Constant Diplopia Research Articles

Adjustment of eye muscle surgery dosage under drop anaesthesia in patients with Grave's orbitopathy

Motility restrictions of the eye muscles represent a common and serious impairment for patients with Grave's orbitopathy. Various surgical approaches have been developed for the rehabilitation of these patients. In this study 64 patients in which only one of the rectus inferior muscles was recessed are presented. The recession was performed using drop anaesthesia. The active cooperation of the patients was necessary for adjustment of the dosage so that undercorrections or more important overcorrections could be prevented. Indications for this recession were a constant diplopia, an abnormal head posture, a pseudoretraction of the upper eyelid or corneal scarring complications. In all patients the squint angle was significantly reduced. A statistical mathematical correlation between the intraoperatively chosen recession length and the reduction of squint angle was found. On the other hand, the variance of the effect of the operation was so large that no dosage recommendations could be made. This operation technique seems to be able to avoid overcorrections (9.3%) for the majority of patients and only a small group of them presented diplopia postoperatively (10.9%). These results show a good functional rehabilitation of our patients. Performing the operation under drop anaesthesia, while taking into account the motility situation, seems to be a good method in order to manage the dosage problems presenting in this clinical entity.

Diplopia after limited macular translocation surgery

Purpose: Full macular translocation surgery relocates the fovea away from choroidal neovascularization, inducing significant postoperative torsional diplopia. In “limited macular translocation,” a saline-induced retinal detachment is followed by scleral imbrication with mattress sutures and spontaneous retinal reattachment. In this study, diplopia was characterized in patients treated with limited macular translocation. Methods: Two surgeons performed retinal translocation surgery on 250 patients over an 18-month time span. The extent and direction of the retinal translocation, and the amount and location of scleral imbrication, were recorded. All patients complaining of diplopia were referred for ocular motility evaluation and treatment. Results: Thirteen (5.2%) patients complained of occasional or constant diplopia. Imbricating sutures were placed supero-temporally in all cases. Inferior foveal translocation ranged from 200 to 2115 μm (median, 1750 μm). Visual acuity ranged from 20/40 to 20/400 in the operated eye. Prism-and-cover testing underestimated the strabismus when compared with subjective testing. In 3 patients, there was no shift on alternate-cover testing despite binocular diplopia. Excyclotorsion ranged from 0° to 16°. Diplopia resolved in 10 cases with prism; 3 required an occlusive filter for distortion or aniseikonia. One patient underwent successful strabismus surgery to eliminate dependence on prism glasses. Conclusions: Limited macular translocation only rarely produces symptomatic diplopia. Suprisingly, traditional prism-and-cover testing does not reliably quantify the misalignment. This may result from the combination of a persistent macular scotoma and a repositioned fovea relative to the peripheral retina. Prism therapy is generally satisfactory in the absence of retinal distortion or aniseikonia. (J AAPOS 2001;5:388-94)

Strabismus as a Complication of “Cuba Therapy” for Retinitis Pigmentosa

Purpose:We studied a case of instant consecutive strabismus in a patient who had undergone “Cuba Therapy” for Retinitis Pigmentosa (RP).Method:We compared the pre- and postoperative orthoptic examinations of a patient complaining of diplopia immediately after she underwent orbital surgery in Havana.Results:A previous small exophoria without diplopia changed into a left exotropia of 20D with constant heteronymous diplopia. Strabismus surgery revealed limited adduction caused by an orbital pedicle flap in the lower temporal quadrant of the left eye. The patient did not regain binocular single vision after corrective orbital and strabismus surgery.Conclusion:This case demonstrates an irreversible strabismus complication after the controversial “Cuba Therapy”.

Long-term Follow-up of Graves Ophthalmopathy in an Incidence Cohort

Purpose: To provide long-term follow-up data on patients with Graves ophthalmopathy in an incidence cohort of 120 patients.Methods: Data were obtained from a comprehensive review of each patient's community medical record, a follow-up survey, or both.Results: The median interval between the initial ophthalmic examination and most recent follow-up was 9.8 years (range, 64 days to 17.4 years). Follow-up of more than 5 years was available for 96 patients (80.0%), whereas follow-up exceeding 10 years was achieved for 59 patients (49.2%). Persistent visual loss from optic neuropathy occurred in two eyes, with final visual acuities of 20/30 and 20/60, respectively. None of the patients reported deterioration of vision attributable to Graves ophthalmopathy in the interval since their last ophthalmic examination at the authors' institution. Two patients (2.2%) had constant diplopia, but it was correctable with spectacles (prisms) in each case. Nearly one third of respondents had had ocular discomfort during the preceding 4 weeks; the most frequent cause in 72% of patients was dry eyes. Among the respondents to the survey, 60.5% believed that the appearance of their eyes had not returned to what it had been before the development of thyroid disease, 51.6% thought that their eyes appeared abnormal, and 37.9% were dissatisfied with the appearance of their eyes.Conclusions: Although with treatment few patients have long-term functional impairment from Graves ophthalmopathy, more than one third of patients are dissatisfied with their ultimate appearance. The psychologic, aesthetic, economic, and social sequelae of the disorder require further definition by formal outcomes studies.

Orthoptic treatment and eye movement recordings in Guillain-Barré syndrome: A case report

A 50-year-old patient with Guillain-Barre syndrome developed a symmetrical, bilateral sixth nerve palsy which resulted in constant esotropia and diplopia. The patient was treated with both prisms and orthoptics, which eliminated the diplopia. This treatment also improved both fu-sional divergence amplitudes and vergence adaptation. Objective eye movement recordings revealed subtle abnormalities of fixation, pursuit and saccades, i.e., square-wave jerks and intermittent saccadic dysmetria.

Acquired Accommodative Esotropia Following Overcorrection by Myopic Epikeratophakia

Complications reported after epikeratophakia for high myopia include under- and overcorrection, glare, irregular astigmatism, delayed reepithelialization, and decrease in best-corrected visual acuity. Overcorrection may also result in anisometropia. This report describes a patient who presented with constant diplopia and esotropia--an unusual manifestation of overcorrection after myopic epikeratophakia. The findings in this patient are those of an acquired accommodative esotropia.

FRESNEL PRISM CORRECTION FOR TRAUMA‐INDUCED DIPLOPIA

Fresnel prisms placed on the spectacle lenses of a patient with optic atrophy resulting from an accident eliminated constant diplopia in the remaining visual field. A reduction in vision due to Fresnel prisms was found to be more tolerable than diplopia.

Acquired Central Disruption of Fusional Amplitude

Acquired central disruption of fusional amplitude is characterized by a complete loss of fusional amplitude, the patient maintaining fusion for only a moment under test conditions before breaking to constant diplopia. Under normal viewing conditions, the patient has constant diplopia with both eyes open. Patients who have bilateral superior oblique palsy may mimic this loss of fusion and constant diplopia, but they are distinguished by fusing readily on the troposcope, which compensates for the excyclotorsion, in contrast to prisms, which do not remove the double vision. Case reports document an association with convergence palsy, an infranuclear unilateral superior oblique palsy, and a nonparetic acquired strabismus in visual adults. Head trauma is the usual cause.

Central disruption of fusional amplitude.

FCRL1 is a tyrosine-phosphorylated receptor found on the surface of B cells and some dendritic cells. FCRL1 co-localizes with BCR signaling complexes following BCR engagement and augments BCR-induced calcium flux. By examination of phosphotyrosine-dependent interactions of FCRL1 with intracellular signaling partners, we have identified interactions between FCRL1-Tyr281 and GRAP, GRB2, SHIP-1, and SOS1, with a requirement for GRB2 to mediate binding of FCRL1 to SHIP-1 and SOS1. Examination of MAP kinase signaling downstream of FCRL1 revealed that FCRL1 suppresses ERK phosphorylation in B cells at a resting state and following BCR engagement. In vivo, naïve FCRL1 knockout mice accumulate more B cells in the spleen, including immature, follicular and marginal zone cells, implicating a potential role for FCRL1 in B cell selection and maturation. By contrast, after immunization with thymus-dependent and independent antigens, FCRL1 knockout mice show impaired production of antigen-specific antibodies indicating an essential role for FCRL1 in humoral immune responses.