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Clinical Medicine (London, England) Mar 2022Diplopia or double vision is the separation of images vertically, horizontally or obliquely and can be monocular or binocular in origin. Binocular diplopia is most...
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.
Topics: Diplopia; Humans
PubMed: 35304368
DOI: 10.7861/clinmed.2022-0045 -
Clinical & Experimental Optometry Mar 2022Myasthenia gravis is a rare autoimmune disease characterised by autoantibodies preventing normal function of acetylcholine receptors at the post-synaptic membrane of the... (Review)
Review
Myasthenia gravis is a rare autoimmune disease characterised by autoantibodies preventing normal function of acetylcholine receptors at the post-synaptic membrane of the neuromuscular junction. This causes weakness of skeletal muscles that can be variable and fatigable, and often manifests as ptosis and/or diplopia, with 60% of patients demonstrating ocular features at onset, and thus may present initially to eye care practitioners. Approximately 15% of patients have ocular myasthenia gravis, where symptoms remain restricted to this distribution. The majority of patients have blocking antibodies against the acetylcholine receptor, but antibodies directed against other related targets account for a smaller proportion and are associated with specific phenotypes. Associations with both thymoma and with other autoimmune phenomena (particularly thyroid disease) can occur. Clinical examination can identify characteristic findings including fatigable ptosis and Cogan's lid twitch sign. Investigations to confirm the diagnosis include simple office-based procedures such as the ice test, and testing for serum autoantibodies, as well as electrophysiological testing such as repetitive nerve stimulation and single-fibre electromyography. The management of ocular myasthenia gravis is discussed, including non-pharmacological options, pyridostigmine, corticosteroids, other immunosuppressive agents, and thymectomy. The goals of management are to alleviate symptoms, and where possible prevent chronic disability or progression to generalised myasthenia gravis.
Topics: Diplopia; Humans; Immunosuppressive Agents; Myasthenia Gravis
PubMed: 35157811
DOI: 10.1080/08164622.2022.2029683 -
Romanian Journal of Ophthalmology 2017Diplopia (seeing double) is an ophthalmologic complaint found mainly in elder patients. It can have both ocular and neurological causes. A careful history and clinical... (Review)
Review
Diplopia (seeing double) is an ophthalmologic complaint found mainly in elder patients. It can have both ocular and neurological causes. A careful history and clinical examination must detail the type of diplopia (monocular/ binocular), onset, and progression, associated and relieving factors. In case of monocular diplopia, refraction and biomicroscopic examination of the ocular media are mandatory. The cause of ocular misalignment for binocular diplopia must be determined and life-threatening conditions (such as posterior communicating artery aneurysm) must imply an immediate treatment. Management and treatment is always according to the specific cause of diplopia.
Topics: Diplopia; Humans; Ophthalmologic Surgical Procedures; Ophthalmology; Vision Tests; Vision, Binocular
PubMed: 29450393
DOI: 10.22336/rjo.2017.31 -
Acta Ophthalmologica Jun 2014To investigate the clinical features of all patients with acute-onset diplopia presenting to the ophthalmology department.
PURPOSE
To investigate the clinical features of all patients with acute-onset diplopia presenting to the ophthalmology department.
METHODS
The notes of every patient who presented with acute onset (<4-week duration) diplopia to the ophthalmology clinic over a 2-year period were reviewed. Data regarding clinical features, underlying aetiology, past medical history, investigations and outcomes were extracted.
RESULTS
One hundred and forty-nine patients presented with 53.7% having an isolated third, fourth or sixth nerve palsy, 10.7% a mechanical cause, 10.1% a dysfunction of higher control, 8.1% decompensation of a pre-existing heterophoria, 6.7% idiopathic, 5.4% causes of monocular diplopia and 5.3% another diagnosis. Neuroradiological investigation identified that <5% of patients had a serious underlying pathology, which required immediate management; 80.5% had a diagnosis and underlying aetiology, which were obvious at presentation based only on clinical information and evaluation.
CONCLUSIONS
Acute onset diplopia is an uncommon and challenging presentation for the ophthalmologist to manage. These results demonstrate that the aetiology is commonly identifiable at the first presentation based on clinical evaluation, only a small percentage require urgent radiological investigation and a small minority of cases are likely to have serious emergent pathology.
Topics: Abducens Nerve Diseases; Acute Disease; Adolescent; Adult; Aged; Aged, 80 and over; Child; Demyelinating Diseases; Diplopia; Female; Humans; Male; Middle Aged; Oculomotor Nerve Diseases; Retrospective Studies; Trochlear Nerve Diseases; Young Adult
PubMed: 23387838
DOI: 10.1111/aos.12062 -
Journal of Neuro-ophthalmology : the... Sep 2016We describe 2 unique cases of visual symptoms occurring during mastication in patients with lateral orbital wall defects. A 57-year-old man reported intermittent double...
We describe 2 unique cases of visual symptoms occurring during mastication in patients with lateral orbital wall defects. A 57-year-old man reported intermittent double vision and oscillopsia after a right fronto-temporal-orbito-zygomatic craniotomy with osteotomy of the lesser wing of the sphenoid for a complex invasive pituitary adenoma. Proptosis of the right globe was present only during mastication. Computed tomography (CT) revealed a bony defect in the right lateral orbital wall. A 48-year-old man presented with transient diplopia and scotoma in the right eye elicited by chewing. CT and magnetic resonance imaging demonstrated a bilobed lesion connecting the temporal fossa to the orbit through a defect in the right lateral orbital wall. The regional neuroanatomy and pathophysiology as pertaining to these cases are discussed.
Topics: Craniotomy; Diplopia; Exophthalmos; Humans; Magnetic Resonance Imaging; Male; Mastication; Middle Aged; Orbit; Postoperative Complications; Sphenoid Bone; Tomography, X-Ray Computed
PubMed: 26919071
DOI: 10.1097/WNO.0000000000000354 -
Survey of Ophthalmology 2021A 13-year-old boy reported acute horizontal binocular diplopia and headache. Ten days before these symptoms he suffered from a gastrointestinal infection....
A 13-year-old boy reported acute horizontal binocular diplopia and headache. Ten days before these symptoms he suffered from a gastrointestinal infection. Ophthalmological examination revealed bilateral ophthalmoparesis and diffuse hyporeflexia. Magnetic resonance imaging of the brain was normal. Lumbar puncture revealed albumin-cytological dissociation. There were no anti-GQ1b antibodies, but serum anti-GM1 antibodies were detected. He received intravenous immunoglobulins and had fully recovered two weeks later. Miller Fisher syndrome and its atypical variants are uncommon in childhood; nevertheless, they should be considered in the differential diagnosis of bilateral acute ophthalmoparesis.
Topics: Adolescent; Autoantibodies; Diplopia; Headache; Humans; Magnetic Resonance Imaging; Male; Miller Fisher Syndrome; Ophthalmoplegia
PubMed: 33010288
DOI: 10.1016/j.survophthal.2020.09.007 -
Ophthalmology Nov 2013To estimate the proportion of patients presenting with isolated third, fourth, or sixth cranial nerve palsy of presumed microvascular origin versus other causes.
PURPOSE
To estimate the proportion of patients presenting with isolated third, fourth, or sixth cranial nerve palsy of presumed microvascular origin versus other causes.
DESIGN
Prospective, multicenter, observational case series.
PARTICIPANTS
A total of 109 patients aged 50 years or older with acute isolated ocular motor nerve palsy.
TESTING
Magnetic resonance imaging (MRI) of the brain.
MAIN OUTCOME MEASURES
Causes of acute isolated ocular motor nerve palsy (presumed microvascular or other) as determined with early MRI and clinical assessment.
RESULTS
Among 109 patients enrolled in the study, 22 had cranial nerve III palsy, 25 had cranial nerve IV palsy, and 62 had cranial nerve VI palsy. A cause other than presumed microvascular ischemia was identified in 18 patients (16.5%; 95% confidence interval, 10.7-24.6). The presence of 1 or more vasculopathic risk factors (diabetes, hypertension, hypercholesterolemia, coronary artery disease, myocardial infarction, stroke, and smoking) was significantly associated with a presumed microvascular cause (P = 0.003, Fisher exact test). Vasculopathic risk factors were also present in 61% of patients (11/18) with other causes. In the group of patients who had vasculopathic risk factors only, with no other significant medical condition, 10% of patients (8/80) were found to have other causes, including midbrain infarction, neoplasms, inflammation, pituitary apoplexy, and giant cell arteritis (GCA). By excluding patients with third cranial nerve palsies and those with GCA, the incidence of other causes for isolated fourth and sixth cranial nerve palsies was 4.7% (3/64).
CONCLUSIONS
In our series of patients with acute isolated ocular motor nerve palsies, a substantial proportion of patients had other causes, including neoplasm, GCA, and brain stem infarction. Brain MRI and laboratory workup have a role in the initial evaluation of older patients with isolated acute ocular motor nerve palsies regardless of whether vascular risk factors are present.
Topics: Abducens Nerve Diseases; Acute Disease; Aged; Aged, 80 and over; Brain Neoplasms; Cerebrovascular Disorders; Coronary Artery Disease; Diabetes Complications; Diplopia; Female; Humans; Hypercholesterolemia; Hypertension; Magnetic Resonance Imaging; Male; Middle Aged; Oculomotor Nerve Diseases; Prospective Studies; Risk Factors; Tomography, X-Ray Computed; Trochlear Nerve Diseases
PubMed: 23747163
DOI: 10.1016/j.ophtha.2013.04.009 -
Current Opinion in Neurology Feb 2021Thyroid eye disease (TED) is a disfiguring disease that can lead to neuro-ophthalmic manifestations including diplopia and optic neuropathy. The aim of this review is to... (Review)
Review
PURPOSE OF REVIEW
Thyroid eye disease (TED) is a disfiguring disease that can lead to neuro-ophthalmic manifestations including diplopia and optic neuropathy. The aim of this review is to shed light on the diagnosis of TED based on clinical examination findings and diagnostic imaging. We will also discuss gold standard as well as newly emerging therapies for TED.
RECENT FINDINGS
We discussed diagnostic criteria for TED and differentiating TED from other causes of binocular diplopia. We also reviewed the pathophysiology and differential diagnoses for dysthyroid optic neuropathy as well as recent developments on controversial causes. New imaging techniques are available for evaluation and prognosis of TED comorbidities. Most of the recent developments in TED have been focused on new treatment modalities that have thus far had promising results. We reviewed recently approved and novel potential therapies that are helpful in treating both diplopia and dysthyroid optic neuropathy.
SUMMARY
TED is a complicated disorder with many clinical manifestations as well as treatment modalities. Our aim of this review was to outline new developments in the diagnosis and management of TED.
Topics: Diagnostic Techniques, Ophthalmological; Diplopia; Graves Ophthalmopathy; Humans; Optic Nerve; Optic Nerve Diseases; Therapies, Investigational
PubMed: 33278144
DOI: 10.1097/WCO.0000000000000894 -
Journal of Cachexia, Sarcopenia and... Dec 2022Ophthalmoparesis and ptosis can be caused by a wide range of rare or more prevalent diseases, several of which can be successfully treated. In this review, we provide... (Review)
Review
Ophthalmoparesis and ptosis can be caused by a wide range of rare or more prevalent diseases, several of which can be successfully treated. In this review, we provide clues to aid in the diagnosis of these diseases, based on the clinical symptoms, the involvement pattern and imaging features of extra-ocular muscles (EOM). Dysfunction of EOM including the levator palpebrae can be due to muscle weakness, anatomical restrictions or pathology affecting the innervation. A comprehensive literature review was performed to find clinical and imaging clues for the diagnosis and follow-up of ptosis and ophthalmoparesis. We used five patterns as a framework for differential diagnostic reasoning and for pattern recognition in symptomatology, EOM involvement and imaging results of individual patients. The five patterns were characterized by the presence of combination of ptosis, ophthalmoparesis, diplopia, pain, proptosis, nystagmus, extra-orbital symptoms, symmetry or fluctuations in symptoms. Each pattern was linked to anatomical locations and either hereditary or acquired diseases. Hereditary muscle diseases often lead to ophthalmoparesis without diplopia as a predominant feature, while in acquired eye muscle diseases ophthalmoparesis is often asymmetrical and can be accompanied by proptosis and pain. Fluctuation is a hallmark of an acquired synaptic disease like myasthenia gravis. Nystagmus is indicative of a central nervous system lesion. Second, specific EOM involvement patterns can also provide valuable diagnostic clues. In hereditary muscle diseases like chronic progressive external ophthalmoplegia (CPEO) and oculo-pharyngeal muscular dystrophy (OPMD) the superior rectus is often involved. In neuropathic disease, the pattern of involvement of the EOM can be linked to specific cranial nerves. In myasthenia gravis this pattern is variable within patients over time. Lastly, orbital imaging can aid in the diagnosis. Fat replacement of the EOM is commonly observed in hereditary myopathic diseases, such as CPEO. In contrast, inflammation and volume increases are often observed in acquired muscle diseases such as Graves' orbitopathy. In diseases with ophthalmoparesis and ptosis specific patterns of clinical symptoms, the EOM involvement pattern and orbital imaging provide valuable information for diagnosis and could prove valuable in the follow-up of disease progression and the understanding of disease pathophysiology.
Topics: Humans; Graves Ophthalmopathy; Blepharoptosis; Ophthalmoplegia; Diplopia; Myasthenia Gravis; Pain
PubMed: 36172973
DOI: 10.1002/jcsm.13089 -
Neurology India 2022Diplopia, or double vision, is a symptom resulting from the perception of two images of a single object. We report a case of a possible silodosin-induced diplopia never...
Diplopia, or double vision, is a symptom resulting from the perception of two images of a single object. We report a case of a possible silodosin-induced diplopia never reported before in the literature. We suggest that binocular diplopia should be considered in people assuming silodosin even if further studies should be conducted to explore possible pathogenetic mechanisms.
Topics: Diplopia; Humans; Indoles; Vision, Binocular
PubMed: 35864693
DOI: 10.4103/0028-3886.349650