesthesia, but peribulbar injections affect the inferior rectus muscle more frequently.
PURPOSE: The purpose of the study is to describe the clinical characteristics and surgical management of strabismus associated with chronic progressive external ophthalmoplegia. METHODS: The authors present four patients with chronic progressive external ophthalmoplegia and strabismus requiring extraocular muscle surgery, with attention to presenting symptoms, patterns of misalignment, results of surgical and nonsurgical therapies, and associated ocular or systemic conditions or both. RESULTS: Three patients reported diplopia before surgery. One patient presented with an esotropia, one with an exotropia, and two with hypertropia. Three patients required only one strabismus surgery, and one patient required multiple surgeries. CONCLUSIONS: Chronic progressive external ophthalmoplegia may have clinical characteristics similar to those of myasthenia gravis or thyroid ophthalmopathy. Patients with chronic progressive external ophthalmoplegia and strabismus frequently have diplopia in primary position and may benefit from extraocular muscle surgery to improve alignment. In addition, because these patients typically have poor motor fusion, prisms often are useful adjuncts to surgery.
Ocular neuromyotonia is a rare clinical entity, which is characterized by spontaneous spasm of ocular muscles resulting in paroxysmal diplopia and strabismus. Inappropriate discharges from ocular motor neurons or axons with unstable cell membranes may cause the sustained contraction of their respective ocular muscles. In most cases, ocular neuromyotonia resulted from radiation therapy to the parasellar and sellar regions or compressive lesions on ocular motor nerves. Among 30 patients reported in the literatür only six patients were accepted as idiopathic. Here, we reported a patient with third nerve myotonia representing with spells of diplopia. No lesion was found and she was accepted as idiopathic ocular neuromyotonia.
PURPOSE: To evaluate the safety and complications of phacoemulsification in a series of patients with congenital coloboma and cataract. SETTING: University-based hospital practice. METHODS: A retrospective review was conducted of consecutive patients who had coloboma and cataract and had phacoemulsification between January 1987 through December 1998. Complications and visual acuity 2 months postoperatively were assessed. RESULTS: Mean age of 7 cases at the time of surgery was 41.6 years +/- 11.1 (SD). Visual acuity improved in 6 of 7 eyes; 1 eye had no change. Six eyes had no serious complications. In 1 eye, a retinal detachment was observed postoperatively, but there was no loss in visual acuity. Another patient developed postoperative monocular diplopia from exposure of the intraocular lens (IOL) edge within the inferonasally located corectopia associated with the coloboma. Nonsurgical treatment was unsuccessful, but this symptom resolved after surgical pupilloplasty. CONCLUSIONS: The results of this small case series affirm that clinically significant cataract develops at a younger age in eyes with congenital coloboma than in eyes with typical age-related nuclear sclerotic cataract. Monocular diplopia, a potential complication after cataract surgery in these eyes, can be managed by pupilloplasty. The improved vision in this study indicates that phacoemulsification and IOL placement are safe and beneficial in patients with typical congenital coloboma and cataract.
PURPOSE: To determine the associated factors of persistent diplopia after retrobulbar anesthesia. SETTING: Strabismus Section, Department of Ophthalmology, Seoul Municipal Boramae Hospital, Seoul, Korea. METHODS: A prism and cover test in the diagnostic positions of gaze, force-generation test, and forced-duction test were performed in 11 patients with vertical rectus overaction after retrobulbar anesthesia. A Tensilon (edrophonium chloride) test, thyroid function test, and orbit computed tomography were performed in 8 patients. RESULTS: None of the 11 patients reported diplopia before receiving local anesthesia. Ten patients showed ipsilateral hypertropia with superior rectus overaction and 1 patient, ipsilateral hypotropia with inferior rectus overaction. One patient had partial fibrosis of the medial half of the superior rectus, presumably caused by a bridle suture. Four (50%) of 8 patients in whom a thyroid function test was performed had abnormal findings; 1 had a history of systemic dysthyroidism. CONCLUSIONS: In this study, permanent vertical strabismus after local anesthesia was entirely the result of overactive vertical rectus muscles, mostly the superior rectus muscle. Half the patients who had a thyroid function study had abnormal findings.
The visual acuity, bifocal capability and quality of vision were evaluated in 14 patients who had implantation of a 3M diffractive posterior chamber intraocular lens (IOL). Initially, four patients had an existing monofocal IOL in the fellow eye as controls. Ten of patients had the unoperated fellow eye as controls. Three of these patients subsequently had monocular IOL implantation, bringing the number of pseudophakic monofocal IOL control eyes to seven. All but two patients noted monocular diplopia; in three patients this was so intolerable that the diffractive lens was explanted and exchanged for a monofocal lens, following which the visual acuity improved by an average of two Snellen lines and complaints of monocular diplopia disappeared. Three patients had bilateral 3M diffractive lens implantation.
We present a case of decompensated nerve IV palsy with vertical diplopia afer bilateral laser in situ keratomileusis. As the patient was given monovision, we believe diplopia occurred with a decrease in vision in 1 eye and interruption of fusion. Although corrective spectacles to restore equal vision at distance were prescribes, the patient needed a prism to eliminate her double vision. We suggest a careful cover/uncover test and versions assessment in all candidates for refractive surgery who want monovision correction and a full ocular motility evaluation if there is any doubt about binocular issues.
We present the case of a 75-year-old man with ankylosing spondylitis who developed surgically induced necrotizing scleritis (SINS) more than 3 years after uneventful extracapsular cataract extraction and posterior chamber intraocular lens implantation. The patient presented with a painful eye and increasing vertical diplopia. To our knowledge, neither the association of SINS and ankylosing spondylitis nor vertical diplopia as its presenting complaint has been described.
PURPOSE: The posterior fixation suture (fadenoperation) is an effective treatment for complicated incomitant vertical strabismus. Traditional operative methods do not permit the simultaneous use of an adjustable recession of the same muscle. METHODS: Seven patients with incomitant vertical strabismus and diplopia were treated with a combined adjustable recession and posterior fixation suture of the same vertical rectus muscle. Preoperative vertical misalignments in the primary position ranged from 4 to 10 prism diopters. Vertical incomitance from the primary position into the field of action of the recessed vertical rectus muscle ranged from 6 to 30 prism diopters (mean, 17 prism diopters). This was the sole operation in five patients and was combined with other vertical muscle surgery in two others. RESULTS: All seven patients experienced improvement in their diplopia. Five of 7 patients (71%) required postoperative adjustments to achieve orthophoria in the primary position. This combined procedure reduced large deviations in the field of action of the recessed vertical muscle in all cases. Six of 7 patients (86%) did not require prismatic correction after this operation. One patient required prism only in his reading glasses. CONCLUSIONS: A combined adjustable recession and posterior fixation suture of the same vertical rectus muscle was effective in reducing or eliminating vertical incomitant strabismus.
INTRODUCTION: Long-term ocular alignment can be difficult to achieve in patients with consecutive and secondary (sensory) exotropia, and botulinum neurotoxin A (BTXA) is a recognized alternative to surgery in this group. PATIENTS AND METHODS: We reviewed the results of 44 patients aged 15 to 77 years (mean 31 years) who underwent their first BTXA injections from 1989 to 1990. In 30% of cases the choice of toxin treatment was made by the patient. In the remainder BTXA was recommended by the clinician to assess the risk of postoperative diplopia. Thirty-three patients (75%) were consecutively exotropic and 68% of patients had had previous strabismus surgery. The mean preinjection deviation was 41 delta of exotropia (range 12 to 85 delta exotropia) and the minimum mean angle change after 1 injection was 27 delta (range 0 to 57 delta). The average number of injections was 3 (range 1 to 17). RESULTS: Of the patient group, 59% went on to strabismus surgery, 14% continued to attend for maintenance treatment, and 9% were discharged with a small, stable deviation. The remainder were either followed up elsewhere or failed to reattend. CONCLUSIONS: Botulinum toxin appears to be a satisfactory treatment for constant exotropia in patients at risk of postoperative diplopia who have undergone multiple operations but, because more than half the group went on to surgery, surgery as a first therapy may be preferable in uncomplicated cases.
BACKGROUND: Strabismus can occur in as many as 30% of patients after scleral buckle procedures for retinal detachments. Most previous case series have reported on horizontal and vertical deviations. This study examines the frequency of torsion after scleral buckle procedures, the abnormalities of extraocular muscles seen during strabismus surgery, and the surgical procedures effective in improving torsion. METHODS: A chart review examined the records of all patients coming to a strabismus referral practice with diplopia reported > or =6 months after scleral buckle procedures. RESULTS: Forty-six percent of patients with diplopia after scleral buckle operations had torsion (88% extorsion, 12% intorsion). The 2 mechanisms that caused extorsion most frequently were inadvertent production of a superior oblique muscle palsy and tightening of the inferior rectus muscle from the underlying scleral buckle. Other mechanisms of extorsion were also seen. The mechanism for production of intorsion was scarring of the superior oblique muscle to the nasal border of the insertion of the superior rectus muscle. Surgical procedures were successful in reducing torsion 4 degrees or more in 59% of cases. CONCLUSION: In patients undergoing surgery for torsion after a scleral buckle procedure, exploration of the superior oblique muscle and the inferior rectus muscle may yield information about the mechanism involved in the production of the torsion.
PURPOSE: The purpose of this study was to define the role of botulinum toxin type A (BTXA) in surgically overcorrected exotropia. METHODS: A retrospective review was performed using the BTXA clinic database of more than 3500 patients to identify patients with a consecutive esotropia. RESULTS: Sixty patients met the inclusion criteria; the patients' ages ranged from 5 to 80 years. Before toxin treatment, an average of 1.8 operations had been performed per patient. The mean distance deviation was 17 PD base out and near deviation was 18 PD base out. The time from the last operation to an injection of BTXA averaged 28.3 months. We divided our patient population into 2 groups: those with fusion potential and those with no expected fusion potential. Of the 36 patients with fusion potential, 15 patients achieved and maintained good ocular alignment and resolution of their diplopia with an injection of BTXA. In the 24 patients with no expected fusion potential, 4 patients (17%) achieved and maintained good alignment with an injection of BTXA. Although they were not cured, 10 additional patients chose to have repeated BTXA injections to maintain their ocular alignment, whereas only 2 patients required occlusive methods to eradicate intractable diplopia. Five patients had additional surgery, of which 3 patients obtained a functional result. CONCLUSIONS: BTXA has a role in surgically overcorrected exotropia for patients in whom a functional result may be obtained. BTXA is of less value for patients with poor binocular function. It has proved especially useful as a treatment given only once for 42% of patients who could regain high-quality stereopsis. The safety and ease of administration of this treatment add to its merit.
We report a 28-year-old man with non-Hodgkin's lymphoma who presented with acute onset of diplopia 3 weeks after the completion of combination chemotherapy with vincristine. He had a left esotropia with marked decrease in abduction. Magnetic resonance imaging scan of the brain showed thickening and enhancement of the left abducens nerve. Lymphomatous and other intracranial pathologies were excluded, and vincristine neurotoxicity was considered as the possible etiology of the abducens nerve palsy. His diplopia improved gradually, then completely resolved 4 weeks after the cessation of vincristine therapy. We concluded that isolated ocular muscle paresis can be the presenting sing of a toxic neuropathy associated with vincristine use.
BACKGROUND AND OBJECTIVES: Intracranial subdural hematoma is a rare but potentially fatal complication of spinal anesthesia (SA). This case is intended to highlight the importance of careful follow-up of patients with a chronic headache that develops after SA. CASE REPORT: A 38-year-old woman underwent saphenous vein ligation for varices under SA. On the first postoperative day, she complained of severe postural headache that was controllable with oral analgesics. Two weeks later, bilateral abducens nerve palsy with diplopia developed. Brain magnetic resonance imaging (MRI) showed small bilateral subdural hygromas. Diplopia and headache (no longer postural) were relieved after administration of dexamethasone, but reappeared 6 wks later. This time, MRI showed large subdural hematomas. The patient was treated with burr-hole decompression. CONCLUSIONS: Persistent headache after SA requires careful neurologic and radiologic follow-up for exclusion of chronic intracranial bleeding. Pharmacologic treatment may mask some neurologic symptoms and delay diagnosis of intracranial complications related to SA.
A 29-year-old male with a 5-year-history of hyperthyroidism complained of diplopia and proptosis. After subtotal thyroidectomy, he still had diplopia in a certain gaze. Computerized tomography showed inferior rectus muscle enlargement in the right eye and inferior rectus, medial rectus, and superior oblique muscle enlargement in the left eye. Ocular examination with the cover and uncover test revealed hyperphoria and exophoria in the left eye. The upward gaze of the right eye was more limited than that of the left eye. Since superior oblique muscle involvement in patients with thyroid orbitopathy is quite rare, we discuss its effect on ocular motility in patients with thyroid-associated orbitopathy.
In 1949, amphetamine sulfate was replaced by propylhexedrine in the nasal decongestant agent Benzedrex because of psychosis, sudden death, and widespread abuse. Propylhexedrine is not without risks, and reported cases of psychosis, myocardial infarction, pulmonary vascular disease and pulmonary hypertension, and sudden death are well documented in the medical literature. We are reporting 2 cases of definite brainstem dysfunction and 5 cases of transient diplopia secondary to IV abuse of Benzedrex. This widely abused drug is prepared by heating Benzedrex and hydrochloric acid, and the resulting crystals are dissolved in water for injection. This agent is called "stove-top speed". All 7 patients had transient diplopia, within seconds after injection. One patient had evidence of a right-internuclear ophthalmoplegia, and another had a depressed right gag reflex and paralysis of the right half of the tongue. The deficits in these two patients, persisted for many months. In young adults with history of drug abuse, the IV use of Benzedrex should be considered in the differential diagnosis of transient or permanent focal brainstem deficits.