Course # Double Trouble

Transcription

1 Course # 112 Double Trouble

2 DOUBLE TROUBLE 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 Jill Autry, O.D., R.Ph. Eye Center of Texas, Houston 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 1

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 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 2

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 3

5 EPIRETINAL MEMBRANE Age-Related Macular Degeneration Monocular diplopia Metamorphopsia Decreased visual acuity/blur Macular pucker Pseudohole Cystoid macular edema (CME) Can also cause binocular diplopia if aniseikonia develops 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 4

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 5

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 years old Intermittent diplopia (usually 6 th nerve) Optic neuritis Nystagmus Tingling or numbness in extremities 6

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 7

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 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 6 th nerve palsy with papilledema Infection (viral or bacterial) Tumor Giant cell 8

10 Edward C. Wade, M.D. Chris Allee, O.D. Jill Autry, O.D. Ting Fang-Suarez, M.D. Gurpreet Singh, M.D. Randy Reichle, O.D. UNILATERAL ORBITAL DISEASE 6565 West Loop South 4415 Crenshaw Rd. Bellaire, TX Pasadena, TX Phone (713) Phone (281) NAME Kathy Summers AGE ADDRESS DATE Rx MRI of brain and orbits with and without contrast Dx: Diplopia Unilateral proptosis Unilateral visual field defect Unilateral decreased acuity APD MRI of brain and orbits REFILLS-- Jill Autry 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. Chris Allee, O.D. Jill Autry, O.D. Ting Fang-Suarez, M.D. Gurpreet Singh, M.D. Randy Reichle, O.D West Loop South 4415 Crenshaw Rd. Bellaire, TX Pasadena, TX Phone (713) Phone (281) NAME Kathy Summers AGE ADDRESS DATE Rx REFILLS-- CT of orbits with and without contrast Dx: Diplopia Jill Autry 9

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 Buy at most drugstores 10

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 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 Can stay in Fresnel if prism cannot be ground into Rx or due to cost issues 11

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 Washington Ave.S Eden Prairie, MN [email protected] TRAINING Can alleviate/control phoria breakdown by increasing ranges Head tilt/turn teaching 4 th nerve palsy Teach to tilt head to side away from hyper eye Teach to turn head to side away from hyper eye (ipsilateral gaze) 6 th nerve palsy Teach to gaze in opposite direction of palsy eye OTHER OPTIONS Botox To ipsilateral medial rectus for 6 th 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 ( ) Convergence insufficiency (378.83) ***Needs separate interpretation and report V2718 Press-on Fresnel/per lens Material charge DIPLOPIA WEB SITES Parks 3 test 12