[Binocular diplopy as the presentation of a haematoma in the rectus inferior]. / Diplopía binocular como presentación de un hematoma del recto inferior.

INTRODUCTION: The presence of quick onset binocular diplopy makes it essential to carry out a comprehensive differential diagnosis. The most frequent causes in adults include vascular, post-traumatic, tumorous and myopathic pathologies. Yet, to perform a differential diagnosis we also have to take into account less common aetiologies such as demyelinating disease, carotid-cavernous fistulas and Tolosa Hunt syndrome, among others. We report the case of a patient who was admitted to our hospital because she presented an acute onset diplopy secondary to a spontaneous haematoma of the left rectus inferior. CASE REPORT: We describe the case of a 54-year-old female with a history of hypercholesterolemia, who was a smoker and allergic to iodine contrasts and who visited because of an acute onset diplopy accompanied by instability and pain in the left eye. The neurological examination revealed paresis of the extraocular muscles dependent on the left oculomotor nerve with left palpebral ptosis, paresis of the rectus inferior, with no involvement of the pupils. Other results of the exploration were within normal limits. A computerised axial tomography scan of the head showed a haemorrhage in the rectus inferior. Magnetic resonance images of the head revealed an increase in the volume of the left-side rectus inferior with signs of bleeding, and the rest of the complementary explorations were normal. The patient progressed favourably and the diplopy gradually disappeared. CONCLUSIONS: Spontaneous bleeding of the extraocular muscles, although infrequent, must be taken into account in the differential diagnosis of painful ophthalmoplegia with diplopy in patients with no underlying pathology, especially in the absence of other neurological disorders.

Diplopía binocular como presentación de un hematoma del recto inferior / Binocular diplopy as the presentation of a haematoma in the rectus inferior

Introducción. La presencia de una diplopía binocular de instauración rápida obliga a un amplio diagnóstico diferencial. Entre las causas más frecuentes en personas adultas encontramos la patología vascular, postraumática, tumoral o miopática. Sin embargo, para realizar el diagnóstico diferencial debemos tener en cuenta etiologías menos frecuentes, como enfermedad desmielinizante, fístulas carotidocavernosas y síndrome de Tolosa-Hunt, entre otras. Presentamos el caso de un paciente que ingresó en nuestro servicio por presentar diplopía de instauración aguda secundaria a un hematoma espontáneo del recto inferior izquierdo. Caso clínico. Mujer de 54 años con antecedentes de hipercolesterolemia, fumadora y alérgica a contrastes yodados, que consulta por diplopía de instauración aguda acompañada de dolor ocular izquierdo e inestabilidad. A la exploración neurológica destaca paresia de la musculatura extraocular dependiente del III par craneal izquierdo con ptosis palpebral izquierda y paresia del recto inferior, sin afectación pupilar. El resto de la exploración estuvo dentro de la normalidad. En la tomografía axial computarizada craneal se observa una hemorragia en el recto inferior. En la resonancia magnética craneal se observó un aumento de volumen del recto inferior izquierdo con signos de sangrado, y el resto de las exploraciones complementarias fueron normales. La paciente evolucionó favorablemente y desapareció progresivamente la diplopía. Conclusión. La hemorragia espontánea de los músculos extraoculares, aunque infrecuente, debe considerarse en el diagnóstico diferencial de la oftalmoplejía dolorosa con diplopía en pacientes sin patología de base, especialmente en ausencia de otras alteraciones neurológicas (AU)

Introduction. The presence of quick onset binocular diplopy makes it essential to carry out a comprehensive differential diagnosis. The most frequent causes in adults include vascular, post-traumatic, tumorous and myopathic pathologies. Yet, to perform a differential diagnosis we also have to take into account less common aetiologies such as demyelinating disease, carotid-cavernous fistulas and Tolosa-Hunt syndrome, among others. We report the case of a patient who was admitted to our hospital because she presented an acute onset diplopy secondary to a spontaneous haematoma of the left rectus inferior. Case report. We describe the case of a 54-year-old female with a history of hypercholesterolemia, who was a smoker and allergic to iodine contrasts and who visited because of an acute onset diplopy accompanied by instability and pain in the left eye. The neurological examination revealed paresis of the extraocular muscles dependent on the left oculomotor nerve with left palpebral ptosis, paresis of the rectus inferior, with no involvement of the pupils. Other results of the exploration were within normal limits. A computerised axial tomography scan of the head showed a haemorrhage in the rectus inferior. Magnetic resonance images of the head revealed an increase in the volume of the left-side rectus inferior with signs of bleeding, and the rest of the complementary explorations were normal. The patient progressed favourably and the diplopy gradually disappeared. Conclusions. Spontaneous bleeding of the extraocular muscles, although infrequent, must be taken into account in the differential diagnosis of painful ophthalmoplegia with diplopy in patients with no underlying pathology, especially in the absence of other neurological disorders (AU)