Diplopia after Sleeve Gastrectomy: The Canary in the Coal Mine.

Wernicke's encephalopathy (WE) is a neurologic emergency requiring timely intravenous thiamine supplementation to prevent permanent neurologic deficits. Historically, the WE diagnosis was limited to individuals with alcohol use disorder. However, it is now widely recognized to occur in patients who are chronically malnourished, post-bariatric surgery, pregnant with hyperemesis gravidarum, and with severe anorexia nervosa. Here we present a young woman who developed WE after undergoing a recent sleeve gastrectomy followed by protracted emesis for several days. This case underscores the importance of performing a thorough neurological review of systems and physical exam in high-risk patients and having a low clinical threshold to initiate appropriate thiamine treatment.

Transient Right-Sided Hemiparesis and Diplopia in the Setting of a Migrated Cervical Spinal Cord Stimulator Lead: A Case Report.

A 36-year-old man with a history of cervical spinal cord stimulator (SCS) lead placement presented with transient right-sided hemiparesis and diplopia that began 2 days after a coughing episode. Imaging revealed lateral and cranial migration of one of the patient's SCS leads. Deactivation of the SCS resulted in rapid improvement of his nonmotor symptoms but did not resolve his motor deficits. The SCS system was surgically explanted, resulting in resolution of the patient's motor symptoms. The unique neurologic symptomatology demonstrated by this patient is a previously undescribed complication of SCS placement and lead migration.

INTRACTABLE PAIN AND DIPLOPIA AFTER SCLERAL BUCKLE SURGERY.

PURPOSE: To report a case of early postoperative scleral buckle slippage because of the dehiscence of scleral belt loop tunnels. METHOD: Case report. RESULTS: A 54-year-old woman presented with painful diplopia after a combination pars plana vitrectomy and scleral buckling procedure. Ocular movements were limited. Forced duction testing was restricted in all directions. Anterior slippage of the silicone band was suggested on computed tomography (CT) scans and was confirmed with surgical exploration. During surgery, it was found that thin-roofed scleral belt loop tunnels were dehisced in three quadrants leading to anterior slippage of the buckle. The displaced buckle was removed. Diplopia and pain resolved, and ocular motility improved immediately afterward. The retina remained attached at six months follow-up. A supplemental video summarizes the surgical findings and postoperative results. CONCLUSION: Spontaneous dehiscence of scleral belt loops may occur in thinly dissected scleral tunnels. Painful eye movement, diplopia, and a positive forced duction test should raise suspicion about a displaced scleral buckle. A CT scan may help with the diagnosis. Early diagnosis and immediate surgical intervention are needed to minimize patient discomfort and to improve long-term ocular motility.

Unilateral visual impairment after a dental procedure: Case report.

The use of intra-oral local anaesthetics for dental procedures is a widely extended practice that may cause side effects. As such, in rare cases it may cause ocular complications such as diplopia, ptosis, blurry vision, miosis, vision loss, or amaurosis. (Most of them are transient, recovering after several hours or days). A case is presented of a 26 year-old male patient who had visual impairment in the right eye 2 days after a dental procedure was performed. Six months later he had a complete restoration of the previous visual acuity, despite the fact that he had not received any treatment. Several ways have been proposed in the literature that may explain the appearance of ocular complications following these kinds of procedures. In this case, inadvertent intravenous injection is believed to have been the cause.

A case of transient diplopia and ophthalmoplegia following dental anesthesia.

Dental anesthesia is one of the most frequently performed medical procedures. Although the frequency of ocular complications is extremely low, these reactions can be highly alarming and may bring up medicolegal issues when they do occur. Dentists and oral surgeons should be well-informed of these adverse reactions and should be aware that both ophthalmologists and emergency physicians might be required to care for these patients.

Neuromyelitis optica spectrum disorders with vertigo as the initial symptom: A case report.

RATIONALE: Brain abnormalities have frequently been reported in neuromyelitis optica spectrum disorders patients, but vertigo as an initial manifestation has rarely been described. PATIENT CONCERNS: A 64-year-old woman who initially presented with vertigo, then accompanied with other brainstem manifestations and spinal cord involvement. DIAGNOSES: MRI revealed medulla oblongata, cervical and thoracic spinal cord lesions. NMO-IgG antibody was seropositive. Taken her previous medical history and clinical manifestations into consideration, the patient was eventually diagnosed as neuromyelitis optica spectrum disorders. INTERVENTIONS: Before diagnosis, symptomatic treatment and acupuncture were adopted, whereas after diagnosis, steroid, intravenous immunoglobulin, and immunosuppressant were supplemented. OUTCOMES: Her dizziness, nausea and vomiting were gradually relieved by symptomatic treatment and acupuncture before the confirmed diagnosis and immunotherapy. After added treatment with steroid, immunosuppressant, especially intravenous immunoglobulin, diplopia and nystagmus disappeared, and superficial sensation was improving. She was fully recovered six months after admission. LESSONS: Vertigo as a rare prodrome of neuromyelitis optica spectrum disorders deserves attention. The symptoms and signs were improved by a combined treatment of steroid, immunosuppressant, acupuncture, and particularly intravenous immunoglobulin.

[Transient diplopia and ophthalmoplegia following dental anaesthesia. Review of the literature and case report]. / Átmeneti kettos látás és szemizombénulás fogászati érzéstelenítést követoen.

Dental anaesthesia is one of the most frequently performed medical procedures. Although the frequency of ocular complications is low, these can be alarming and can potentially give rise to medicolegal issues. Dentists and oral surgeons should be well-informed of these adverse reactions. Ophthalmologists and emergency physicians might be required for appropriate care of these patients. Fortunately, most ocular complications related to dental anesthesia are transient. Differential diagnosis includes stroke and intracranial hemorrhage and so vital signs are to be closely monitored. The planned surgical procedure can be carried out once the patient is fully informed and gave consent. The psychological aspect of such unexpected complication must be managed appropriately. We report a case with diplopia and ophthalmoplegia of a reversible and temporary nature. We also include a literature review of ophthalmologic complications after intraoral local anaesthesia in this paper. Orv Hetil. 2018; 159(52): 2212-2216.

Anteromedial thalamic infarct: a rare presentation.

We report a rare presentation of an anteromedial thalamic infarct in a 50-year-old woman with acute onset left eye ptosis, vertical gaze paresis and confusion. MRI identified an acute left anteromedial thalamic infarct with a severe left P1 stenosis. Thalamic infarcts are associated with marked neurobehavioural disturbances with dominant thalamic lesions causing language deficits, verbal perseveration, memory disturbances, abulia and disorientation. Ocular movement deficits can also be present and typically accompany paramedian lesions. Rarely, patients can develop an ipsilateral ptosis. We discuss these symptoms and review the literature.

Surgery option in the management of delayed diplopia after radiation therapy for nasopharyngeal carcinoma.

PURPOSE: Radiation therapy is a standard treatment for nasopharyngeal carcinoma. Diplopia due to radiation damage to the sixth nerve significantly erodes the patient's quality of life. This study investigated the effectiveness of extraocular surgery in the treatment of delayed diplopia caused by radiation therapy. METHODS: A retrospective case series of 16 patients (7 men and 9 women) with delayed diplopia after radiation therapy for nasopharyngeal carcinoma was enrolled in the study. Unilateral lateral rectus resection was performed under topical anesthesia. Follow-up time was more than 12 months. Outcome measures were prism diopter and self-reported symptoms. RESULTS: All patients diagnosed with sixth nerve palsy reported elimination of symptoms on postoperative day 1 without complications. One patient required a second procedure due to recurrence of symptoms. At 12-month follow-up, no patient reported recurrence of symptoms. The absolute horizontal deviation significantly decreased from a preoperative value of 16 prism diopter to a value of 1.5 prism diopter postoperatively (p < 0.001). CONCLUSION: These results suggest that unilateral lateral rectus resection under topical anesthesia is an effective treatment for delayed diplopia after radiation therapy for nasopharyngeal carcinoma. A large randomized prospective study to confirm these findings is warranted.

[Ocular complications of local anaesthesia in dentistry]. / Oculaire bijwerkingen van lokale anesthesie in de tandheelkunde.

An estimated 1 in 1,000 local anaesthetic injections in the maxilla or the mandible lead to unwanted effects on the ipsilateral eye. We have seen a case with diplopia and lateral rectus palsy following bimaxillary anaesthesia. A systematic literature review of reports on this type of complication resulted in a total of 144 documented cases published between 1936 and 2016. The most frequently reported symptoms included diplopia (72%), partial or full ophthalmoplegia (26%), ptosis (22%), mydriasis (18%), amaurosis (13%) and orbital pain (12%). This type of complication is best understood by pathophysiological hypotheses that include intra-arterial injection, intravenous injection, autonomic dysregulation, or deep injection and diffusion. If ocular symptoms appear after local intraoral anaesthesia, the patient should be reassured. In the case of diplopia, the eye should be covered with a gauze dressing, and the patient should be instructed about associated safety risks. If symptoms persist or when vision deteriorates, referral to an ophthalmologist is advisable.

Isolated pseudoabducens palsy in acute thalamic stroke.

Oculomotor abnormalities are rarely noted in thalamic strokes. We describe isolated right pseudoabducens palsy in a young patient with acute left thalamic infarction revealed by diffusion-weighted magnetic resonance imaging. The patient's horizontal diplopia and oculomotor palsy resolved within 3days. This case supports the hypothesis that a lesion can cause isolated esotropia by interrupting descending inhibitory convergence pathways that traverse the paramedian thalamus and decussate in the subthalamic region to innervate the contralateral third oculomotor nucleus. Esotropia contralateral to the thalamic lesion results from tonic activation of the medial rectus, producing pseudoabducens palsy.

A case of double depressor palsy followed by pursuit deficit due to sequential infarction in bilateral thalamus and right medial superior temporal area.

BACKGROUND: We present a unique case of a patient who suffered two rare events affecting the supranuclear control, first of the vertical and second of the horizontal eye movements. The first event involved bilateral thalamic infarcts that resulted in double depressor palsy. The second event occurred 1 year later and it involved supranuclear control of horizontal eye movements creating pursuit deficit. CASE PRESENTATION: A 47-year-old male presented with complaints of diplopia upon awakening. He had atrial fibrillation, mitral valve regurgitation, aortic valve regurgitation, and a history of spleen infarction 1 year ago. His right eye was hypertrophic and right eye downgaze was limited unilaterally of equal degree in adduction and abduction. The patient was diagnosed with double depressor palsy of the right eye. Magnetic resonance imaging (MRI) of the brain showed an old infarction of the left thalamus, and diffusion MRI showed acute infarction of the right thalamus. The patient's daily warfarin dose was 2 mg and it was increased to 5 mg with cilostazol 75 mg twice a day. Seven weeks later, the patient's ocular movement revealed near normal muscle action, and subjectively, the patient was diplopia free. At follow-up 12 months later, the patient revisited the hospital because of sudden onset of blurred vision on right gaze. He was observed to have smooth pursuit deficit to the right side, and orthophoric position of the eyes in primary gaze. MRI of the brain showed an acute infarction in the right medial superior temporal area. CONCLUSIONS: The patient experienced very rare abnormal eyeball movements twice. This case highlights the importance of evaluating vertical movement of the eyes and vascular supplies when patients present with depressor deficit and supports the theory of a supranuclear function in patients who present with pursuit deficit.

Ruthenium-106 brachytherapy for choroidal melanoma without transpupillary thermotherapy: Similar efficacy with improved visual outcome.

PURPOSE: To evaluate efficacy and toxicity of two different protocols for eye-conserving treatment of patients with small to intermediate-sized choroidal melanomas; the current ruthenium-106 (Ru106) brachytherapy protocol and the preceding protocol of Ru106-brachytherapy with transpupillary thermotherapy (Ru106/TTT). METHODS AND MATERIALS: Long-term outcomes of 449 consecutive patients, of whom 196 (43.6%) treated using Ru106/TTT and 253 (56.3%) treated using Ru106, were compared in terms of local control, survival, eye preservation and visual outcome. RESULTS: Median follow-up was 82.8 months. Patients in the Ru106-group had smaller, less centrally located tumours and better pre-treatment visual acuity (VA). Five-year cumulative incidence of local failure was 11.2% for Ru106/TTT and 5.2% for Ru106, which was not statistically significant after correction for differences in baseline characteristics (hazard ratio for Ru106 = 0.57, p = 0.14). Cumulative incidence of distant metastases was 11.2 versus 6.2%, and cumulative incidence of cause-specific death was 22.4 versus 5.5% for Ru106/TTT and Ru106 respectively. Enucleation was performed in 9.2 versus 4.0% for Ru106/TTT versus Ru106; 5.1 versus 3.2% for local failure and 2.6 versus 0.8% for complications. At one year of follow-up, significantly more patients had lost useful vision (VA < 0.33) in the Ru106/TTT-group than in the Ru106-group (50.0 versus 24.5%). After two and three years, the differences decreased (54.6 versus 34.0% and 61.7 versus 45.8%, respectively) and lost statistical significance. CONCLUSIONS: Both the current Ru106 and the preceding Ru106/TTT-protocols provided excellent tumour control, cosmetic and functional eye preservation and vital prognosis. The Ru106-protocol yielded prolonged preservation of VA and should be regarded the current standard of treatment.

[Spasm of the near reflex. Treatment with botulinum toxin]. / Espasmo del reflejo de cerca. Tratamiento con toxina botulínica.

CLINICAL CASE: A 38-year old female with diplopia and esotropia, with limitation of ocular abduction in both eyes, with full abduction after doll's head rotation also being observed. She was diagnosed with spasm of the near reflex. Treatment with injections of botulinum toxin in both medial rectus has temporally resolved the convergence spasm. DISCUSSION: Near reflex spasm is characterized as miosis, pseudomyopia, and convergent strabismus that lead to diplopia, blurred vision, headache, and variable, progressive, and intermittent esotropia. As the spasm worsens there will be limited ocular versions and ductions simulating a sixth nerve palsy. Botulinum toxin may be effective in some cases.

Post-radioiodine De Novo Onset Graves' Ophthalmopathy: Case Reports and a Review of the Literature.

New-onset Graves' ophthalmopathy (GO) following radioiodine treatment (RAI) and worsening of existing GO are well-described in the endocrinology literature. These phenomena are recognized by ophthalmologists, yet poorly documented in the ophthalmology literature. Two male patients, aged 43 and 62 years, respectively, with Graves' disease without GO, received RAI. Four months later, one patient developed acute GO with unilateral reduction in visual acuity, conjunctival chemosis, lagophthalmos, bilateral severely restricted ocular motility, and lid retraction. High-dose intravenous steroids, followed by oral steroids, led to a dramatic clinical improvement. The second patient received a second dose of RAI for persistent hyperthyroidism and subsequently developed acute GO-comprising restricted ocular motility, peri-orbital swelling, and conjunctival chemosis. Symptoms gradually resolved on continued carbimazole treatment. Neither patient received pre-RAI prophylactic glucocorticoids, as currently they are only recommended for patients with pre-existing GO or multiple risk factors. We discuss the limitations of using this risk-based approach in preventing new-onset GO following RAI therapy.

Ocular complications after posterior superior alveolar nerve block: a case of trochlear nerve palsy.

Many intraoperative complications occurring during third molar surgery are described in the literature. Unilateral trochlear nerve palsy secondary to dental anaesthesia is a rare complication. We report the case of a 36-year-old healthy man, ASA I classification, requiring upper third molar extraction. Articaine 1:200,000 epinephrine for right posterior superior alveolar (PSA) nerve block was administered locally in the mucobuccal fold above the upper third molar. A few minutes after PSA nerve block the patient experienced double-vision. The patient was subsequently visited by an ophthalmologist and the condition was diagnosed as transient unilateral vertical diplopia due to temporary paralysis of the superior oblique muscle as a result of the anaesthetic solution involving the IV cranial nerve. The authors report this unusual case and discuss the possible anatomical pathways that might explain this rare phenomenon.

Persistent vertical diplopia after cataract surgery: a case report.

Diplopia is an event that can occur following cataract surgery, although its rate of occurrence is limited and ranges from 0.67% to 0.85%. The authors present a case of vertical diplopia arising after peribulbar anaesthesia for cataract surgery in a 78-year-old woman. Diplopia appeared at distance in primary position, while at near there was binocular single vision. Stereopsis was present at the Lang I - II Test, but the Wirth Test was incomplete. Although in the literature the frequency of these "accidents" is very limited, we think it is relevant to emphasize the need to perform pre-operative routine using a careful orthoptic examination along with a thorough medical, especially strabological, history.

Neurocysticercosis presenting as a vertical one-and-a-half syndrome with associated contralesional horizontal gaze paresis.

We describe a patient presenting with vertical one-and-a-half syndrome and concomitant contralesional horizontal gaze paresis as the result of a solitary neurocysticercosis (NCC) lesion in the right midbrain extending into the thalamomesencephalic junction. The patient received an albendazole-dexamethasone course which resulted in resolution of his symptoms. The neuro-ophthalmological complications of NCC are reviewed and the clinical topography of the neuro-ophthalmological findings of this unusual observation are discussed.

Diplopia following sub-tenon's anaesthesia: an unusual complication.

Diplopia is a rare but well recognised complication following retrobulbar and peribulbar local anaesthesia but it has not been widely reported following sub-tenon's local anaesthesia (STLA). We report on a 76-year-old woman who developed vertical diplopia after left phacoemulsification. She had received a STLA. She had left hypotropia measuring 30 prism diopters for near and distance. She was managed with occlusion but there was no improvement in her findings over 6 months. Ocular motility opinion was then sought and a presumptive diagnosis of inferior rectus fibrosis was made. She subsequently underwent a left inferior rectus recession using adjustable sutures. Postoperatively she had a residual left hypotropia measuring 8 prism dioptres and single vision. Possible causes of inferior rectus fibrosis include muscle damage during traumatic sub-tenon's block or myotoxicity due to local anaesthetic agents. This case highlights the importance of close supervision of inexperienced staff administering regional anaesthetics.