Cranial Nerve Six Palsy After Vaginal Delivery with Epidural Anesthesia: A Case Report.

BACKGROUND: This case report describes a 34-year-old woman who developed diplopia and strabismus 2 weeks after a vaginal delivery and epidural anesthesia. CASE REPORT: A 34-year-old women presented to the emergency department (ED) with continued headache and new-onset diplopia after having undergone epidural anesthesia for a vaginal delivery 2 weeks prior. During that time, she underwent two blood patches, rested supine, drank additional fluids, and consumed caffeinated products for her spinal headache. When she developed double vision from a cranial nerve VI palsy, she returned to the ED. At that time, she had a third blood patch performed, and she was evaluated by a neurologist. The medical team felt the cranial nerve VI palsy was due to the downward pull of the brain and stretching of the nerve. Magnetic resonance imaging and neurosurgical closure of the dura were considered as the next steps in treatment; however, they were not performed after being declined by the patient. All symptoms were resolved over the next 3 weeks. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates the uncommon complication of a cranial nerve VI palsy from a persistent cerebrospinal fluid leak after a dural puncture. Emergency physicians must be aware that diplopia can be a rare presenting symptom after patients undergo a lumbar puncture. Furthermore, emergency physicians should be aware of the multiple treatment options available. Knowledge of the timeline of resolution of the diplopia is necessary to make shared decisions with our patients about escalating care.

Visual Morbidity in Patients With Ophthalmic Segment Aneurysms Treated With Flow Diverters: A Dual-Center Experience.

BACKGROUND AND OBJECTIVE: Flow diverter (FD) treatment for aneurysms of the ophthalmic segment of the internal carotid artery (ICA) may raise concerns about visual morbidity related to coverage of the ophthalmic artery by the device. Our objective was to evaluate clinical and angiographic outcomes associated with FD treatment of these aneurysms, with particular emphasis on visual morbidity. METHODS: We performed a retrospective analysis of the endovascular databases at 2 US centers to identify consecutive patients with aneurysms along the ophthalmic segment of the ICA that were treated with FDs between January 2010 and December 2022. Baseline demographics, aneurysm characteristics, and periprocedural and postprocedural data, including the occurrence of visual complications, were collected. RESULTS: One hundred and thirteen patients with 113 aneurysms were identified for inclusion in this study. The mean age of the patients was 59.5 ± 12.4 years, and 103 (91.2%) were women. The ophthalmic artery origin was involved in 40 (35.4%) aneurysms, consisting of a neck origin in 33 (29.2%) and a dome origin in 7 (6.2%). New transient visual morbidity during the hospital stay included impaired visual acuity or blurriness in 1 (0.9%) patient, diplopia in 1 (0.9%), and floaters in 1 (0.9%). New transient visual morbidity during follow-up included impaired visual acuity or blurriness in 5 patients (4.4%), diplopia in 3 (2.7%), ipsilateral visual field defect in 1 (0.9%), and floaters in 6 (5.3%). Permanent visual morbidity occurred in 1 patient (0.9%). Among the 101 patients who had angiographic follow-up, the Raymond-Roy occlusion classifications were I (complete aneurysm occlusion) in 85 (84.2%), II (residual neck) in 11 (10.9%), and III (residual aneurysm) in 5 (4.9%). CONCLUSION: In our experience, flow diversion for ICA ophthalmic segment aneurysms resulted in low rates of visual morbidity, which was mostly transient in occurrence.

Eye movement training and gaze analysis for a patient with binocular diplopia after traumatic brain injury: a case report.

BACKGROUND: Patients with traumatic brain injury often develop sequelae such as eye movement disorders, including diplopia. Eye movement training is effective in diplopia management. However, few longitudinal follow-up studies have been conducted from the subacute disease stage, owing to the complexity of methods for quantifying diplopia. CASE PRESENTATION: The patient is a 30-year-old Japanese man who presented with diplopia and underwent eye movement training for approximately 4 weeks. The angle of diplopia, distance of abduction of the eye, gaze analysis, and self-assessment of diplopia using Holmes' diplopia questionnaire were evaluated. The degree of diplopia increased from 12° to 40° on the right side. The distance of eye abduction increased from 10.4 to 12.8 mm. The self-assessment score improved from 76 to 12 points. Analysis of gaze transition revealed a reduction in the error between the target and gaze. CONCLUSION: Eye movement training was successful in ameliorating the symptoms of diplopia in the patient with binocular diplopia. Furthermore, for patients with diplopia symptoms, it was suggested that the oculomotor approach to eye movement training should not only focus on the direction of the diplopia but also on the direction opposite to the diplopia (the weak side).

Management of acute acquired comitant esotropia in children.

Aim: This report aims to discuss and review the diagnosis and management of acute acquired comitant esotropia (AACE) in children and to add several cases to the limited literature available on this unusual condition in the pediatric population. Materials and methods: We present two cases of AACE with large-angle deviations that were investigated and followed-up according to current recommendations. Both cases required strabismus surgery for AACE, but different procedures were chosen, with good postoperative results. Results: Unilateral recession of the medial rectus and resection of the lateral rectus (R&R) were performed in one case and bilateral medial rectus (MR) recession in the other, with resolution of the diplopia and full recovery of binocular vision. Discussion: Although isolated AACE is usually benign, studies have reported the presence of intracranial disease in up to 10% of cases, making it a potential first sign of an underlying serious pathology. Therefore, AACE should be investigated as a medical emergency and neuroimaging should be performed in all patients with unclear onset of AACE, as well as in those with associated neurological symptoms, such as headache, cerebellar imbalance, weakness, or nystagmus. Conclusion: Acute acquired comitant esotropia (AACE) is an infrequent type of esotropia that usually appears in older children. It is characterized by esotropia and diplopia with acute onset. Neurological examinations and neuroimaging should be performed to exclude any potential intracranial disease. Treatment of AACE without underlying neurological disease is focused on managing the diplopia and resolving the esotropia. Strabismus surgery has good motor and sensory results and can successfully restore good binocular function. Abbreviations: AACE = Acute acquired comitant esotropia, LR = lateral rectus, MR = medial rectus, PD = prism diopters, R&R = recession and resection, BSV = binocular single vision, PAT = prism adaptation test.

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.

To prioritize treatment options for acute acquired comitant esotropia.

The management of acute acquired comitant esotropia (AACE) is controversial, and no clear guidelines exist to guide its treatment options. Therefore, the author proposes his idea that treatment options for AACE should be prioritized to achieve optimal outcomes with fewer potential complications for this type of esotropia. In this manner, treatment should be started with less invasive, muscle-sparing procedures while the patient is regularly checked for improvement in esotropia and diplopia. This is also a good scheme because the patient can go through vital neurological and ophthalmological assessments while he/she is spared from invasive interventions in the beginning.

Evaluation and Management of Symptomatic Vertical Strabismus and Diplopia.

The evaluation and management of vertical strabismus is more challenging and nuanced than that of horizontal strabismus. Vertical strabismus often results from a variety of restrictive or paretic causes, which can be further characterized as either acquired or congenital. In some cases, identifying the correct etiology of the strabismus can mean uncovering a potentially life-threatening condition, such as a brain tumor or stroke. The keys to identifying the correct diagnosis are, first and foremost, a careful history, and secondly, a detailed examination. The characteristics, etiologies, and evaluation of vertical strabismus will be reviewed here.

Evaluation and Management of Divergence Insufficiency-Type Esotropia.

Divergence insufficiency-type ET is a common cause of distance diplopia in elderly adults. A recent prospective multicenter data collection study has provided additional guidance on management. Either base-out prism glasses or strabismus surgery were found to have high success rates, based on patient report of diplopia, and health-related quality-of-life domain scores. It was concluded that either prism or surgery were reasonable initial treatment strategies. Although allocation bias precluded formal comparison of prism versus surgery (evident in baseline differences between groups), there were hints that surgery may yield superior outcomes. For surgery, the most common approach was bilateral medial rectus recession, which was highly successful when assessed 10 weeks and 12 months postoperatively. It was unclear whether adjustable sutures were helpful, but in the vast majority of adjustable cases, additional recession at the time of adjustment was performed, suggesting that larger than standard surgical doses are needed.

Acquired Diplopia in Adults: Heavy Eye Syndrome.

Heavy eye syndrome is a condition that results in an acquired, progressive strabismus that is due to extreme myopia and long axial length. The underlying pathogenesis of the condition is due to prolapse of the supero-temporal aspect of the myopic globe causing displacement of the lateral and superior rectus muscles inferiorly and nasally, respectively. Treatments for heavy eye syndrome often target this anatomical defect and seek to re-place the globe within the extraocular muscle cone. This review will discuss current theories of pathogenesis and treatment of heavy eye syndrome.

Clinical Characteristics of Acquired Diplopia in Adults.

PURPOSE: To describe the common causes of symptomatic strabismus and treatment required to resolve diplopia in adult patients seen by one orthoptist. PATIENTS AND METHODS: Retrospective cross-sectional study of consecutive adult patients 18 years or older seen by one orthoptist over a 3-year period with a chief complaint of double vision. RESULTS: Two hundred twenty-four consecutive adult patients were examined by the author. Chief complaint was double vision, followed by blurred vision, monocular diplopia, and eye strain. Past ocular histories were significant for early-childhood strabismus in 23 patients. Amblyopia was identified in five patients. Hypertension was a medical risk factor most associated with symptomatic strabismus. Cranial nerve paresis was the most common cause of the strabismus followed by benign, age-related divergence insufficiency esotropia. Prism was the most common treatment in 53% of patients followed by Bangerter foil occlusion in 44 patients (20%). Strabismus surgery was recommended in 11 patients (5%). Manifest refraction was successful in resolving symptoms of binocular diplopia in nine heterophoric patients (5%). Opaque pirate style occlusion was not used for any patient in this series. CONCLUSIONS: Symptomatic acquired esotropia was a common type of strabismus encountered by the author and trochlear nerve paresis a common cause of symptomatic strabismus in this retrospective cross-sectional study. Press-On™ or ground-in spectacle prism of 12 prism diopters or less resolved diplopia in 124 patients (55%).

Ocular neuromyotonia: a review of diagnosis and treatment.

PURPOSE OF REVIEW: The current review will cover the clinical presentation, causes, epidemiology, differential diagnoses, workup, and treatment of ocular neuromyotonia (ONM) in detail. RECENT FINDINGS: While ONM largely remains a unilateral eye movement disease affecting adults with a history of sellar radiation, recent case reports highlight an expansion of this presentation to include bilateral, pediatric, and congenital cases. SUMMARY: ONM is a rare but recognizable ocular motility disorder involving sustained contraction of the extraocular muscle, commonly resulting in intermittent diplopia. Diagnosis of ONM relies upon a thorough history and clinical exam, with particular attention to history of radiotherapy and eccentric gaze testing. Treatment with carbamazepine remains first-line therapy, although other membrane stabilizing agents and surgical interventions can be effective.

Results of fusional vergence therapy in managing consecutive esotropia: A case series.

Purpose: To analyze the efficacy of fusional vergence therapy (FVT) in management of consecutive esotropia with diplopia after intermittent exotropia (IXT) surgery. The current study is carried on how FVT affects the duration of treatment, sensory fusion, and exotropic drift. Methods: This was a retrospective study for the medical record of 11 patients with consecutive esotropia after IXT surgery of 543 patients over the period of 5 year, with mean surgery age of 9.5 (range: 4-33 y). FVT was planned after minimum 6 weeks of surgery and was considered for maximum 24 weeks. Patients underwent a combination of office-based and home-based FVT. Successful outcome of therapy was considered where diplopia resolves in free space and achieves sensory fusion, stereopsis with no manifest deviation. Results: Record of 543 patients who had horizontal muscle surgery for IXT were identified and reviewed. Records of 11 patients who showed consecutive esotropia of 10 prism diopter (PD) or more with normal retinal correspondence, with or without diplopia complaint, after 6 week of surgery and had undergone vision therapy management were reviewed. A successful outcome of binocular single vision with good sensory and motor fusion with no manifest deviation or prism requirement was achieved with in the mean duration of 4.8 month of therapy. With a mean duration of 4 weeks of therapy, the mean angle of deviation reduced by 53% for distance (17 PD to 8 PD) and 27% for near (11 PD to 8 PD) and mean stereopsis improvement by 80% with 94% patients demonstrating sensory fusion on Bagolini test and 94% of patients having no symptoms of diplopia or squint. Conclusion: With nonsurgical management involving refractive error correction, FVT, and prism, consecutive esotropia was resolved in 74% cases. Management of consecutive esotropia with FVT can result in satisfactory sensory fusion and successful motor alignment.

Elastoma of the Orbit: A Case Report.

A 78-year-old man presenting for revision ptosis surgery was found to have an asymptomatic left inferomedial orbital mass visible below the left lower eyelid on external inspection, and subconjunctivally on examination. This was subsequently diagnosed as an isolated elastoma. A mass in a similar location was excised 60 years previously. His other ophthalmological history included stable diplopia corrected with prism, left-sided ectropion, bilateral sequential phacoemulsification, and past bilateral ptosis which has been persistent on the left side despite surgical repair and revision. His examination revealed left hypertropia but was otherwise largely unremarkable. However, imaging demonstrated the soft tissue lesion abutting the left globe. An anterior orbitotomy was performed, and the lesion was biopsied and specimens sent for histopathological examination and immunohistochemistry. This is the first case of an elastoma of the orbit reported in the literature to the best of the authors' knowledge.

Diplopia: Diagnosis and management.

Diplopia or double vision is the separation of images vertically, horizontally or obliquely and can be monocular or binocular in origin. Binocular diplopia is most commonly caused by ocular misalignment or strabismus that can be detected using simple clinical tests. All patients with diplopia of acute onset should be investigated urgently and those with a headache or pupillary involvement need to be referred for same-day urgent imaging. Diplopia secondary to microvascular causes on the other hand often spontaneously resolves within six months.

Tiempo de evolución y eliminación de la diplopía binocular en pacientes con paresia o parálisis oculomotoras / Evolution Time and Elimination of Binocular Diplopia in Patients with Oculomotor Paresis or Paralysis

Objetivo: Determinar la relación existente entre tiempo de evolución y eliminación de la diplopía binocular en pacientes con paresia o parálisis oculomotoras. Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo de una serie de casos que acudieron a la consulta del Servicio de Oftalmología Pediátrica del Instituto Cubano de Oftalmología Ramón Pando Ferrer y que cumplían con los criterios de inclusión en el periodo comprendido entre mayo del 2018 a junio del 2019. Se evaluaron las variables: sexo, tiempo de evolución, opciones de tratamiento, eliminación de diplopía, fusión y estereopsis. Resultados: El mayor número de casos acudieron a consulta entre una semana y menos de un mes de evolución de la enfermedad y más de seis meses. No resultó significativo la relación sexo, etiología y tiempo de evolución en acudir los pacientes a consulta externa. El 66,7 por ciento de la muestra estudiada resolvió solo con tratamiento médico, incluidos el 100 por ciento de los pacientes con menos de una semana de evolución. Todos los pacientes con tiempo de evolución menor de seis meses eliminaron la diplopía y se encontró diferencia estadística (p = 0,04) entre estas variables. El 76,7 por ciento logró fusión y el 56,7 por ciento estereopsis. Conclusiones: La mayor parte de los pacientes con tiempo de evolución menor de seis meses eliminaron la diplopía solo con tratamiento médico, incluidos el 100 por ciento de los pacientes con menos de una semana de evolución, observándose una relación entre la recuperación y la cronicidad de la diplopía(AU)

Objective: To determine the relationship between time of evolution and elimination of binocular diplopia in patients with oculomotor paresis or paralysis. Methods: A descriptive, longitudinal and prospective study was carried out, from May 2018 to June 2019, of a series of cases that were assisted in consultation of the Pediatric Ophthalmology Service at Ramón Pando Ferrer Cuban Institute of Ophthalmology and that met the inclusion criteria. The variables evaluated were sex, evolution time, treatment options, elimination of diplopia, fusion and stereopsis. Results: The largest number of cases were assisted in consultation between one week and less than one month of evolution of the disease and more than six months. The relationship between sex, etiology and time of evolution in attending the outpatient clinic was not significant. 66.7 percent of the studied sample solved only with medical treatment, including 100 percent of patients with less than one week of evolution. All patients with evolution time of lesser than six months eliminated diplopia and a statistical difference was found (p = 0.04) between these variables. 76.7 percent achieved fusion and 56.7 percent stereopsis. Conclusions: Most of the patients with evolution time of lesser than six months eliminated diplopia only with medical treatment, including 100 percent of patients with less than one week of evolution, observing a relationship between recovery and chronicity of diplopia. Diplopia(AU)

Diplopía binocular por paresia o parálisis oculomotoras: resultados de las opciones de tratamiento / Binocular Diplopia due to Oculomotor Paresis or Palsies: Outcomes of Treatment Options

Objetivo: Determinar resultados de las opciones de tratamiento para la diplopía binocular en pacientes con paresia o parálisis oculomotoras. Método: Se realizó un estudio descriptivo, longitudinal y prospectivo de una serie de casos que acudieron a la consulta del Servicio de Oftalmología Pediátrica del Instituto Cubano de Oftalmología Ramón Pando Ferrer. Se evaluaron las variables: edad, sexo, etiología, opciones de tratamiento, limitación de los movimientos oculares, eliminación de diplopía, fusión y estereopsis. Resultados: La etiología más frecuente fue la microvascular. El 66,7 por ciento de la muestra estudiada se resolvió solo con tratamiento médico, de ellos el 100,0 por ciento con diagnóstico de paresias o parálisis del tercer nervio craneal, seguido por el sexto y cuarto con 63,6 por ciento y 33,3 por ciento, respectivamente. Necesitaron tratamiento médico, quirúrgico y aplicación de toxina botulínica seis pacientes, el 33,3 por ciento del cuarto y el 22,7 por ciento del sexto nervio craneal. El resto de las opciones de tratamiento solo con un paciente. No se halló asociación significativa entre opciones de tratamiento y nervio craneal afectado. El 86,6 por ciento finalizó sin limitación de los movimientos oculares. El 86,7 por ciento de los casos eliminaron la diplopía en todas las posiciones diagnósticas de la mirada. El 76,7 por ciento logró fusión y el 56,7 por ciento estereopsis. Conclusiones: El tratamiento médico y el combinado de médico más inyección de toxina botulínica y cirugía de músculos extraoculares fueron las opciones más utilizadas y permitieron alineamiento ocular y eliminación de la diplopía binocular(AU)

Objective: To determine outcomes of treatment options for binocular diplopia in patients with oculomotor paresis or paralysis. Method: A descriptive, longitudinal and prospective study was carried out of a series of cases that were assisted at the consultation of the Pediatric Ophthalmology Service at Ramón Pando Ferrer Cuban Institute of Ophthalmology. The variables evaluated were age, sex, etiology, treatment options, limitation of ocular movements, elimination of diplopia, fusion and stereopsis. Results: The microvascular etiology was the most frequent. 66.7 percent of the studied sample was resolved only with medical treatment, 100.0 percent of them had a diagnosis of paresis or paralysis of the third cranial nerve, followed by the sixth and fourth with 63.6 percent and 33.3 percent, respectively. Six patients required medical and surgical treatment and application of botulinum toxin, 33.3 percent of the fourth and 22.7 percent of the sixth cranial nerve. The rest of the treatment options with only one patient. No significant association was found between treatment options and affected cranial nerve. 86.6 percent finished without limitation of eye movements. 86.7 percent of cases eliminated diplopia in all diagnostic gaze positions. 76.7 percent achieved fusion and 56.7 percent stereopsis. Conclusions: Medical treatment and combined medical treatment plus botulinum toxin injection and extraocular muscle surgery were the most used options and allowed ocular alignment and elimination of binocular diplopia(AU)

Prisms in the treatment of diplopia with strabismus of various etiologies.

PURPOSE: We aimed to study the success of prism in regard to diplopia resolution score and associated factors in patients presenting with symptomatic diplopia arising from various etiologies. METHODS: In this descriptive, retrospective study diplopia resolution among 31 patients who were prescribed prism were analyzed. RESULTS: Fifty-four patients were evaluated for diplopia and 31 were included for the study done over 3 years. The mean follow-up was 15 months. Esotropia, exotropia, and hypertropia were seen in 39%, 51%, and 19.4% of patients, respectively. Furthermore, 71% received Fresnel prism and 29% were given ground glass prism. The mean prism power prescribed was 13.3 PD. 87% had complete resolution of diplopia; 96.8% continued usage of prism. High success rates were seen among patients with decompensated strabismus, sixth and fourth nerve palsy. Horizontal prism and oblique prism in the form of Fresnel prism yielded complete resolution of diplopia (P = 0.028). There was no association between the success of prism and etiology (P 0.058), history of trauma (P = 0.212), and type of deviation (P = 0.387). The study showed that oblique Fresnel prism can be considered for combined deviation. CONCLUSION: Our study showed prism to be effective in alleviating diplopia over a varied range of etiologies.

Approach to Common Visual Complaints Presenting to the Outpatient Neurologist.

Visual complaints are commonly encountered by the practicing neurologist. We review assessment of vision loss, diplopia, and positive visual phenomena, all of which require a thoughtful evaluation to localize disease and refine management. While many causative entities are unlikely to cause poor visual outcomes, including dry eyes, migraine, and congenital strabismus, others may threaten vision, life, or both, such as posterior communicating artery aneurysms, pituitary apoplexy, or temporal arteritis. A systematic approach to vision loss and diplopia is reviewed along with focused differential diagnoses.

Reverse exercises in a case of intractable diplopia.

The aim of this presentation is to highlight how orthoptic exercises can be adapted from the standard implementation and gain results in an intractable diplopia case. A 16-year-old male presented with a 20 prism diopters residual right esotropia and intractable diplopia following Surgery and Botulinum Toxin. Having had further BT and surgery ruled out and no success with Fresnel prisms or occlusion, he commenced on standard orthoptic exercises without success. Additional orthoptic assessment discovered that the patient could achieve binocular single vision (BSV) on convergence at 10 cm. The patient then proceeded on a course of exercises to help extend this area of BSV. These exercises included a reverse dot card and a variation of the distance cat stereogram. Over the next couple of visits, the area of binocularity was extended to 30 cm and the esotropia measured 18 prism diopters. However, the patient felt that progress was slow, and they were keen to learn to drive and so opted for an occlusive contact lens instead. It is unfortunate that the patient did not continue with the exercise program as it showed potential to increase his area of BSV. However, this case does demonstrate how utilizing current knowledge concepts of both exercises and BSV, and adapting them to a specific patient could lead to improvement in the likes of intractable diplopia and be a potential management option.