Grand Rounds - Diplopia

[Richard_Hom]

A 41 year old woman presents to the clinic upon the referral from the
neurology department. You have been asked to solve this patients recent onset of diplopia that is assumed to have occured from a brain aneurysm. She reports diplopia in primary gaze, worsening in upgaze. She would like to requalify for a driver's license and cannot, automatically, because of LOC ("loss of consciousness") from the aneurysm.

She sees 20/20 in each with plano manifest refraction. In primary gaze, she
is 8 PD of constant exotropia and can fuse with 4. In upgaze the exotropia
is 35-40PD. In downgaze, she is fusing.

How would you manage this patient?

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[Andrew_Doan]

A 41 year old woman presents to the clinic upon the referral from the
neurology department. You have been asked to solve this patients recent onset of diplopia that is assumed to have occured from a brain aneurysm. She reports diplopia in primary gaze, worsening in upgaze. She would like to requalify for a driver's license and cannot, automatically, because of LOC ("loss of consciousness") from the aneurysm.

She sees 20/20 in each with plano manifest refraction. In primary gaze, she
is 8 PD of constant exotropia and can fuse with 4. In upgaze the exotropia
is 35-40PD. In downgaze, she is fusing.

How would you manage this patient?

Where was the aneurysm?

This patient presents with a V-pattern Exotropia.

On extra-ocular examination, does she exhibit over action of the inferior obliques OD & OS?

Perhaps she has a double superior oblique palsy secondary to an aneurysm near the brain stem? Did she have recent head trauma, perhaps from her LOC? The 4th CN has the longest course in the head and is damaged easily.

Did you check a double maddox rod test for excyclotorsion, which helps to confirm the superior oblique palsy?

With strabismus due to double SO palsy, the patients have the options of:
1) doing nothing if not bothered
2) patch one eye
3) prism for primary gaze (she's likely not bothered by diplopia in upgaze b/c people spend little time looking upwards)
4) surgery, but I wouldn't operate on this lady if prism works for her or options 1 or 2.