Implementation of a Magnetic Resonance Imaging scanner dedicated to emergencies in cases of binocular diplopia: Impact on patient management.

RATIONALE AND OBJECTIVES: Evaluate the implementation of an MRI scanner dedicated to emergencies on the management of patients admitted in the emergency department (ED) for binocular diplopia (BD). MATERIAL AND METHODS: This was a prospective non-interventional single-center study from February 2018 to February 2020. A total of 110 patients were included: 52 patients during the first stage (29 women; 23 men; mean age 65.2 years); 58 during the second stage (29 women; 29 men; mean age 51.4 years). Patients underwent an enhanced-CT examination in the first stage and an MRI examination in the second stage. Criteria used to evaluate the new management of patients were: proportion of patients with an imaging diagnosis explaining BD, turnaround time (TT), ED length of stay (EDLOS), hospital admission rate, hospital length of stay (HLOS), number of MRI examinations requested as a second procedure for the same indication and radiation doses. Descriptive statistics were used to present results with Student's test for quantitative variables and chi-square test for qualitative variables. RESULTS: Respectively 1 (1.92%) and 17 (29.31%) patients had definitive diagnosis in stages 1 and 2, with a significant difference in examination modalities (p=0.0001). The TT, EDLOS, hospital admission rate, and HLOS were not significantly different between the two stages. Radiation dose was significantly different between the two groups (p<0.05). CONCLUSION: Implementation of an MRI scanner dedicated to emergencies can improve the etiological diagnostic performance of binocular diplopia and reduce patient's exposure to ionizing radiation without increasing the average turnaround time or emergency department length of stay.

MRI dedicated to the emergency department for diplopia or dizziness: a cost-effectiveness analysis.

OBJECTIVES: The purpose of this study was to compare the costs and organizational benefits of diagnostic workup without and with MRI dedicated to the ED. METHODS: We conducted a prospective observational uncontrolled before-after study in one ED of a university hospital in France from July 1, 2018, and January 3, 2020. We included all consecutive patients presenting with dizziness or diplopia. The main outcomes were the clinical decision time of ED physicians and the total costs for each strategy. Outcomes were compared using propensity score with inverse probability weighting in the 2 arms and an incremental cost-effectiveness ratio (ICER) was calculated. RESULTS: Among the 199 patients during the "before" period (average age: 60.4 years ± 17.6): 112 men (57%), and 181 during the "after" period (average age, 54.8 years ± 18.5): 107 men (59%), the average costs were €2701 (95% CI 1918; 3704) and €2389 (95% CI: €1627; 3280) per patient, respectively. The average time to clinical decision was 9.8 h (95% CI: 8.9 10.7) in the group "before" and 7.7 h (95% CI: 7.1; 8.4) in the group "after" (ICER: €151 saved for a reduction of 1 h in clinical decision time). The probabilistic sensitivity analysis estimated a 71% chance that the MRI dedicated to ED was dominant (less costly and more effective). CONCLUSION: Easy access to MRI in the ED for posterior circulation stroke-like symptoms must be considered a relevant approach to help physicians for an appropriate and rapid diagnostic with reduction of costs. TRIAL REGISTRATION: NCT03660852 KEY POINTS: • A dedicated MRI in the ED for diplopia or dizziness may be considered an efficient strategy improving diagnostic performance, reducing physicians' decision time, and decreasing hospital costs. • This strategy supports clinical decision-making with early treatment and management of patients with posterior circulation-like symptoms in the ED. • There is 71% chance that the MRI dedicated to ED was dominant (less costly and more effective) compared with a strategy without dedicated MRI.

Acute-onset binocular diplopia in neurological unit: Aetiological factors and diagnostic assessment.

OBJECTIVES: To investigate the aetiology of acute-onset binocular diplopia (AOBD) in neurological units and identify the key diagnostic procedures in this setting. MATERIALS AND METHODS: Clinico-demographic data from patients hospitalized for AOBD from 2008 to 2019 were retrospectively reviewed. AOBD due to an underlying neurological disorder known to cause diplopia was addressed as secondary diplopia. Ophthalmoparesis plus was defined when subtle neurological signs/symptoms other than ophthalmoparesis were detected during neurological examination. RESULTS: A total of 171 patients (mean age 57.6 years) were included in the study. A total of 89 subjects (52%) had an oculomotor disturbance consistent with sixth nerve palsy, and 42 (24.6%) showed multiple oculomotor nerve involvement. The most common cause of AOBD was presumed to be microvascular in 56 patients (32.7%), while a secondary aetiology was identified in 102 (59.6%). Ophthalmoparesis plus and multiple oculomotor nerve involvement significantly predicted a secondary aetiology in multivariable logistic regression analysis. Brain CT was never diagnostic in isolated ophthalmoparesis. A combination of neuroimaging examinations established AOBD diagnosis in 54.9% of subjects, whereas rachicentesis and neurophysiological examinations were found to be performant in the remaining cases. CONCLUSIONS: AOBD may herald insidious neurological disease, and an extensive diagnostic workup is often needed to establish a diagnosis. Neurological examination was pivotal in identifying patients at higher risk of secondary aetiology. Even in cases of apparently benign presentation, a serious underlying disease cannot be excluded. Brain MRI was found to perform well in all clinical scenarios, and it should be always considered when managing AOBD.

Correlation of Clinical Findings With Computed Tomography in Orbital Traumas.

BACKGROUND: Although the eye is a well-protected organ, it is frequently affected by trauma. The timely detection of ocular injuries is extremely important. In this study, the authors evaluated the consistency between findings in computed tomography (CT) examination for orbital fractures and globe integrity and clinical findings in patients presenting to the emergency department due to orbital trauma. METHODS: The authors retrospectively reviewed the files of patients presenting with orbital trauma between January 2015 and January 2018 from emergency department records. Ophthalmology consultation and follow-up notes, radiology reports, and the emergency physician's notes were reviewed. RESULTS: During the study period, 286 patients presented to the emergency department with orbital trauma. A total of 119 eyes of 83 patients who underwent orbital CT were included in the study. Orbital bone fracture was detected in 54.6% (n = 65) of the eyes. Of these, 73.8% (n = 48) involved multiple fractures. Among all eyes, the distribution of fractures in the orbital walls was lateral wall in 41.2% (n = 49), floor in 32.8% (n = 39), medial wall in 31.1% (n = 37), and roof in 10.9% (n = 13). Multiple wall fractures were detected in 36.9% (n = 44) of the eyes. At least 1 clinical finding such as diplopia, laceration, abnormal pupillary response, hypoesthesia, and exophthalmos was observed in 47.1% (n = 56) of the eyes. This rate was 56.8% among eyes with orbital fractures and 35.2% in those without fracture. There was a statistically significant relationship between floor fractures and diplopia (P = 0.002). No significant correlations were found between the other radiological and clinical findings. CONCLUSION: Our study revealed a relationship between the presence of orbital fracture and eye damage. In particular, the authors found that the frequency of diplopia was significantly higher in eyes with maxillary bone fracture in the orbital floor. However, orbital CT findings other than bone fracture were not consistent with clinical findings.

Visual complaints in intracranial germinomas.

OBJECTIVE: Patients with brain tumors often report having visual complaints. This may be due to increased intracranial pressure, compression/invasion of the optic pathway or diplopia. We assessed the incidence and the etiology of visual symptoms in patients with intracranial germinoma tumors (ICGTs). METHODS AND MATERIALS: We performed a blinded retrospective review of the clinical charts and the initial magnetic resonance imaging (MRI) of 28 patients with ICGT. Thirteen tumors were pineal, five suprasellar, seven bifocal, and further three involved either the optic nerve, the corpus callosum, or the brainstem. RESULTS: Twelve patients reported visual disturbances, seven of whom mainly experienced a decrease in vision. Two of those were initially managed as "retrobulbar neuritis" when endocrinologic symptoms prompted assessment by MRI. Involvement of the optic pathway was underestimated, and both relapsed. Field deficits were definitive sequelae, whereas visual acuity was sometimes regressive in the absence of optic atrophy. CONCLUSIONS: Compression or invasion of the optic pathway by germinomas is not a rare occurrence, and this possibility should not be overlooked when thickening or contrast enhancement is detected. Radiotherapy fields should be extended accordingly.

CLIPPERS and the need for long-term immunosuppression.

Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) is a rare chronic inflammatory disorder of the central nervous system. Herein, we describe the case of a 62-year-old female who presented with right sided facial tingling, gait ataxia and diplopia. Neuroimaging revealed pontine curvilinear enhancing lesions with extension into cerebellar peduncles, characteristic of CLIPPERS. This report discusses the differential diagnosis and the importance of prolonged immunomodulatory treatment for this rare neuro-inflammatory disorder. Long-term immunosuppression appears to be mandatory in order to achieve sustained remission and prevent disability related to atrophy of the structures involved in repeated attacks.

Progressive multifocal leukoencephalopathy in a patient without apparent immunosuppression.

Progressive multifocal leukoencephalopathy (PML) is a viral demyelinating disease due to the reactivation of the JC virus (JCV), which usually occurs in the context of immunosuppression in HIV infection, malignancy, or in patients on disease modifying therapy for autoimmune diseases, such as multiple sclerosis (MS) and Crohn's disease. Notably, there is growing recognition that PML can occur in patients with transient immune dysfunction. Here, we present a case of a 55-year-old man without history of immunosuppression or evidence of ICL who was diagnosed with PML on brain biopsy. We will discuss the potential etiologies of mild and transient immunosuppression that can lead to PML with non-apparent immunosuppression.

Reconstruction of Inferior Orbital Wall Fractures Using Bone Fragments.

INTRODUCTION: Various materials have been used as implants in orbital floor fractures. The fractured bone fragments, however, are not usually used because of their small size and delicate characteristics. To overcome this limitation, the authors used autologous bone fragments combined with fibrin glue and an absorbable plate to repair inferior orbital wall fractures. METHODS: Thirty-four patients with orbital floor fractures treated in a single center from January 2013 to September 2014 were prospectively evaluated. Patients' demographic characteristics, clinical signs and symptoms, physical examination findings, postoperative complications, and preoperative and postoperative computed tomography findings were assessed. Fracture repair by a transconjunctival approach in which bone fragments were merged with fibrin glue and an absorbable plate was performed in all the patients. RESULTS: Postoperative computed tomography showed good orbital fracture reduction and soft tissue restoration in all the patients. Five patients developed postoperative diplopia; however, this symptom resolved spontaneously. Exophthalmometry showed that the degree of enophthalmos had improved significantly. CONCLUSION: Based on the results of this study, the combination of autologous bone fragments and absorbable mesh appears to be a safe and feasible option for the reconstruction of orbital floor fractures.

Diplopia and orbital wall fractures.

Diplopia is a symptom that is frequently associated with orbital wall fractures. The aim of this article was to present the incidence and patterns of diplopia after orbital wall blow-out fractures in 2 European centers, Turin and Amsterdam, and to identify any correlation between this symptom and such fractures. This study is based on 2 databases that have continuously recorded data of patients hospitalized with maxillofacial fractures between 2001 and 2010. On the whole, 447 patients (334 males, 113 females) with pure blow-out orbital wall fractures were included. The most frequently involved orbital site was the floor (359 fractures), followed by medial wall (41 fractures) and lateral wall (5 fractures). At presentation, 227 patients (50.7%) had evidence of diplopia. In particular, in most patients, a diplopia in all directions was referred (78 patients). Statistically significant associations were found between diplopia on eye elevation and orbital floor fractures (P < 0.05) and between horizontal diplopia and medial wall fractures (P < 0.000005). In patients under evaluation for orbital trauma, the observation of diplopia on eye elevation and horizontal diplopia at presentation could be useful clinical indicators orbital floor and medial wall fractures, respectively.

Acute diplopia as the presenting sign of silent sinus syndrome.

Silent sinus syndrome is a rare acquired condition that typically presents as enophthalmos and hypoglobus due to atelectasis of the maxillary sinus. The chronic negative pressure in the sinus slowly retracts the orbital floor, altering orbital anatomy and affecting the function of orbital contents. The authors present the first case of acute vertical diplopia as the presenting symptom of silent sinus syndrome.

Cosmetic orbital inferomedial decompression: quantifying the risk of diplopia associated with extraocular muscle dimensions.

PURPOSE: To quantify the risk of new diplopia in inferomedial orbital decompression performed for cosmetic reasons. METHODS: Retrospective analysis of 114 patients with Graves orbitopathy who underwent an inferomedial orbital decompression. No patient had diplopia in any of the gaze positions or optic neuropathy. A single coronal slice 9 mm posterior to the lateral orbital rim was employed to quantify the muscular index of the extraocular recti and of the superior complex. A control group of 56 patients imaged for other reasons were also measured. After surgery the oculomotor status of all patients who complained of diplopia and of 51 patients free of diplopia was measured with the prism and cover test in the primary and secondary gaze positions. RESULTS: The rate of new-onset diplopia was 14.0% (16 patients). Eye deviations were confirmed in 14 patients. Of these, 10 had significant strabismus that warranted surgical or prism treatment. Most patients had esotropia associated with small vertical deviations. The size of the medial and inferior recti was significantly associated with the development of diplopia. The estimated odds for the appearance of diplopia in patients with muscle enlargement was 12.76 (medial rectus) and 5.21 (inferior rectus). Small-angle deviations were also detected in 27.4% of patients who did not experience diplopia. CONCLUSIONS: Medial and inferior recti enlargement is a strong predictor of new-onset diplopia. A large number of patients who do not report diplopia also present with small-angle deviations.

Magnetic Resonance Imaging in Diplopia: Neural Pathway, Imaging, and Clinical Correlation.

The role of magnetic resonance imaging (MRI) in diplopia is to diagnose various diseases that occur along the neural pathway governing eye movement. However, the lesions are frequently small and subtle and are therefore difficult to detect on MRI. This article presents representative cases of diseases that cause diplopia. The purpose of this article was to 1) describe the anatomy of the neural pathway governing eye movement, 2) recommend optimal MRI targets and protocols for the diagnosis of diseases causing diplopia, 3) correlate MRI findings with misalignment of the eyes (i.e., strabismus), and 4) help familiarize the reader with the imaging diagnosis of diplopia.

Diplopia Related to a Pediatric Cervical Rhabdoid Tumor in 18 F-FDG PET.

ABSTRACT: Increased muscle uptake is commonly seen with 18 F-FDG PET/CT because of an important physiological muscle glucose metabolism. Muscle uptake can express a recent significant muscle activity. However, the absence of muscle uptake is almost never described or interpreted. We describe the case of an 8-year-old boy with extrarenal rhabdoid tumor in the right carotid space. An MRI and an 18 F-FDG PET/CT were performed for the diagnostic workup. There was no uptake in the lateral rectus oculomotor muscle unlike all other oculomotor muscles. The ophthalmological examination found a diplopia confirmed by the Lancaster test.

CT parameters in pure orbital wall fractures and their relevance in the choice of treatment and patient outcome: a systematic review.

Computed tomography (CT) is commonly used for the diagnosis, treatment planning, and prognosis of pure orbital fractures of the orbital floor and medial wall. The aim of this study was to systematically review the current literature in order to establish an overview of CT parameters relevant to the choice of treatment and (long-term) clinical outcome for patients treated operatively and conservatively. The PRISMA guidelines were followed. Databases were searched using the terms 'orbital fracture' and 'computed tomography'. Studies evaluating the relationship between CT parameters and the treatment decision or clinical outcome (enophthalmos, diplopia, and/or limitation of ocular movement) were included. The search yielded 4448 results of which 31 were included (except for three, all were retrospective). The systematic use of CT imaging in orbital fractures of the floor and the medial wall can be of great value in the treatment decision and prediction of (long-term) clinical outcomes for both conservatively and surgically treated patients. The following parameters were found to be the most relevant: fracture size, fracture location, orbital volume, soft tissue involvement, and craniocaudal dimension. Although some show great individual potential, it is likely that incorporating all parameters into an algorithm will provide the best predictive power and thus would be the most practically applicable tool.

Isolated bilateral abducens nerve palsy without radiographic etiology and unique mechanism of injury.

Isolated bilateral abducens palsy is a rare event, especially in the setting of closed head injury. Cases that lack radiographic or pathologic findings to explain the etiology of the palsy are limited to case reports. Injury mechanisms have been postulated, but a consensus does not exist. The authors describe a case of traumatic isolated bilateral abducens palsy lacking radiographic and pathologic findings. A previously unreported potential pathophysiologic injury mechanism is theorized based upon anatomical structure and mode of injury.

Functional Anatomy of Muscle Mechanisms: Compensating Vertical Heterophoria.

PURPOSE: Magnetic resonance imaging (MRI) of extraocular muscle function was used to evaluate the role of newly recognized mechanisms underlying compensation of large heterophoria by vertical fusional vergence (VFV). DESIGN: Prospective case series. METHODS: At one academic center, 8 adults with large hyperphoria and supernormal VFV underwent MRI during monocular and binocular fixation of a centered, near target. Contractility of the rectus and superior oblique (SO) extraocular muscles in hypertropic and hypotropic eyes was determined from changes in posterior partial volume (PPV). RESULTS: Five of 8 patients could sustain binocular fusion in the scanner. In those patients, VFV corrected approximately 5-degree misalignment, approximately 5-fold greater than normal VFV. Vertical strabismus was compensated mainly by significant contractility of the lateral more than the medial compartment of the inferior rectus (IR) in both eyes (P < .005). The superior rectus (SR) and inferior oblique muscles had no significant contractile contribution, although the hypotropic SO relaxed significantly. The IR lateral compartment and SR medial compartment significantly co-relaxed when binocular fusion was attained from monocular target fixation (P < .01). CONCLUSIONS: Although VFV protects patients from small muscle imbalances over the lifespan, even enhanced VFV may be inadequate to avert diplopia. Compensation of hyperphoria by VFV is accomplished mainly by IR muscle relaxation in the hypotropic eye, principally in its selectively innervated lateral compartment, whereas the SO contributes little. Fusion involves compartmentally selective co-relaxation in hypotropic eye vertical rectus muscles. Taken together, these overall findings suggest a physiologic basis to prefer therapeutic surgical weakening of the medial IR in the hypotropic eye.

Isolated abducens nerve palsy in a patient with asymptomatic SARS-CoV-2 infection.

The neuro-ophthalmological complications of SARS-CoV-2 infection are emerging but the spectrum of presentations and pathophysiological mechanism underpinning the association remains to be fully determined. We describe the case of a 44-year-old female who presented with a 12-hour history of diplopia preceded by a mild headache and found to have an isolated right abducens nerve palsy. Initial vital signs were normal but she developed a fever and nasopharyngeal swab confirmed SARS-CoV-2 infection by RT-PCR. All other investigations returned normal including blood tests, chest X-ray, MRI brain and cerebrospinal fluid analysis. She remained systemically well, and there was complete resolution of the abducens palsy and diplopia at two week follow up. In the absence of an alternative underlying cause or risk factors identified, the aetiology was presumed to be microvascular and potentially related to the viral infection. We add to the evolving literature of neuro-ophthalmological associations of SARS-CoV-2, discuss possible causal mechanisms and suggest considering asymptomatic SARS-CoV-2 infection in cases of isolated abducens palsy without clear risk factors.