Course # Double Trouble

(1)

Double Trouble

Course #

(2)

DOUBLE TROUBLE

Jill Autry, O.D., R.Ph. Eye Center of Texas, Houston

[email protected]

DIPLOPIA

• Common subjective complaint

• Adult patients report almost exclusively

– Children rarely report diplopia

– Immature visual system suppresses image

• Often the first manifestation of systemic

disorder

DIAGNOSING DIPLOPIA

• Binocular (75%) vs. Monocular (25%) • Horizontal, vertical, or oblique? • Intermittent vs. Constant • How long since first noticed? • Worse in certain gaze? • Worse at distance or near? • Worse in am or pm?

• Any recent trauma/surgery to eye/face/head? • Previous episodes?

MONOCULAR VS. BINOCULAR

• Does diplopia disappear with either eye

covered?

– Monocular diplopia is present with only one eye open. – Binocular diplopia disappears with occlusion of either

eye.

• Is second image clear and distinct? – Binocular

• Is second image a “ghost image” or shadow? – Monocular

• Does pinhole/refraction/artificial tear remove second image?

– Monocular

MONOCULAR DIPLOPIA

• Intermittent vs. Constant – Intermittent—Dry eye

– Constant—Ex. uncorrected astigmatism, ERM • How long since first noticed?

– Gradual—Ex. cataract, dystrophy/degeneration, others – Acute—Ex. corneal abrasion, others

• Worse in am or pm? – Worse in PM—Dry eye

• Any recent trauma/surgery to eye?

– Healing line, PKP, Lasik/PRK, Membrane peel, others

COMMON CAUSES OF

MONOCULAR DIPLOPIA

• Refractive correction

– Spectacle/CL

• Corneal irregularity

• Cataract

• Epiretinal membrane/macular disease

• Dry Eye

(3)

REFRACTIVE CORRECTION

• Uncorrected refractive error

– Astigmatic correction common cause – Spherical component uncommon cause

• Incorrect lens alignment

– Off axis astigmatic correction – Incorrect seg height

• Poor fitting contact lens/warpage

CORNEAL IRREGULARITY

• Keratoconus

• Pellucid Marginal Degeneration

• Irregular topography

• Irregular astigmatism

• Post-operative

• Corneal dystrophy/degeneration

• Corneal opacity/scar/abrasion

• Dry eye (Intermittent)

KERATOCONUS

• Decreased BVA

• Changing Rx especially astigmatism • Inferior steepening on topography • Steep Ks

• Characteristics

– Fleischer’s ring, Vogt’s striae, Munson’s sign, scissoring on retinoscopy, poor mires on keratometry, hydrops, corneal scarring, frequent change in Rx • Try RGP in office to help diagnose

• Treatment with RGP/transplant/INTACS

PELLUCID MARGINAL

DEGENERATION

• A variant of keratoconus

• Affects males more than females

• 20-40 years of age

• High amounts of ATR astigmatism and

increasing hyperopia

• Peripheral thinning with inferior ectasia

• Treatment with RGP/transplant

IRREGULAR TOPOGRAPHY

• Lid abnormalities

– Chalazion

• Irregular astigmatism

• Form fruste keratoconus

• Post-operative

• Post-traumatic

POST-OPERATIVE

• Lasik

– Decentered ablations – Central islands – Irregular astigmatism – Central striae

– Severe epithelial ingrowth – Ectasia

(4)

POST-OPERATIVE

• RK

– Irregular astigmatism • PRK

– Healing lines

– Central haze (blur more than diplopia) • Corneal transplant

– Irregular and high astigmatism • Phacoemulsification

– Multifocal IOL – Irregular LRI/CRI

CORNEAL

DYSTROPHY/DEGENERATION

• Epithelial Basement Membrane Dystrophy

– EBMD or Map-Dot Dystrophy – Epitheliopathy

• Terrien’s Marginal Degeneration – Irregular astigmatism

• Salzmann’s

– Irregular astigmatism • Pterygium

– Irregular astigmatism

• Other corneal degeneration/dystrophy

CORNEAL OPACITY/SCARRING

• Traumatic

• Post-operative

• RGP induced

• Resolved hydrops

• Abrasion/healing line

CATARACT

• Nuclear sclerotic, cortical, posterior

subcapsular

• Gradual decrease in visual acuity

• Halo/glare especially with night driving

• Myopic shift with nuclear sclerosis

• Monocular diplopia

(5)

EPIRETINAL MEMBRANE

• Monocular diplopia • Metamorphopsia

• Decreased visual acuity/blur • Macular pucker

• Pseudohole

• Cystoid macular edema (CME)

• Can also cause binocular diplopia if aniseikonia develops

Age-Related Macular Degeneration

• DRY AMD

– Mild to moderate drusen deposits – Atrophy and pigment mottling of the RPE – GARPE produces the most vision loss with dry form – Soft and confluent drusen increases risk of choroidal

neovascularization (CNV) • WET AMD

– CNV leads to exudation, retinal edema and scarring of macula

MONITORING/TREATMENT

• Visual acuity

• Amsler grid

• Macular OCT

• Steroid and/or NSAID for CME

• Surgery (PPV, MP) once BVA 20/50 or

worse

OTHER MACULAR CONDITIONS

• Cystoid macular edema

• Subfoveal neovascular membrane • Other macular bleeding

– Valsalva retinopathy, severe diabetic retinopathy • Macular scarring – AMD – Resolved CSR – Lacquer cracks • Retinal detachment

INTERMITTENT MONOCULAR

DIPLOPIA

• Dry eye

– Disappears briefly with blink or artificial tears – Better in AM, worse in PM

– Other symptoms of DES

• Burning, epiphora, FBS

• Contact lens problem – Rotating toric

– Too small OZ for patient with larger pupils can cause monocular diplopia at night only

UNCOMMON CAUSES OF

MONOCULAR DIPLOPIA

• Dislocated lens (natural or implant)

• Multiple pupillary openings

• Psychiatric disease/Malingering

• Vitreous opacities

(6)

BINOCULAR DIPLOPIA

• Horizontal, vertical, or oblique?

– Horizontal--Lateral Rectus, Medial Rectus – Vertical--Inferior or Superior recti, oblique muscles

• Intermittent vs. Constant

– Intermittent—MG, MS, Thyroid

– Constant—Nerve Palsy, muscle entrapment

• How long since first noticed?

– Acute—Nerve Palsy

– Chronic—Phoria breakdown, tumor, thyroid, MG

• Worse in certain gaze?

– Helps diagnose muscle of concern

– No increase in certain gaze suggests phoria breakdown

BINOCULAR DIPLOPIA

• Worse at distance or near?

– Distance—Lateral, inferior, or superior recti – Near—Medial recti or oblique muscles • Worse in am or pm?

– MG worse in pm

– Phoria breakdown often worse when tired in pm • Any recent trauma/surgery to eye/face/head?

– Face lift, airbag, MVA, retinal surgery • Previous episodes?

• Full EOMs? Check separately and together.

REVIEW OF SYSTEMS

• Diabetes/hypertension

• Trauma

• Headache, jaw claudication, scalp

tenderness

• Pain

• Weakness/fatigue

• Dysphagia

• Face/head surgery

• Medications

BINOCULAR

• Cranial nerve palsy – III, IV, or VI • Phoria breakdown • Orbital disease – Thyroid – Inflammatory/infectious proptosis • Multiple sclerosis • Myasthenia Gravis • Post-operative • Post-traumatic

INTERMITTENT BINOCULAR

DIPLOPIA

• Phoria breakdown

• Thyroid eye disease

• Myasthenia gravis

• Multiple sclerosis

PHORIA BREAKDOWN

• Intermittent diplopia

• History of childhood patching/strabismus

• Long-standing head tilt/turn

• Approximately equal in all gazes

(comitant)

• Large fusional ranges

• Full ductions and versions

(7)

THYROID EYE DISEASE

• Pseudoptosis

– Proptosis – Lid retraction – Scleral show

• Intermittent or constant diplopia

– Inferior rectus-most often affected first

• Diplopia worse in upgaze due to IR restriction – Medial rectus

– Superior rectus – Lateral rectus

THYROID TESTING

• Diplopia worse in morning

• Diplopia generally vertical

• Do CT of orbits rather than MRI for thyroid

• Thyroid blood testing

– TSH with T4

– Most commonly hyperthyroid – Can also be hypothyroid or euthyroid

MYASTHENIA GRAVIS

• Ptosis

• Intermittent diplopia

• Younger women; older men

• Worse at end of day or with fatigue

• Ask about difficulty swallowing or

breathing

• Muscle weakness worse at end of day

MYASTHENIA GRAVIS

• Diplopia

– Intermittent

– Multiple muscles can be affected – Variable ocular measurements – Worse at end of day

– Worse with fatigue

DIAGNOSING MYASTHENIA

• Check for increased ptosis with fatigue • Check orbicularis muscle function • MRI of Brain and Orbits • Tensilon test

• Ice-test (“Poor man’s Tensilon test”) • Acetylcholine receptor antibodies

– AChR binding antibody; if negative order AChR modulating

• Thyroid panel

• EMG and/or single fiber EMG

MULTIPLE SCLEROSIS

• Female > Male • 18-45 years old

• Intermittent diplopia (usually 6th_nerve)

• Optic neuritis • Nystagmus

(8)

CONSTANT DIPLOPIA

• Cranial nerve palsy

– III, IV, VI

• Unilateral orbital disease

• Post-operative

• Post-traumatic

• Aniseikonia

EOM REVIEW

• Elevators

– Superior rectus (SR), Inferior oblique (IO)

• Depressors

– Inferior rectus (IR), Superior oblique (SO)

• Abduction

– Lateral rectus (LR)

• Adduction

– Medial rectus (MR)

EOM REVIEW

• Evaluate SR and IR in abduction

• Evaluate IO and SO in adduction

3

rd

NERVE PALSY

• Diplopia

• Exotropia and/or hypotropia

– Exotropia dominates

• Ptosis

• Classic-Down and out presentation

• May or may not have pupil involvement

3

rd

Nerve Pupil Testing

• Pupil involving

– Fixed, dilated pupil; minimally reactive to light – MRA with MRI

– Posterior communciating artery aneurysm

• Pupil Sparing

– Pupil equal in size to other eye – Normal light reaction

– Ischemic microvascular disease

3

rd

NERVE PALSY

• Diplopia

– Horizontal images with or without vertical component – Generally see exo movement on primary gaze worse

in gaze to opposite side.

– Complete palsy: Limitation of ocular movement in all fields of gaze except temporally

– Incomplete palsy: Partial limitation of ocular movement

(9)

3

rd

NERVE PALSY

• Causes

– Ischemia – Demyelination

– Tumor (usually at chiasm)

– Posterior communicating artery aneurysm (PCA)

4

th

NERVE PALSY

• Vertical or oblique diplopia with

hypertropia

• Worse at near

• Head tilt towards unaffected side to

decrease or eliminate diplopia

• In adduction, palsy eye is elevated

4

th

Nerve Palsy

• Causes

– Congenital – Trauma – Infection – Inflammation – Ischemia – Tumor (uncommon) – Demyelinating (uncommon)

PARK’S THREE STEP

• www.eyedock.com

• Park’s 3 Test

– Hypertropia, worse in opposite gaze, worse in same side head tilt

– Right, left, right – Left, right, left

6

th

NERVE PALSY

• Horizontal diplopia worse at distance

• Esotropia on cover test

• Worse in temporal gaze of affected eye

• Decreased diplopia in gaze away from

affected eye

6

th

NERVE PALSY

• Causes

– Vasculopathic – Demyelinating – Trauma

– Increased intracranial pressure

• May present as bilateral 6th_{nerve palsy with}

papilledema

– Infection (viral or bacterial) – Tumor

(10)

Edward C. Wade, M.D. Ting Fang-Suarez, M.D. Chris Allee, O.D. Gurpreet Singh, M.D. Jill Autry, O.D. Randy Reichle, O.D.

6565 West Loop South 4415 Crenshaw Rd.

Bellaire, TX 77401 Pasadena, TX 77504

Phone (713)797-1010 Phone (281)998-3333

---NAME Kathy Summers AGE

ADDRESS_____________________________________________________DATE 6-27-08___ Rx MRI of brain and orbits with and without contrast

Dx: Diplopia

REFILLS--

Jill Autry

UNILATERAL

ORBITAL DISEASE

• Unilateral proptosis

• Unilateral visual field defect

• Unilateral decreased acuity

• APD

• MRI of brain and orbits

UNILATERAL

ORBITAL DISEASE

• Optic nerve gliomas • Meningiomas • Lymphomas

• Cavernous hemangiomas • Mucoceles

• Infection (orbital cellulitis)

• Inflammation (orbital pseudotumor) • Thyroid

– although bilateral, often asymmetric

POST-OPERATIVE

• Damage to extraocular muscles

– Scleral buckle placement

– Retrobulbar and peribulbar anesthesia – Overcorrection of strab surgery

• Induced anisometropia

– Phacoemulsification – Scleral buckle

POST-TRAUMATIC

• Orbital blowout fracture

• Entrapment of inferior rectus most

common

– Diplopia is superior gaze > inferior gaze – Can have some diplopia in both

– Forced duction test to diagnose entrapment

• CT of orbit

• Surgery if no resolution

Edward C. Wade, M.D. Ting Fang-Suarez, M.D. Chris Allee, O.D. Gurpreet Singh, M.D. Jill Autry, O.D. Randy Reichle, O.D.

6565 West Loop South 4415 Crenshaw Rd.

Bellaire, TX 77401 Pasadena, TX 77504

Phone (713)797-1010 Phone (281)998-3333

---NAME Kathy Summers AGE

ADDRESS_____________________________________________________DATE 6-27-08___ Rx CT of orbits with and without contrast

(11)

OTHER DIAGNOSTIC SIGNS

• Pupils

– III nerve palsy

• Ptosis

– III nerve palsy, MG

• Eyelid retraction

– Thyroid

• Proptosis

– Orbital tumor – Thyroid disease

OTHER DIAGNOSTIC SIGNS

• Head tilt/turn

– III, IV, or VI nerve palsy

• Large fusional amplitudes

– Decompensating phoria

• Tingling/numbness/young female

– Multiple sclerosis

• Visual field defect

– Unilateral-orbit – Temporal hemianopsia-chiasm

DIPLOPIA CAUSING

MEDICATIONS

• SSRIs • Xanax (alprazolam)

– Possibly due to an increase in phorias • Synthroid initiation/dosage changes • Muscle relaxants

– Norflex, Congentin, Baclofen • Neurontin (gabapentin) • Dilantin (phenytoin) • Ambien (zolpidem)

• Suspect any highly active CNS medication

OPTOMETRIC MANAGEMENT

• Proper testing/imaging/referral for diagnosis • Referral to systemic specialist prn

• Reassurance • Counseling

– Driving and machinery precautions • Occlusion therapy

• Prism therapy • Monitor VF if affected

OCCLUSION PATCHING

• Commonly prescribed with temporary

etiologies

• Often a necessity when angle is too large

for prism therapy

• Often a necessity with multiple nerve

palsies/ variable presentations

• Impairs peripheral vision and peripheral

fusion

OCCLUSION PATCHING

• Pirate patch

– Rarely recommended – Poor cosmetic choice – Uncomfortable

– OK if patient doesn’t wear glasses – OK if temporary etiology

(12)

OCCLUSION PATCHING

• Adult patients dislike Opticlude

– Provides no peripheral image – Cosmetically unacceptable

• Occlusion foil

– Better option for patients who wear glasses – Fog lens to eliminate diplopia

– Bangerter by Fresnel

• Increasing density to allow peripheral fusion

• Scotch tape

SPOT PATCHING

• Eliminate diplopia without compromising

peripheral vision

– Better cosmesis

– Better mobility, balance, field of view

• Round piece of translucent tape place on

the inside of glasses

• Directly in line of sight of diplopic images

• Start with one centimeter in size

– May to trial larger sizes/varying shapes

PRISM CORRECTION

• III Nerve Palsy

– Occlude if >20∆_XT

– If <20∆_{can split BI between 2 eyes} – 10-15∆_{can place in one eye} – BI on palsy eye

– BD on hyper eye

– Follow every 6-8 weeks until stable or resolved

PRISM CORRECTION

• IV Nerve Palsy

– Base down for hyper (palsy) eye

– More difficult if cyclorotatory component is present

• Often present in down gaze only

• Can place BD in palsy eye and sector occlude inferior one-half

PRISM CORRECTION

• VI Nerve Palsy

– BO in front of palsy eye – Can split between the 2 eyes

PRISM PEARLS

• Start with Fresnel

• Cheaper and easier to change than specs • Thickness and weight is minimized • Blur induced if >20∆

• <20∆_{can split between 2 eyes}

• Place Fresnel in front of the non-dominant or worse acuity eye

(13)

PRISM PEARLS

• May need 2 pairs of prism specs

depending on near vs. far activity

– Magnitude often changes with altering views

• Difficult to grind more than 10

∆

per eye into

glasses (total 20

∆

)

• Need thick, large frame for increased

prism

MATERIALS

• Fresnel Prism & Lens Co.

6824 Washington Ave.S

Eden Prairie, MN 55344

email: [email protected]

1-800-544-4760

TRAINING

• Can alleviate/control phoria breakdown by

increasing ranges

• Head tilt/turn teaching

– 4th_{nerve palsy}

• Teach to tilt head to side away from hyper eye • Teach to turn head to side away from hyper eye

(ipsilateral gaze) – 6th_{nerve palsy}

• Teach to gaze in opposite direction of palsy eye

OTHER OPTIONS

• Botox

– To ipsilateral medial rectus for 6th_{nerve palsy}

– Under local or general anesthesia – Inject into antagonist muscle – Can diffuse into adjacent muscles

• Surgery

– If permanent and stable – Resection-tightening – Recession-weakening

CODES

• Sensorimotor exam (92060)

– Diplopia (368.20) – Strabismus (378.00-378.9) – Convergence insufficiency (378.83) – ***Needs separate interpretation and report

• V2718 Press-on Fresnel/per lens

– Material charge

DIPLOPIA WEB SITES

• www.eyedock.com

– Parks 3 test