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Hello,
I am a general practicioner and I found this forum while searching for causes of diplopia. Maybe some of you can help me.
I have a patient who has double vision. I could not determine a diagnosis and sent him to a reputed specialist. I think that the diagnosis he was given there is incorrect, but I am not sure.
I have a patient (and friend of mine) who has complaints of double vision. I could not determine a diagnosis and sent him to a reputed specialist. I think that the diagnosis he was given there is incorrect, but I am not sure. 😳
Heres a summary of the case (including the diagnoses of the ophthalmologist):
The patient is 40 years old.
He is working with a computer 8-10 hours per day.
He sees distorted shapes when looking at bright light sources, such as traffic lights, candles etc. The patterns he sees are changing over time slowly, but he says they are rather stable within a period of a day or so. Usually there is a blurred displacement of the source to the right side, and there are other, smaller patterns, usually in a radial, horizontal direction. At daytime he sees ghost images of brighter objects (white letters on a dark background, white sunlit clothes etc.). He says this condition started a few months ago and is getting worse rather rapidly: the perceived distortion is increasing.
His diplopia is monocular (right eye only, remains unchanged if the left eye is covered).
Its degree is changing with the direction of the gaze. The diplopia is increasing with the distance of the object.
The diplopia does not improve even after prolonged rests to the eye (e.g. after not watching computer screen and cutting back on other types of reading for several days).
Looking through a pinhole abates the diplopia.
Daytime visual acuity (measured on a Snellen chart) is normally good, but sometimes he has blurred vision for a day or so only on the right eye. (But usually he is 1.0 (or 20/20) on both eyes.)
There is no visible injury, scar, swelling etc. on the right eye. Cornea and lens seem normal. Field of vision is normal. Amsler grid no perceived distortions. Retina is normal (according to fundoscopy).
There is no history of diabetes. I could identify no recent trauma of the eye, head or the nervous system.
He wore glasses at early childhood to correct strabismus. Otherwise he never needed any correction.
The ophthalmologist determined that the problem is caused by strabismus that was not properly treated in childhood and so it causes a constant strain on the muscles of the right eye. She said this should be corrected with a prism lens.
But I have doubts: to the best of my knowledge, strabismus always causes binocular diplopia, never monocular. (Am I correct?) Also, diplopia caused by strabismus tends to worsen during the day and improve after rest. In the case of this patient, the pattern is fairly constant within a day. (Also, if the distortion is not constant over time, I doubt that it can be corrected with a prism.)
I was first thinking about dry eye that often occurs among computer users. He does have occasional feelings of dryness and he blinks a bit too often, but in my experience dry eye should improve after a few days of rest to the eye and applying drops, but in his case it did not. (I prescribed him Visine initially there was no amendment for weeks.) Also, there is no redness in the eye.
I also suspected cataract, but the ophthalmologist should have noticed it, and according to her diagnosis the lens is clear. Also, the patient is only 40 years old, and cataract is not common at this age. Still, I would keep this possibility alive. (Do you agree or not: does any of the symptoms exclude a cataract?)
Irregular cornea - astigmatism? Is it possible for astigmatism to develop so suddenly at this age? In my experience it is fairly constant with time, and in this case the complaints started only a few months ago.
It may be some other refractive error, but I do not know what it could be that an experienced ophthalmologist does not notice.
Am I wrong in any of the above? Do you have any idea about the possible diagnoses or direction of further examination?
Thanks, and have a good day!
I am a general practicioner and I found this forum while searching for causes of diplopia. Maybe some of you can help me.
I have a patient who has double vision. I could not determine a diagnosis and sent him to a reputed specialist. I think that the diagnosis he was given there is incorrect, but I am not sure.
I have a patient (and friend of mine) who has complaints of double vision. I could not determine a diagnosis and sent him to a reputed specialist. I think that the diagnosis he was given there is incorrect, but I am not sure. 😳
Heres a summary of the case (including the diagnoses of the ophthalmologist):
The patient is 40 years old.
He is working with a computer 8-10 hours per day.
He sees distorted shapes when looking at bright light sources, such as traffic lights, candles etc. The patterns he sees are changing over time slowly, but he says they are rather stable within a period of a day or so. Usually there is a blurred displacement of the source to the right side, and there are other, smaller patterns, usually in a radial, horizontal direction. At daytime he sees ghost images of brighter objects (white letters on a dark background, white sunlit clothes etc.). He says this condition started a few months ago and is getting worse rather rapidly: the perceived distortion is increasing.
His diplopia is monocular (right eye only, remains unchanged if the left eye is covered).
Its degree is changing with the direction of the gaze. The diplopia is increasing with the distance of the object.
The diplopia does not improve even after prolonged rests to the eye (e.g. after not watching computer screen and cutting back on other types of reading for several days).
Looking through a pinhole abates the diplopia.
Daytime visual acuity (measured on a Snellen chart) is normally good, but sometimes he has blurred vision for a day or so only on the right eye. (But usually he is 1.0 (or 20/20) on both eyes.)
There is no visible injury, scar, swelling etc. on the right eye. Cornea and lens seem normal. Field of vision is normal. Amsler grid no perceived distortions. Retina is normal (according to fundoscopy).
There is no history of diabetes. I could identify no recent trauma of the eye, head or the nervous system.
He wore glasses at early childhood to correct strabismus. Otherwise he never needed any correction.
The ophthalmologist determined that the problem is caused by strabismus that was not properly treated in childhood and so it causes a constant strain on the muscles of the right eye. She said this should be corrected with a prism lens.
But I have doubts: to the best of my knowledge, strabismus always causes binocular diplopia, never monocular. (Am I correct?) Also, diplopia caused by strabismus tends to worsen during the day and improve after rest. In the case of this patient, the pattern is fairly constant within a day. (Also, if the distortion is not constant over time, I doubt that it can be corrected with a prism.)
I was first thinking about dry eye that often occurs among computer users. He does have occasional feelings of dryness and he blinks a bit too often, but in my experience dry eye should improve after a few days of rest to the eye and applying drops, but in his case it did not. (I prescribed him Visine initially there was no amendment for weeks.) Also, there is no redness in the eye.
I also suspected cataract, but the ophthalmologist should have noticed it, and according to her diagnosis the lens is clear. Also, the patient is only 40 years old, and cataract is not common at this age. Still, I would keep this possibility alive. (Do you agree or not: does any of the symptoms exclude a cataract?)
Irregular cornea - astigmatism? Is it possible for astigmatism to develop so suddenly at this age? In my experience it is fairly constant with time, and in this case the complaints started only a few months ago.
It may be some other refractive error, but I do not know what it could be that an experienced ophthalmologist does not notice.
Am I wrong in any of the above? Do you have any idea about the possible diagnoses or direction of further examination?
Thanks, and have a good day!
