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Diplopia by yugandhar tummala


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Diplopia by yugandhar tummala

  2. 2. DEFINITION OF DIPLOPIA O The term diplopia is derived from Greek O Diplous  Double O Ops  Eye O The eyes are normally positioned so that the image falls exactly on the same spot on the retina of each eye O Slightest displacement of either eye causes DIPLOPIA as the image is shifted to a different position on the retina of the displaced eye.
  3. 3. Anatomy of Extra ocular muscles
  4. 4. Normal Physiology of Vision Fixation : Principle
  5. 5. Diplopia
  6. 6. Evaluation of Diplopia O Determine the nature either O Monocular or Binocular O Monocular is often an ocular problem O Binocular : occur when the images produced by the two eyes do not absolutely match. O So that images produced are relatively misaligned O Mainly a neurological problem.
  7. 7. OUncrossed diplopia : occurs with abductor paralysis O It is seen with lateral rectus , superior oblique and inferior rectus paralysis. Ocrossed diplopia : occurs with adductor muscle paralysis O It is seen with medial rectus, superior rectus and inferior rectus paralysis
  8. 8. Common causes of monocular diplopia O Dry eyes O Ectopia lentis O Corneal opacities O Lens opacity or irregularity O Macular or O Retinal disorder
  9. 9. Binocular diplopia O Due to weakness of extra ocular muscles of eye O Defective movement of affected eye results in image of object falling on two different points on the retina of two eyes.
  10. 10. O History: Sivani, a 26-year-old gymnastics instructor, presents with complaints of muscle weakness in her face that comes and goes, but has been getting worse over the past two months. Most notably, she complains that her "jaw gets tired" as she chews and that swallowing has become difficult. She also notes diplopia ("double vision") which seems to come on late in the evening, particularly after reading for a few minutes. O On physical examination, she has notable ptosis ("drooping") of both eyelids after repeated blinking exercises. When smiling, she appears to be snarling. O Electromyographic testing revealed progressive weakness and decreased amplitude of contraction of the distal arm muscles upon repeated mild shocks (5 shocks per second) of the ulnar and median nerves. Both her symptoms and electromyographic findings were reversed within 40 seconds of intravenous administration of edrophonium (Tensilon), O Blood testing revealed high levels of an anti-acetylcholine receptor antibody in her plasma,
  11. 11. Myasthenia gravis O Major cause of diplopia O Diplopia is often intermittent,variable , not confined to single ocular motor nerve distribution. O Fluctuating ptosis may be present. O Diagnois : O IV edrophonium inj. reversal of eyelid or eye muscle weakness. O Antibodies against ACH receptor or MuSK protein.
  12. 12. Analysis of diplopia O Rules governing the relationship of two images O RULE 1.displacement of the false image may be horizontal or vertical or both O RULE 2 : separation of the 2 images is greatest in the direction in which the weak muscle has its purest action O RULE 3: False image is displaced furthest in the direction in which the weak muscle should move the eye
  13. 13. Method of examination O Cover one of the patients eye with the transparent RED shield and using a point of light and move the object (as in routine ocular examination) O In each position , ask the patient : O Whether he sees one object or two O If double , the two images lie side by side or one above the other O In which position are they furthest apart O Which is the red image
  14. 14. Interpretation O If the images are exactly side by side it will be only the external or internal recti that are involved. O If they are one above the other, either of the obliques, or the superior and inferior recti, may be defective.
  15. 15. Hirschberg test (corneal light reflection test ) O To demonstrate the degree of diplopia and to document .
  16. 16. Diplopia charting
  17. 17. Cover test O Two types : O Alternating cover test O Unilateral cover test ( cover-uncover test ) O Lazy eye will deviate inward and outward.
  18. 18. Maddox Rod test O Subjective test O To detect small ocular deviations O If normal alignment : redline will pass directly through white light. O If ocular misalignment : redline will
  19. 19. Assesment of patient with diplopia O History : O Define symptoms O Effect of covering either eye O Horizontal /vertical seperation of images O Monocular/binocular O Effect of distance or target ( worse at near or far ) O Effect of gaze direction O Tilting of one image
  20. 20. Observation O Head tilt or turn O when the weak extraocular muscle is unable to move the eye , the head moves the eye. O There fore head tilts or turns or both in the direction of action of weak muscle O Ptosis(fatigue) O Pupil size O Proptosis O Spontaneous eye movements
  21. 21. Examination O Visual acuity ( each eye seperately ) O Versions ( pursuits, saccades & muscle overaction O Convergence O Ductions O Ocular alignment ( muscle balance) O Pupils O Lids O Vestibulo ocular reflex ( Dolls eye reflex) O Bells phenomenon O Prism measurements O Optokinetic nystagmus
  22. 22. General approach O 1.Was the onset acute or gradual : O Worsening suggests infiltration of the nerves O 2.Is there any variability or remission O If symptoms vary from time to time : latent strabismus or Myasthenia gravis O 3. Is there any associated ptosis O In acute 3rd nerve palsy there is complete ptosis O Lesser/variable degree of ptosis Myasthenia gravis/progressive ocular myopathy
  23. 23. O 4.Any pain O Berry aneurysm3rd nerve palsy O Aneurysmal dilatation of the intra cavernous part of the carotid artery 3rd or 6th nerve palsy O When there is associated incomplete loss of eye movements and severe congestion of eye Tolosa Hunt Syndrome (or)Pseudo tumor of orbit O Migraine headache may be complicated by a transient extra ocular nerve palsy. O Herpes zoster ophthalmicus with an extra ocular nerve palsy.
  24. 24. O 5 Any exophthalmos or proptosis O Aneurysm in cavernous sinus O Thrombosis of cavernous sinus with vascular congestion O Tumor in orbit.
  25. 25. Causes of III, IV and VI nerve palsies Site Common causes • Brain stem • Stroke • Demyelination • Intraxial neoplasm • Meningeal • Meningitis • Raised ICT • Aneurysms • Cerebellopontine angle tumor • Trauma
  26. 26. Cavernous sinus Infection Thrombosis Aneurysm Cortico cavernous fistula Superior orbital fissure Granuloma Tumor Orbit Ischemic Infection Tumor Trauma
  27. 27. 3rd nerve palsy O Complete 3rd nerve lesion causes total paralysis of the eye lid, so diplopia occurs only when the lid is held up. O When the lid is lifted the eye will be found deviated outwards and downwards. O Pupil may be dilated sluggish reactive or normal in size. O Compressive or non compressive 3rd nerve palsy differentiation is made based on the involvement or sparing of pupil. O In elderly patients with DM/HTN sudden onset painful 3rd nerve palsy with spared pupil non compressive or microvascular etiology.;
  28. 28. Trochlear nerve palsy O Principal action of the muscle is depress and intort globe– palsy of it causes hypertropia and excyclotorsion. O Head Tilt test : Vertical diplopia is seen upon reading or looking down– exacerbated by tilting the head towards the side with muscle palsy and alleviated by tilting away. ( Cardinal diagnostic feature) O A base down prism (Fresnel lens ) may serve as a temporary measure to alleviate diplopia
  29. 29. Abducens nerve palsy O Abducens nuclear lesion produces a complete lateral gaze palsy from weakness of both ipsilateral lateral rectus and contralateral medial rectus O Most common causes O Infarct O Tumor O Hemorrhage O Vascular malformation O Multiple sclerosis O UL/BL abducens palsy is a classic sign of raised intracranial pressure O Diagnosis is confirmed by papilladema (Fundus )
  30. 30. Differential Double vision
  31. 31. Inter nuclear ophthalmoplegia O Results from the damage to the medial longitudanal fasiculus ascending from the abducens nucleus in the pons to the oculomotor nucleus in the midbrain ( hence “Inter”nuclear Opthalmoplegia. O Damage to it results in a failure of adduction of on attempted lateral gaze. O Causes : O Multiple sclerosis (most common ) O Tumor O Stroke O Trauma
  32. 32. Treatment O Patching ( occlusive ) therapy O Identify and treat the underlying cause of the problem. O Other options include eye exercises, O wearing an eye patch on alternative eyes, O prism correction O In more extreme situations, surgery or botulinum toxin
  33. 33. References  Bickerstaff Neurology  John Patten Neurological Differential Diagnosis  Harrison 19th edition  API updates 2016  Anatomy and Physiology of eye : AK Khurana