Complaints Of Double Vision Research Articles

Binocular Diplopia as Ocular Manifestation in Pediatric Miller Fisher

Miller Fisher Syndrome (MFS) is a rare variant of neuropathy spectrum of Guillain-Barré syndrome that occur less frequently in children. 11 years old suffered from weakness of limbs with walking and posture bearing difficulty for 3 days before admission. Patient also had complaint of double vision with gaze restriction and difficulty while chewing or swallowing. During admission patient had respiratory failure that inquired intubation and ventilator support. Clinical improvement was achieved after patient was intravenous immunoglobulin (IVIG) for 5 days. First ophthalmology examination showed 15 degrees exotropia of left eye with 30 prism dioptres (PD) at near and far distance. The Worth four dot test revealed crossed diplopia, along with gaze restrictions in all directions. Follow-up 2 months after admission, the patient's symptoms had resolved. Miller Fisher Syndrome (MFS) is diagnosed clinically, characterized by the triad of ataxia, areflexia, and ophthalmoplegia. Treatment for MFS primarily involves supportive care, including respiratory support and immunotherapy if required. The prognosis for MFS is generally favorable. Recovery usually starts in two until four weeks after onset and generally completing within six months.

Binocular Diplopia in Miller Fisher Syndrome Pediatric Patient: A Rare Case Report

Introduction : Miller Fisher Syndrome (MFS) is a rare variant of Guillain-Barré syndrome that usually presents with ataxia, areflexia and ophthalmoplegia. It is more common among patients in their 40s and number of cases in pediatric patients is significantly smaller. Our objective is to report a rare case of diplopia in Miller Fisher.
 Case Illustration : An 11 years old boy came with complaint of double vision and history of gaze restriction. Patient had history of inpatient admission due to acute progressive generalized limb weakness and walking difficulty followed by respiratory failure. Patient also had history of chewing and swallowing difficulty. Inpatient treatment included intravenous immunoglobulin (IVIG) for 5 days which resultedin clinical improvement. Electromyography examination done while hospitalization showed normal results. Orthoptic examination revealed 15 degrees exotropia of left eye with 30 prism dioptres (PD) at near and far distance. Worth four dot test resulted in cross diplopia with no abnormality in head CT scan. After 2 months follow-up with push-up pencil exercise, patient showed improvement of symptoms.
 Discussion : MFS is a clinical diagnosis that can be assessed by clinical triad of ataxia, areflexia and ophthalmoplegia. Diagnosis can be supported by ancillary test such as cerebrospinal fluid analysis, electrophysiologic studies or antibody anti-GQ1b . Treatment of MFS are mainly for supportive care with respiratory support and immunotherapy if needed in severe cases.
 Conclusion : The outcome of MFS is usually good with a complete recovery. The improvements generally begin within two to four weeks after the onset of neurological symptoms and complete within six months.

An Alternative in Managing Duane Retraction Syndrome Type I Using Modified Nishida Procedure: A Case Report

Introduction : Various surgical approaches have been proposed to address the challenge in managing abduction deficit in Duane Retraction Syndrome (DRS) Type I, with no clear guidelines to achieve optimal result. This report aims to describe the outcome of combining medial rectus (MR) recession and modified Nishida procedure to improve abduction in DRS Type I.
 Case Illustration : Twenty six year-old female came with inability to abduct her left eye (LE) since early childhood and an abnormal left head turn. No complaints of double vision nor visual impairment. There was -5 abduction on LE with a noticeable narrowing of vertical palpebral fissure during adduction. Prism alternate prism cover test shared a 30 PD esotropia with normal anterior and posterior segment. Patient was assessed with DRS Type I of LE and managed with 5mm MR recession combined with modified Nishida procedure (vertical rectus transposition without tenotomy and muscle splitting). On postoperative day 1 and last follow-up (1 year), the alignment was ortophoric, abduction improvement of -2, and diminished anomalous head posture.
 Discussion : Although studies have only reported successful cases of modified Nishida procedure in CN VI palsy, it can be assumed that the procedure can also be implemented to treat lateral rectus muscle innervation abnormality such as in DRS type I. Surgical intervention may not normalize abduction deficit. However, the procedure successfully corrects ocular alignment, eliminates anomalous head posture, and able to improve abduction with no complications.
 Conclusion : Modified Nishida procedure can be implemented as an alternative in managing DRS type I with relatively satisfactory result.

SUCESSFULL MANAGEMENT OF CHILDHOOD BASIC-TYPE ESOTROPIA IN ADULT PATIENT

Introduction : Strabismus in adults may indicate other pathological causes, such as neurological disorders or trauma. Diagnosis of esotropia in adult patients has to be made carefully to determine the right treatment. Management’s goal of strabismus in adult patients is mainly cosmetic by diminishing deviation.
 Case Illustration : A 46-year-old woman, complaint of inward deviation of both eyes since childhood. There were no complaints of double vision, headaches, nor trauma history. Visual acuity of right eye was 0.4 with BCVA and left eye was 0.8 with BCVA 0.8. Hirschberg test was 45o (Figure 2A). Prism cover test was 75 PD base out in near and distance. Patient was diagnosed with basic-type esotropia. The patient already given spectacles but the deviation persisted so she underwent bilateral medial rectus recess surgery (Figure 2B). Ocular alignment without spectacles 1 week after surgery showed orthotropia and small esophoria. (Figure 2C).
 Discussion : Each esotropia types has a different treatment approach. Basic-type esotropia with large deviation usually needs surgical treatment. Management of childhood onset strabismus in adult patients is challenging because those patients have lesser ability to maintain fusion. Older patients and large deviation are poor prognostic factors to achieve good functional and cosmetics outcome after strabismus surgery.
 Conclusion : Establishing a definite diagnosis in adult strabismus patients, including esotropia, is challenging. Careful diagnosis and management decision will determine the outcome of the patient’s condition.

Acute Onset Isolated Abducens Paralysis After Exposure to Arc Welding

Exposure to welding is associated with many diseases, especially some of the eye injuries. We present a 49-year-old male patient applied to us with the complaints of double vision and blurred vision for a week. The symptoms started after looking welding machine light for a few minutes without protective glasses. After excluding another causes, the diagnosis of idiopathic abducens paralysis was made. As a result of exposure to metals and ultraviolet radiation, conjunctival disorders, presbyopia, refractive errors, corneal damage, and retinal pathologies can be seen in patients. It is also known that UV is a stress factor that will initiate reactions that lead to apoptosis of neurons. We think that exposure to UV rays may have played a role in the possible etiological process in our case.The patient was followed up with conservative treatment and all symptoms resolve within a month.

Death also have color, this time purple; Methanol

Introduction: Methanol is a colorless and odorless alcohol type that is toxic by its metabolites and is obtained by distillation of wood.Case Report: A 64-year-old female patient was admitted to our emergency department with complaints of double vision, difficulty in answering questions and drowsiness. Her extremities had pink-purple hyperemia, suggesting widespread dermatitis in both knees. It was found that dermatitis developed after the patient was applied wrapping from wood alcohol for knee pain, and the patient was diagnosed with methanol poisoning. Upon the disruption of her consciousness, an intubation decision was made and hemodialysis was performed in the anesthesia and reanimation unit of our hospital while the patient was intubated. After 3 days of her hospitalization in the intensive care unit, the patient was exitus with a development of cardiac arrest.Discussion: We aimed to remind you that in metabolic acidosis cases with increased anion gap, methanol toxicity is a reason that should not be neglected and may be fatal.

P1244 Mitral valve abscess caused by Klebsiella pneumoniae in a patient with diabetes melitus

Abstract Introduction Infective endocarditis (IE) still leads to high mortality, despite the achievements of modern medicine. Particular attention should be paid to the group of patients in whom the occurence of IE is caused by rare atypical bacteria, such as Klebsiella pneumoniae. It is known that Klebsiella is the cause of IE in only 1.2% of cases in patients with native valves (Anderson MJ, Janoff EN, 1998), at the same time disease proceeds extremely aggressive. Case presentation Patient M., 47 years old, complained of shortness of breath, fever up to 40 degrees Celcius and general weakness. In medical history patient had diabetes melitus (DM) for a 15 years. 10 days before hospitalization the patient was subjected to hypothermia, after that he noted the appearance of fever, chills and general weakness. 4 days after the symptoms appears he turned to a general practitioner and was diagnosed with acute respiratory viral infection. Since the patient did not notice the effect of treatment for 5 days (general weakness and fever persisted, shortness of breath appeared), he called an ambulance and was taken to our clinic with suspected pneumonia. Conducted computer tomography (CT) revealed no signs of pneumonia. During hospitalization, transthoracic echocardiography (TTE) was performed. There was no heart disease in the patient"s medical history. TTE revealed the hyperechoic mobile mass (15x15 mm) on the posterior cusp of a mitral valve. Mitral regurgitation was within physiological range. For the verification, patient was recommended to undergo transesophageal echocardiography (TEE), but he categorically refused this examination. Against the background of ongoing antibiotic therapy fever persisted. Subsequently, the patient was consulted by a neurologist about a complaint of double vision, and a brain CT was performed and revealed acute infarction in the right occipital lobe. Stroke was regarded as cardioembolic. The patient"s condition progressively worsened, miltiple organ failure was increasing, he was intubated and transferred to the intensive care unit. We performed an ultrasound as heart murmur appeared. TEE revealed a large hyperechoic formation 30x30 mm with anechoic collapsing cavity in the center and defect in the posterior cusp up to 20 mm, mitral regurgitation reached 4 degrees. Despite adequate therapy the patient"s condition progressively worsened, and the next morning biological death was diagnosed. The autopsy results confirmed IE caused by Klebsiella pneuminiae. Conclusion Our clinical case shows that we cannot neglect a small percentage of cases of IE caused by such atypical bacteria as Klebsiella. The disease in this case was extremely severe and difficult to treat, which can be explained by the tendency of patients with DM to the occurence of infections. Abstract P1244 Figure.

Nonsurgical treatment of diplopia.

As the population ages, the number of patients presenting to ophthalmologists with complaints of double vision is increasing. Diplopia is known to occur for optical, neuroophthalmological, strabismological and even iatrogenic reasons following various ophthalmic surgical procedures. The mainstays of the nonsurgical treatment of diplopia including no treatment, partial or total occlusion, press-on or ground in prisms and vergence exercises (to increase fusional vergence amplitudes) have been utilized for some time. Although a review of the literature demonstrates that very little has been published on this topic in recent years, subtle treatment variations have evolved. The ability to successfully manage patients' diplopia symptoms remains important to decrease the risk of patient injuries, as well as maximize their independence and quality of life. These concerns are especially important as patients age.

Double vision in adults

ABSTRACTPurpose: To determine the patient characteristics, patterns in presentation and incidences of the various etiologies in adult patients with the chief complaint of double vision.Design: Retrospective review.Subjects: All persons greater than 18 years of age who presented to a single provider (DG) in a nonacademic private practice over a 2-year period, from 2011 to 2013, with the chief complaint of double vision. The provider is part of a multispecialty eye care group practice with both ophthalmologists and optometrists. This group practice provides a large adult referral base.Methods: Examination for each patient included refraction, versions, alignment in different positions of gaze at distance and at near, binocular sensory testing, neuro-ophthalmologic examination, and dilated fundus examination if not recently documented. Alignment was measured with cover–uncover testing and alternate cover testing with prism bars or free prisms, using Snellen letters for fixation. Appropriate refractive correction was ensured. Alignment was measured in the primary position at distance and in gaze directed 20 degrees L, R, up, and down. The near deviation was measured in the reading position with the large letters on a near card for fixation. Sensory testing was performed with the Worth 4-dot at distance and near and with the Titmus stereopsis test. Vectograph testing was also performed at distance on many patients, particularly those with small-angle deviations. The prismatic correction necessary to correct diplopia subjectively at distance in the primary position and at near in the reading position was also recorded.Primary outcome: Ocular alignment and etiology of diplopia. Management, response to treatment, and outcome were also recorded.Results: A total of 125 patients were included in the analysis. Subjects ranged from 18 to 93 years of age. Most cases of idiopathic strabismus were in the elderly, but the age range varied with category of underlying strabismus. Small-angle HT was the most common type of strabismus, comprising 21% of all subjects. ET, usually of the divergence insufficiency type (20%); XT (14%); and palsies not including trochlear palsy (12%) and trochlear palsy (8%) were the next most common etiologies. No strabismus was found in 11% of subjects.Conclusions: Most cases of diplopia in adults presenting as an outpatient can be classified into a few categories based on their type of strabismus. These categories of strabismus share typical age ranges and features. While diplopia in adults is usually idiopathic, diplopia can be the presenting sign of serious underlying pathology. Thus, a thorough history; examination; and, in some cases, diagnostic testing is necessary.

Surgical Resection and Adjuvant Radiation Therapy in the Treatment of Skull Base Chordomas

Chordomas are rare tumors of notochordal origin that are known to be locally aggressive and are often treated with surgical resection followed by adjuvant radiation therapy (RT). The accepted standard of treatment for chordomas of the mobile spine, which includes en-bloc resection with wide margins, cannot be easily applied to the chordomas of the skull base because of their proximity to critical neurovascular structures. We describe our experience with the role of surgery and adjuvant RT in the treatment of chordomas over 16 years. We performed a retrospective chart review on patients with diagnoses of clival chordoma between the years 2000 and 2015 at Northwestern Memorial Hospital. We reviewed presenting symptoms, tumor location and size, extent of resection, complications, recurrence, adjuvant treatment, and follow-up duration. A total of 20 patients underwent 32 surgeries. Of the 20 initial surgeries, 80% underwent gross total resection, and 20% had subtotal resection. The mean follow-up time was 60.75 months. Mean tumor volume was 23.07 cm3. Most common presenting signs and symptoms were headaches (70%), cranial nerve palsies (45%), and diplopia (55%). Diplopia was defined as complaints of double vision without any objective evidence of a cranial nerve palsy. Median time to progression was 57 months, and median overall survival was 136 months. Initial tumorvolume and the need for a second dose of RT eitheras sole or as adjuvant treatment of a recurrence hada statistically significant effect on progression-free survival (P= 0.009, 0.009). None of the factors studied had a statistically significant effect on overall survival. The treatment of chordomas remain challenging and requires multimodal treatment strategies spanning different specialties. Initial tumor size and need for second dose of RT for recurrence appear to play a significant role in progression-free survival. Adjuvant RT after gross total resection may play a role in improved progression-free and overall survival in patients with clival chordomas.

Miller Fisher Syndrome- a Case Report and Review of Literature

Background and Objective:: Miller Fisher syndrome (MFS) is a variant of Guillan Barre syndrome characterized by ophthalmoplegia, ataxia and areflexia. Although self-limiting disease course is expected, disease modifying treatment options for MFS are no different than for GBS and include intravenous immune globulin (IVIG) and plasmapheresis. Here, we report a case of MFS presented with bilateral ptosis, ophthalmoplegia, ataxia with quadriparesis and normal NCS. Patient
 Methods: A 14- year-old young boy was admitted to our hospital with the complaints of double vision, vertigo, difficulty in walking, imbalance. He had no diarrhea or upper respiratory tract infection prior to this illness. On neurological examination, he had limited ability to move his eyes up and out, had bilateral ptosis, ataxia. The muscle strength was mildly impaired. The plantar reflexes were flexor and the deep tendon reflexes were absent.
 Results: The blood laboratory, CT and brain MRI were normal. In the first sample of CSF, there was no change. Subsequent sample after 14 days revealed high protein with albuminocytological dissociation. The NCS and EMG were normal. Anti GQ 1b antibody was negative. He showed marked improvement with conservative management.
 Conclusion: MFS is a rare disease that must be diagnosed with the clinical findings and in the following days the diagnosis can be supported by the laboratory findings.
 Bangladesh Journal of Neuroscience 2016; Vol. 32 (1): 47-51

Case Report: One Eye, Two Images

A 25 year-old Caucasian male is present for an annual comprehensive eye exam with a chief complaint of double vision in the left eye only. The patient’s last eye exam was 3 months ago when treated for an uncomplicated corneal abrasion secondary to trauma. The onset of diplopia was 1.5 months ago upon awakening in the morning. The double vision was constant with no other associated symptoms including, but not limited to, pain, irritation or photophobia. The patient’s best-corrected visual acuities (BCVA) were 20/20 OD and 20/40 OS; the patient has a history of accommodative spasm causing his best-corrected visual acuity to fluctuate. The patient had normal ocular motility, confrontation visual fields, binocularity and pupillary responses.

Unilateral Proptosis as the initial presentation of Multiple Myeloma

A 75 year lady presented with the complaints of double vision on up gaze since 1 year and gradually progressive painless protrusion of the left eye since 2 months. There was a history of repeated admission to the hospital in past 1 year for weakness. On systemic examination patient had pallor, pedal edema and a borderline splenomegaly. Ocular examination revealed eccentric proptosis. CT scan of head and orbit showed an isointense ill-defined mass in superior anterio-lateral extraconal space extending to the medial side which was eroding the fronto-zygomatic bones. Fine Needle aspiration cytology showed binucleate plasma cells and plasma blasts suggestive of multiple myeloma. Serum electrophoresis showed 2 abnormal bands of paraproteins in the gamma region. Though uncommon, proptosis could be the initial presentation of multiple myeloma. A high clinical suspicion helps us to make a diagnosis of multiple myeloma. Early diagnosis and timely treatment would help to prolong the patient\'s life and to improve quality of life. Key words: Multiple myeloma, Unilateral proptosis, Plasma cell

Vision Therapy Management for Dissociated Horizontal Deviation

Dissociated horizontal deviation (DHD), a rare subtype of strabismus, is a change in horizontal eye alignment that does not obey Hering’s law. The variation is unrelated to a change in accommodation and depends on which eye is fixating. Both esotropia (ET) and exotropia (XT) can manifest in the same patient with DHD. Surgery has been reported to manage DHD, but often a second or third surgery is necessary. We report two cases of DHD that were managed with vision therapy (VT). Case one: A 9-year-old girl presented for eye examination with her parents noting an eye drifting out. Cover test showed a DHD that varied from 15Δ left ET to 15Δ alternating XT. A 40Δ XT manifested when she was inattentive. Antisuppression, vergence, accommodation, and oculomotility were addressed with VT. Upon completion of VT, binocular vision functions were normal except for appreciation of global stereopsis. No strabismus was observed during the examination. These findings were stable at a 7-month follow-up visit. Case two: A 40-year-old man presented for eye examination with the complaint of double vision and eye strain. Cover test revealed a DHD that varied from 5Δ ET to 15Δ XT, along with DVD. A 30 to 40Δ XT was observed during visual inattention. Antisuppression and vergence skills were addressed with VT. At the end of VT, most binocular vision functions were normal. No strabismus was observed on cover test. Follow-up examination 16 years later showed no strabismus by cover test, although XT manifested when he was inattentive. In two DHD cases, control of eye alignment improved with VT. To the best of our knowledge, these are the first case reports to describe management of DHD with VT. Eye care practitioners should be aware that a long period of VT may be necessary to successfully manage DHD.

Extraocular Muscle Enlargement as a Paraneoplastic Effect of Breast Carcinoma in a Male Patient

The authors report a rare case of a male patient who was diagnosed with breast cancer following investigations for proptosis secondary to extraocular muscle enlargement. A 65-year-old man presented with complaints of double vision and proptosis. CT scan of the orbits showed bilateral superior rectus muscle enlargement. On further investigation, the patient was detected to have a right breast mass. Biopsy of the mass showed an intermediate-grade carcinoma in situ. The patient underwent a right radical mastectomy following which his proptosis and symptoms of double vision resolved. Repeat MRI scans showed reduction in the size of the superior rectus muscle after mastectomy. Extraocular muscle enlargement has not been previously identified as a paraneoplastic effect of breast carcinoma in a male patient. Extraocular muscle enlargement can be a presenting feature of malignancies, and an appropriate systemic workup for the occult primary when all other preliminary tests are negative should be considered.

NERVE-2: A Three-Dimensional Patient Simulation of Oculomotor Nerve Palsy

Abstract This module portrays a simulated patient who presents to a clinic or emergency room with a complaint of double vision. The purpose of this simulation is to promote effective history taking...

Diagnosing multiple sclerosis: expect the unexpected

A previously healthy 41-year-old Hong Kong Chinese man, who emigrated to the UK at the age of 20 years, presented with a complaint of visual blurring and of painless double vision but without directional selectivity. Ophthalmological assessment found normal visual acuity, colour vision, visual fields, and pupillary reactions; examining eye movements there was a left hypertropia, with weak left inferior rectus on Hess chart. A diagnosis of acute partial pupil-sparing left oculomotor (third) nerve palsy was made. Symptoms resolved spontaneously within 2 weeks, but magnetic resonance brain imaging arranged at the initial consultation showed multiple high signal intensity lesions in the white matter of the cerebral hemispheres periventricularly and in the corpus callosum, suggestive of demyelination, although no brainstem lesions were noted. When subsequently seen in the neurology clinic, the patient was asymptomatic and there were no neurological or neuro-ophthalmological signs. Serum angiotensinconverting enzyme level and chest X-ray were both normal. Interval magnetic resonance brain imaging 7 months later showed no new changes, and since the patient was asymptomatic he declined further investigation or follow up. Five years later, the patient presented again with a complaint of double vision without directional selectivity. Signs were now of a right abducens (sixth) nerve palsy, without any other neurological or neuro-ophthalmological signs. Symptoms resolved spontaneously after 4 months. Magnetic resonance brain imaging again showed multiple high signal lesions in the periventricular white matter and corpus callosum, but no brainstem or cerebellar lesions were seen. Pattern shift visual evoked potentials were within normal limits, providing no evidence for a demyelinating optic neuropathy. The patient agreed to lumbar puncture, and CSF analysis showed normal protein, glucose, cell count, angiotensin-converting enzyme level, and cytology, but oligoclonal bands were present in a type 2 pattern consistent with a diagnosis of multiple sclerosis.

Double Vision.

When evaluating a patient with a complaint of double vision, it is important to distinguish monocular versus binocular diplopia, which are differentiated by asking the patient to cover each eye separately. In the setting of binocular double vision, one of the two images disappears when either eye is covered, because diplopia is the result of ocular misalignment. On the other hand, monocular double vision resolves when the affected eye is covered, but remains when the opposite eye is occluded. Causes of monocular diplopia include cataract, refractive error, and retinal disease, which can be managed accordingly by an ophthalmologist. However, an unusual form of monocular double vision can occur in the setting of cortical dysfunction. Cerebral polyopia describes the perception of multiple images and arises from an occipital disturbance. It can occur with migraine headaches and can be accompanied by a homonymous hemianopia. Palinopsia refers to the persistence of an image that is no longer in view (visual perseveration or stroboscopic effect) and results from an occipital lesion as well. The exact mechanism of polyopia and palinopsia are uncertain and both conditions are extremely rare. The majority of this discussion will focus on binocular double vision and its management. The main treatment objective of binocular diplopia is to restore the largest area of single binocular vision. Ideally, patients would be able to achieve single vision in all fields of gaze, but this is not always possible. The majority of patients are treated with either prism lenses or eye muscle surgery.

吹きぬけ骨折（眼か壁単独骨折）の画像診断と治療経過

Thirty-four cases of blow-out fracture were evaluated by high-resolution CT, Hess test for red and green color and synoptophore. The results of these tests were compared with the final outcome of the fractures. The fractures were classified on the basis of the location (floor, medial wall or roof), extent (total, partial or linear) and type of fragments (punched-out or trapdoor). The medial wall type included many cases (33%) with no complaint of double vision, and many cases with a combination of disturbances in ocular mobility in both the horizontal and vertical directions. The floor type showed a low incidence of disturbances in ocular movement in the horizontal directions. Regarding the extent of the fracture, all cases with the total type showed disappearance of double vision within three months. Many of the partial and linear types had a poor outcome. With regard to the type of fragments, all of the trapdoor type cases showed a favorable result with disappearance of double vision within three months. Some of the punched-out type cases, however, showed a poor outcome.