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Causes of diplopia.

A prospective study of 96 diplopia patients was analyzed concerning the common types and causes in order to develop early and proper management. Two-thirds (62) of the patients were male (64.6%). The average age was 34.5 +/- 15.7 years (+/- SD). The result revealed that the common types of diplopia were horizontal, vertical and torsional diplopia, respectively. The common causes of diplopia were head trauma (38.5%), systemic diseases from diabetes mellitus, hypertension (20.8%), undetermined group (15.6%), eye diseases (9.4%), and etc. Sixth cranial nerve paralysis was frequently found among the third, fourth and sixth cranial nerves. There were 13 cases of spontaneous fusion in the primary position. Only 7 of 12 surgical cases eventually achieved satisfactory alignment and fusion.

Adolescent↗

Fixation switch: an unusual cause for adolescent and adult onset diplopia.

Sudden diplopia for adolescent and adult patients having childhood onset strabismus is an unusual occurrence. Recently, I examined three patients with a long history of strabismus and recent onset diplopia. All three patients acquired diplopia as a result of switching fixation from their normally preferred to their normally nonpreferred eye. Clinicians confronted with adolescent and/or adult patients having a long history of strabismus as well as a recent onset diplopia should consider a change in fixation as a possible mechanism.

Adult↗

Eclamptogenic Gerstmann's syndrome in combination with cortical agnosia and cortical diplopia.

Cortical blindness is defined as a loss of vision due to bilateral retrogeniculate lesions (geniculocalcarine blindness). Gerstmann's syndrome is a combination of disorientation for left and right, finger agnosia, and profound agraphia, alexia, and acalculia. It is due to a lesion in the left angular gyrus, situated at the confluence of the temporal, parietal, and occipital lobes. We report on a patient who suffered from severe underdiagnosed eclampsia and who developed bilateral extensive medial temporal, parietal, and calcarine ischemic infarctions during an eclamptic fit. In addition, ischemia destroyed the left angular gyrus. The combination of these lesions led to Gerstmann's syndrome with additional cortical agnosia and cortical diplopia. For the first few months following the ischemic insult, the patient had been cortically blind. Thereafter, the patient slowly regained a visual acuity of 0.1 in both eyes. She then experienced monocular and binocular diplopia. Her ocular motility was normal; there was no phoria or tropia. Monocular and binocular diplopia slowly became less severe over the following year. Now, 2 years after the incident, the patient has a visual acuity of 0.2 in both eyes and no double vision. However, the handicapping symptoms of Gerstmann's syndrome, which make leading a normal life impossible, have persisted--the patient still cannot cope alone, mainly due to the severe disorientation for left and right. The picture of cortical agnosia, cortical diplopia, and Gerstmann's syndrome is a very rare combination. Visual recovery and rehabilitation in cortical blindness are severely affected and made difficult by the symptoms of Gerstmann's syndrome. In our case the reason for such a dramatic clinical picture was eclampsia, whose prodomes had not been diagnosed in time.

Adult↗

The correction of diplopia after cataract extraction.

The records of 12 patients with persistent diplopia after cataract extraction were reviewed. All patients were corrected surgically using an adjustable-suture technique. After strabismus surgery, the diplopia in nine of the 12 patients resolved without adjunctive therapy. Three patients had occasional diplopia postoperatively. Prismatic correction postoperatively was unwarranted in two patients because diplopia occurred on rare occasions, but the third required postsurgical prismatic correction with improvement.

Adult↗

Binocular diplopia associated with subretinal neovascular membranes.

A series of patients were seen with binocular diplopia secondary to subretinal neovascular membrane in one eye. The pathophysiology underlying the diplopia is the establishment of rivalry between central and peripheral fusional mechanisms. This diplopia is not relieved by appropriate prism therapy.

Adult↗

Surgical correction of enophthalmos and diplopia. A report of 38 cases.

Enophthalmos, hypophthalmos, and diplopia are complications of orbital injury. This article reviews the causes of these sequelae, describes a method of strategic implantation of bone grafts to the orbit (and malar bone), and reports the long-term (six months to eight years) results in 38 cases. As a result of bone grafting, all but two patients had a correction of the enophthalmos to within 1 to 2 mm of the opposite eye. Of the 20 patients with diplopia, 15 had correction, and an additional four had an improvement of diplopia so it occurred in only one field of gaze. Of the 22 patients with grafts to the malar bone, 16 were thought to have good to excellent results; however, six developed some degree of reabsorption at the graft site. No patients had any decrease in vision. The advantages and disadvantages of the surgical procedure are described and compared with other methods.

Adolescent↗

Diplopia after retinal detachment surgery.

In the Amsterdam Academic Medical Centre with an annual rate of 200 retinal detachment procedures, about the same incidence (4.5%) of diplopia after detachment surgery was found as by Fison and Chignell (1987). In 13 out of 18 patients with diplopia (sent for orthoptic evaluation between 01.01.1986 and 31.12.1987) double vision could be eliminated by various ways: orthophorization with or without temporary prismatic therapy was seen in 3 patients; a compensatory head posture eliminated diplopia in two cases, and prisms were effective in 4 cases (one of them had additional squint surgery). In 4 patients strabismus surgery alone restored binocular single vision. Binocular single vision was not restored in 5 cases.

Adolescent↗

Monocular diplopia accompanying ordinary refractive errors.

Monocular diplopia is commonly encountered in ophthalmic practice. We discovered that it could be induced in nine (82%) of 11 normal eyes with ordinary spherical or astigmatic defocus of the retinal image. Possible mechanisms responsible for this effect include retinal processing, diffraction effects, and spherical aberration. By employing geometric blur circle theory and using a simple optical model to photograph the effect, we concluded that monocular diplopia in the setting of ordinary refractive error is secondary to relatively minor optical irregularity such as spherical aberration. Contour enhancement properties of the retina probably accentuate this effect. Ordinary refractive error should therefore not be overlooked or discounted in patients with monocular diplopia.

Adult↗

Diplopia after cataract surgery.

A 69-year-old man developed binocular, vertical diplopia after undergoing cataract extraction in both eyes. He had normal extraocular motility and a 2 prism diopter right hypertropia that was comitant but could not be relieved with overlying prisms. Funduscopy revealed an epiretinal membrane within the macula on the left more than the right. After his metamorphopsia worsened, and his visual acuity decreased to 20/40 in the left eye, he underwent pars plana vitrectomy with removal of the epiretinal membrane and his diplopia resolved. Macular pathology including epiretinal membranes and choroidal neovascular membranes may rarely cause binocular diplopia because of foveal displacement and rivalry between central and peripheral fusional mechanisms.

Aged↗

Persistent binocular diplopia after cataract surgery.

We reviewed the records of 38 consecutive patients who had persistent binocular diplopia after cataract surgery. The patients were divided into ten categories based on the suspected conditions underlying the diplopia. Of 16 patients who underwent strabismus surgery, five achieved the therapeutic goal of single binocular vision in the primary and reading position, and four attained this with prismatic or botulinum toxin therapy in addition to surgery. Seven patients continued to have diplopia despite strabismus surgery and adjunctive therapy. Even small residual deviations were often intolerable, because of highly diminished fusional amplitudes.

Adult↗

Torsional diplopia after transantral orbital decompression and extraocular muscle surgery associated with Graves' orbitopathy.

Graves' orbitopathy can be associated with horizontal, vertical, and torsional diplopia. Of 428 patients treated with transantral orbital decompression, 21 had incycloduction (mean, 12.8 degrees; range, 5 to 20 degrees) and five had excycloduction (mean, 12 degrees; range, 5 to 20 degrees). All 26 patients had had recessions of the medial or inferior rectus muscle (or both) before onset of torsional diplopia. Mean recession was 5.5 mm (range, 4 to 10 mm) and 5.3 mm (range, 2 to 10 mm) of medial rectus muscle and inferior rectus muscle, respectively. An A pattern was often associated with the condition. Superior oblique tenectomy and inferior oblique myectomy were performed most frequently for incycloduction and excycloduction, respectively. Superior oblique tenectomy induced a mean incycloduction decrease of 7.1 degrees (range, 0 to 12 degrees). Exotropia in downgaze was decreased, and a small ipsilateral hyperdeviation was induced. Bilateral inferior oblique myectomy in one patient decreased excycloduction 10 degrees without inducing new deviation. At follow-up (mean, 63.7 months) after last strabismus operation, 15 patients with incycloduction and two with excycloduction had no diplopia.

Adult↗

Cluster of diplopia cases after periocular anesthesia without hyaluronidase.

PURPOSE: To describe a cluster of cases of iatrogenic diplopia after cataract surgery that occurred in 1998, when hyaluronidase was unavailable for use in periocular anesthetic regimens. SETTING: The clinical practices of the authors. METHODS: This study comprised a retrospective chart review. RESULTS: Twenty-five cases of transient or permanent diplopia were reported. Of these, 13 eyes had retrobulbar and 10 had peribulbar injections; in 2 cases the injection technique was unknown. The inferior rectus was affected in 19 eyes; of these, 1 had a temporary palsy and 18 had permanent restriction. Temporary paresis developed in the lateral rectus in 5 cases and the superior rectus in 2. Eleven cases were submitted by 4 anterior segment surgeons, who collectively had a zero incidence of iatrogenic postoperative diplopia in the preceding 4 to 11 years of practice (approximately 6900 cases). CONCLUSION: Hyaluronidase may be more important than previously suspected in preventing anesthetic-related damage to the extraocular muscles. The inferior rectus muscle is particularly vulnerable, presumably because of the injection technique.

Aged↗

Persistent binocular diplopia following cataract surgery: aetiology and management.

We studied all patients referred to the orthoptic department with binocular diplopia following cataract surgery between January 1991 and June 1993. Persistence of diplopia for a minimum of 3 months after cataract surgery was required for inclusion in the study. Eighty-one patients (2% of all patients who underwent cataract surgery during this time) satisfied the entry criteria. The patients fell into two groups: non-traumatic and traumatic cataracts. Horizontal deviations were seen in 24 patients. Vertical deviations were seen in 8 patients and a combined horizontal and vertical deviation was seen in 49 patients. Fresnel prisms were used to manage the diplopia in 58 patients. Of these, 48 patients in the non-traumatic group regained binocular single vision with this prism while 10 in the traumatic group benefited. Mechanical and sensory causes are discussed.

Adolescent↗

ENT pathology and diplopia.

ENT pathology causes diplopia in a minority of patients. Because the various ENT conditions that can produce diplopia are relatively unusual they often escape early detection. We describe the various ENT disorders that can produce diplopia and illustrate this with our experience between 1992 and 1998. We wish to emphasise the benefit which can be obtained from undertaking an ENT history and examination in arriving at the correct diagnosis.

Aspergillosis↗

Vertical diplopia following local anaesthetic cataract surgery: predominantly a left eye problem?

PURPOSE: Vertical diplopia is an uncommon but disappointing complication of otherwise successful local anaesthetic cataract surgery. We studied strabismus patterns in a group of such patients to identify the nature and extent of extraocular muscle involvement. METHODS: A retrospective review identified 15 cases of vertical diplopia following local anaesthetic cataract surgery between July 1994 and January 1998. Peribulbar anaesthesia was used in all cases and given by right-handed professionals. RESULTS: All cases had otherwise successful cataract surgery (mean age 80.5 years; median pre-operative VA 6/18; median post-operative VA 6/9). The mean level of vertical diplopia was 7.2 prism dioptres (PD) in the primary position (range 2-25 PD). The left inferior rectus (IR) was paretic in 6 cases and restricted in 5 cases. The left superior rectus (SR) was not affected in any of the cases. The right IR was restricted in a single case. The right SR was paretic in 2 cases and restricted in a single case. None of the cases had clinical involvement of the oblique muscles. Eleven of the cases were managed successfully with prisms. Two of the cases required strabismus surgery. CONCLUSIONS: The incidence of left eye extraocular muscle involvement was greater than right eye involvement, although this did not reach statistical significance (73% vs 27%; p = 0.075). This may be due to the more difficult access of right-handed individuals giving left eye peribulbar injections with the needle tract being directed more closely to the muscle cone. The IR muscle is more commonly affected than the SR (80% vs 20%; p = 0.019). An equal incidence of paretic and restricted rectus muscle pathology was found in this study (53% vs 47%; p = 0.818). The exact aetiology of muscle injury is unknown but could be due to direct muscle or nerve trauma, anaesthetic toxicity, periocular haemorrhage or a combination of these.

Aged↗

Diplopia from peribulbar ropivicaine.

PURPOSE: To report a previously undescribed side-effect of ropivicaine (Naropin) used in peribulbar anaesthesia. METHODS: We report nine cases identified prospectively with symptomatic diplopia, predominantly vertical, following Ropivicaine use for peribulbar anaesthesia in routine cataract surgery. These nine cases occurred in a 10-week period from a total of 77 patients given 7 mL peribulbar ropivicaine (10 mg/mL) with 750 units hyalase prior to cataract extraction by a single surgical team. RESULTS: None of the cases had preoperative ocular motility disturbances and none had superior rectus traction sutures. All diplopia resolved in less than 30 h. CONCLUSIONS: Ropivicaine may have a prolonged motor block resulting in diplopia of up to 30 h duration after peribulbar anaesthesia.

Amides↗

Diplopia as a complication of laser in situ keratomileusis surgery.

A case is presented of a patient with high myopia who developed vertical binocular diplopia after decentred laser in situ keratomileusis (LASIK) surgery with associated decompensation of pre-existing exophoria into an exotropia. A 40-year-old man underwent LASIK surgery for high myopia in his right eye. Preoperatively, he was approximately -26.00/-2.00 x 35 degrees with visual acuity of 6/12(-2) in that eye. He also had an asymptomatic exophoria. After LASIK surgery, he achieved a refraction of -3.25/-0.50 x 80 degrees with 6/21 best-corrected visual acuity. He also developed binocular diplopia. The ablation zone had been decentred upwards and there was also an exo- and hypo-deviation of his right eye. He was able to superimpose the two images in free space with vertical and horizontal prisms.A hard contact lens also resulted in superimposition of the two images. Vertical decentration of the ablation zone can induce a vertical prism effect after LASIK surgery and result in vertical diplopia. This together with abnormal optics also caused loss of best-corrected vision and decompensation of his pre-existing exophoria into an exotropia.

Adult↗

[Vertical diplopia after cataract operation].

PURPOSE: Presentation and analysis of patients with vertical diplopia appearing after cataract surgery in retrobulbar anesthesia. SUBJECTS AND METHODS: Between 1990 and 1998 9 Patients with vertical diplopia following cataract surgery in retrobulbar anesthesia were studied in our Orthoptic Department. Each patient had complete orthoptic examination with Hess-screen-test. Additionally, some patients underwent neuroradiologic imaging and forced-duction testing. RESULTS: We subdivided the patients in a group of 4 patients with hypertropia and of 5 patients with hypotropia of the operated eye. All hypotropias were left-sided. Seven patients showed an overaction of the involved muscle without regression. Seven patients underwent surgery of a vertical muscle. Only 1 patient needed prismatic therapy postoperatively. The other 2 non-operated patients were satisfied with prisms alone. CONCLUSIONS: The proposed pathogenesis of vertical diplopia in these cases is fibrosis and contracture of the injured muscle, which could be due to anesthetic myotoxicity after direct injection into the muscle or to an intramuscular hemorrhage. On the other hand hypertropia could be a result of placement of bridle sutures. We discuss prevention and therapy of such complications.

Aged↗