Visual rehabilitation indicating neuroplasticity in an esotropic adult patient with diplopia after sudden visual acuity loss in the non-amblyopic eye: A case report.

BACKGROUND: The aim of this case report is to present the successful management of both diplopia and amblyopia in a specific clinical situation, demonstrating neuroplasticity of the visual system in an adult patient. Causes of diplopia include eye pathologies in monocular diplopia and ischemic ocular motor nerve palsies, sudden life-threatening and chronic conditions in central nervous system in binocular diplopia. Strabismic amblyopia and nonarteritic anterior ischemic optic neuropathy are quite often ophthalmic conditions, first one is caused by suppression during developmental period and the latter one by ischemia of the optic nerve in adults. Coexistence of aforementioned conditions may cause unusual clinical situation in which ability of nervous system to functional reorganization could be demonstrated. CASE PRESENTATION: In our adult patient, diplopia was incited by the loss of suppression of the strabismic amblyopic eye, which was the consequence of a sudden decrease of the visual acuity in the previously better eye in the course of nonarteritic anterior ischemic optic neuropathy. This led to impairment in daily activities. RESULTS: Visual training rehabilitation improved distance and near visual acuity in the amblyopic eye over three months, and prescribing two pairs of glasses with prisms enabled the patient to return to daily activities. CONCLUSION: The discussed patient lost the suppression of the strabismic amblyopic eye. Management of amblyopia is usually undertaken in children, however considering neuroplasticity we successfully attempted to improve visual functioning of our patient, despite lower intensity of neuroplasticity functions in an adult brain.

IOL-Induced Extreme Blur to Alleviate Intractable Diplopia Secondary to Dragged-Fovea Diplopia Syndrome.

A 73-year-old male presented with one year of intractable binocular diplopia and metamorphopsia in the right eye. He was unable to maintain fusion with prismatic correction, refused cosmetically noticeable forms of occlusion, and was not an occlusive contact lens candidate due to chronic neuropathy affecting his hands. The patient underwent cataract surgery with placement of a high plus intraocular lens to induce extreme blur. The uncomplicated procedure was successful in eliminating his diplopia. Cataract extraction with a high minus refractive target is an option for treating intractable diplopia associated with dragged-fovea diplopia syndrome.

Occupational therapists' perspectives on binocular diplopia in neurorehabilitation: A national survey.

BACKGROUND: Oculomotor dysfunction affects a significant number of adults with neurological conditions and binocular diplopia is a common symptom which impacts an individual's ability to participate in meaningful daily activities. Occupational therapists use partial and complete occlusion to minimize binocular diplopia, however a review of the literature reflected a lack of standardized protocol for each intervention technique. The purpose of this study was to examine occupational therapists' perspectives on the use of partial and complete occlusion and the clinical reasoning process used. METHODS: An electronic survey was distributed to occupational therapists working in a variety of practice settings. The survey contained questions relating to demographics, the selected occlusion technique, and clinical reasoning for that selection. RESULTS: More than half of the 106 respondents used partial occlusion more frequently than complete occlusion. There was no correlation between respondent experience and self-report of competence in managing binocular diplopia. Respondents based their clinical reasoning on available evidence, client factors, and clinical expertise. CONCLUSION: Respondents offered conflicting perspectives on each occlusion technique. Future studies are required to examine which occlusion technique benefits clients.

Nylon foil (supramid) orbital implants in pediatric orbital fracture repair.

PURPOSE: To present the authors experience with the nylon foil (Supramid) implant as a safe and effective method to repair pediatric orbital wall fractures. METHODS: A retrospective chart review of all pediatric patients (≤18 years) that underwent orbital wall fracture repair with an unsecured 0.4-mm Supramid implant between 2007 and 2010. Outcome variables were diplopia and surgical complications. This study was carried out with IRB approval. RESULTS: A total of 59 orbits in 57 patients underwent orbital fracture repair using solely the 0.4-mm Supramid implant that were included in this retrospective chart review with the average age being 12 years. Trauma related to daily activities (42.1%) was the most frequent cause of orbital fractures. Eight patients (14.0%) had associated ocular/orbital injuries. Thirty-one patients (54.8%) were symptomatic at presentation with the most common presenting symptom being diplopia (n = 19, 33.3%). The most common fracture pattern sustained was combined orbital floor and medial wall fractures, which occurred in 21 patients (36.8%). Of the 3 patients (5.3%) that required immediate intervention due to extraocular muscle entrapment resulting in vasovagal responses, all returned to full and normal extraocular motility. There were 2 postoperative complications without any permanent sequelae; no patient developed postoperative enophthalmos recognizable by both physician and parents, and diplopia improved in all the 6 patients who suffered from immediate postoperative diplopia (10.7%). CONCLUSIONS: The nylon foil implant is a safe and effective method to repair pediatric orbital wall fractures given the low complication rate.

[When is the prescription of prismatic eyeglasses reasonable?]. / Wann ist eine Prismenverordnung sinnvoll?

Prismatic glasses are used to deflect rays of light. In ophthalmology, prisms are mainly used to correct double vision caused by strabismus which is acquired after early childhood. In congenital or infantile strabismus, the image of the deviated eye is usually suppressed so that double vision does not occur and prismatic glasses are not indicated. Latent strabismus is very common and only rarely leads to double vision or asthenopic symptoms so that correction with prismatic glasses is only indicated in exceptional cases. The "Measuring and Correcting Methodology after H.-J. Haase" is based on flawed assumptions, and therefore can not be recommended for the prescription of prisms.

Reposition of a misaligned Zeiss AT TORBI 709M® intraocular lens 15 months after implantation.

PURPOSE: To report the treatment of a patient with a misaligned intraocular lens (IOL). METHODS: We describe a case of a misaligned bitoric single-piece, plate haptic IOL (AT TORBI 709M®, Carl Zeiss Meditec AG, Jena, Germany) 15 months after uneventful phacoemulsification and IOL implantation in the capsular bag. Keratoconus with partly regular astigmatism was preexisting. RESULTS: Thorough examination showed a misalignment of the bitoric IOL of 25 degrees, explaining the patient's symptoms (monocular diplopia). Despite capsular fibrosis, surgical revision with IOL rotation was advised and could be performed without major difficulty. A follow-up visit showed a corrected distance visual acuity of 16/20 and a correctly aligned toric IOL. CONCLUSIONS: A long preceding operation should not detain the surgical revision of a misaligned toric IOL in the capsular bag.

Mini-plication to treat small-angle strabismus: A minimally invasive procedure.

BACKGROUND: Mini-plication is a new rectus muscle tightening procedure for the correction of small-angle strabismus that can be performed under topical anesthesia. The purpose of this study was to report the outcomes of mini-rectus muscle plication. METHODS: We retrospectively reviewed the medical records of patients who underwent mini-plication. In this procedure, 6-0 polyglactin 910 suture was secured to the central 3 to 4 mm of the muscle belly 5 mm posterior to the insertion and was then passed through the sclera just anterior to the muscle insertion to plicate the central portion of the muscle. This differs from the standard procedure, in which the entire width of the muscle is plicated. Two groups were analyzed: those who underwent mini-plication alone and those who underwent mini-plication after prior antagonist muscle-weakening surgery. RESULTS: Our review identified nine patients aged 5 to 78 years. Topical anesthesia was used for all adults, who experienced no local or systemic complications. Mini-plication reduced vertical and horizontal deviations an average (± SD) of 6.7(Δ) ± 3.5(Δ). The mini-plication-only group (3 patients) had an average postoperative correction of 5.5(Δ) ± 2.6(Δ); the prior surgery group (6 patients), an average of 9(Δ) ± 2.7(Δ). Diplopia was noted in 50% of the adults preoperatively and none postoperatively. All patients experienced a decrease in strabismus, with an average outcome of <5(Δ) of postoperative deviation. CONCLUSIONS: Mini-plication, which can be performed under topical anesthesia, corrected small deviations and was especially useful for adult strabismus patients with diplopia.

Use of Bangerter filters with adults having intractable diplopia.

PURPOSE: The aim of this study was to describe the use of Bangerter filters in adults having intractable diplopia. METHODS/CASE REPORTS: A series of adults having intractable diplopia caused by either cyclotorsion, retinal disease, monocular diplopia, or rapid alternating fixation who were treated with Bangerter filters is reported. Detailed case reports on 4 of the 10 patients are included. CONCLUSION: Bangerter filters can be used to mitigate diplopia that cannot be eliminated with either prism, modification of the spectacle prescription, vision therapy, or extraocular muscle surgery. The weakest density filter that eliminates the diplopia should be prescribed. Prospective studies reporting the long-term efficacy and quality of life with the filters are needed.

Presumed corneal argyrosis from occlusive soft contact lenses: a case report.

PURPOSE: To report a case of presumed corneal argyrosis associated with sliver nitrate-coated cosmetic soft contact lens wear. METHODS: A 67-year-old woman wore silver nitrate-coated occlusive soft lenses for 17 years for the management of intractable diplopia. Slit-lamp examination revealed a diffuse blue-gray deposit that was characteristic of corneal argyrosis just anterior to Descemet membrane. Confocal microscopy, anterior segment optical coherence tomography, and noncontact specular microscopy were performed. RESULTS: Confocal microscopy showed hyperreflective granules in Bowman layer, deep stroma, and Descemet membrane. The granules were below the resolution of anterior segment optical coherence tomography. Confocal and specular microscopy showed an abnormal reflection from the region of Descemet membrane. Central corneal endothelial cell density was 2560 cells per square millimeter. CONCLUSION: Presumed corneal argyrosis can occur after long-term use of silver nitrate-coated contact lenses.

Low vision rehabilitation for a target-shooting marksman with visual field loss and diplopia.

BACKGROUND: In the United States in 2006, there were 17.8 million hunters and 17.1 million target shooters. When these sportsmen suffer significant visual loss, it can have a devastating effect on their participation in the shooting sports. According to the National Rifle Association, there are no reliable data sources on the number of target shooters with visual impairment. This case report describes a retired, nationally ranked, competitive target shooter who suffered bilateral visual field loss secondary to nonarteritic anterior ischemic optic neuropathy and diplopia secondary to cerebral vascular accident. CASE REPORT: A retired 67-year-old white man was referred by a local optometrist to a neuro-ophthalmologist with a suspicious finding of disc pallor and a restriction of the visual field. Examination revealed right hypertropia and visual field defects: binocular superior altitudinal losses and inferior arcuate loss in his dominant, right eye. He had best-corrected distance acuity of 20/20 - 2 in the right eye and 20/25 - 2 in the left eye. Because of this, he received several adaptive rehabilitation devices to help him regain his shooting performance. These included a single-vision add for the pistol sight, yellow tint, low-power telescope, and patching. In this report, the fundamentals of eye care for competitive shooting are described with an emphasis on providing the best acuity for presbyopic patient prescriptions at nonstandard distances and the avoidance of diplopia. CONCLUSION: A visually impaired sportsman who participated in shooting sports at a high level was attempting to return to his previous shooting performance. This case report shows how sports vision and low vision rehabilitation techniques can improve the visual function of a competitive shooter.

Stroke and visual rehabilitation.

Many patients will experience some type of visual dysfunction following a stroke. The visual changes associated with stroke can be categorized as sensory (visual acuity and visual field), motor (extraocular muscle motility), and perceptual. These disturbances affect the patient's quality of life and can impede overall rehabilitation. Many of these impairments can be addressed by simple yet effective techniques. As a result, vision rehabilitation specialists are becoming an important part of the multidisciplinary stroke rehabilitation team.

Decompensated strabismus after laser in situ keratomileusis.

We present a case of decompensated nerve IV palsy with vertical diplopia afer bilateral laser in situ keratomileusis. As the patient was given monovision, we believe diplopia occurred with a decrease in vision in 1 eye and interruption of fusion. Although corrective spectacles to restore equal vision at distance were prescribes, the patient needed a prism to eliminate her double vision. We suggest a careful cover/uncover test and versions assessment in all candidates for refractive surgery who want monovision correction and a full ocular motility evaluation if there is any doubt about binocular issues.

[Prismatic treatment for heterophoric decompensation after onset of presbyopia]. / Traitement prismatique de la décompensation phorique à l'age de la presbytie.

This study presents the results of the prescription of small prisms in horizontally (N = 11) and vertically (N = 5) heterophoric patients after the onset of presbyopia. There was a high incidence of diplopia (69%) at an age where fusionnal adaptation capacities are limited. Prismatic treatment released the diplopia and asthenopic complaints in 100% of the cases. The prisms were easily included in prescriptions for progressive lenses in half of the cases. Their strength was eventually decreased in 12.5% of the cases, and they were totally eliminated in 12.5%. The prescription had to be increased in only one case. The mean follow-up was 2.8 years (with a range from 1 to 7.5 years).

Balanced orbital decompression for Graves' ophthalmopathy.

OBJECTIVE/HYPOTHESIS: Surgical management of Graves' ophthalmopathy is an alternative to medical therapy with corticosteroids or external beam radiotherapy. Orbital decompression has commonly been performed via a transantral approach to the medial orbital wall and floor. Although an endoscopic approach to these walls has been described, a balanced approach (incorporating a lateral decompression by an ophthalmology team) is desirable. STUDY DESIGN: Retrospective review. METHODS: Endoscopic medial decompression and extended lateral decompression were accomplished in 18 orbits (11 patients); inferior decompression was performed in 11 of these. Five additional procedures were performed. RESULTS: Exophthalmos improved by a mean of 4.6 mm. All patients who underwent decompression for vision loss had improved vision after surgery. Exposure keratitis improved in six of six orbits. Two of five patients undergoing orbital decompression for vision loss developed postoperative diplopia, which was successfully treated with strabismus surgery or prism glasses. There were no other significant complications. CONCLUSIONS: The endoscopic approach to the medial orbital wall is an important component of balanced orbital decompression for patients with Graves' ophthalmopathy. Balancing the decompression and preserving the medial orbital strut between the ethmoid cavity and the orbital floor may minimize the risk of diplopia.

Superior oblique damage from the traction suture at cataract surgery.

A 41-year-old woman underwent uneventful phacoemulsification and posterior chamber lens implantation in the right eye. Approximately a month later similar surgery was performed in the left eye. The surgery was performed with the patient under retro-bulbar anesthesia with a combination of bupivacaine (Marcaine) 0.75% and lidocaine (Xylocaine) 4% administered through a lower lid injection. Immediately after the patch was removed, the patient was aware of constant vertical diplopia. Over the ensuing 6 months the symptom worsened. Orbital computed tomography showed no abnormalities.

Oftamoplegia internuclear bilateral por esclerosis múltiple / Bilateral internuclear ophthalmoplegia by multiple sclerosis

La Esclerosis Múltiple se ha descrito como causante de Oftalmoplegia Internuclear, especialmente bilateral. Se presenta el caso de una mujer de 38 años con OIN bilateral de 8 meses de evolución sin otras manifestaciones. La HRPE mostró bandas oligoclonales intensas y la inmunofijación detectó cadenas livianas kappa y lamda. La RM reveló dos placas de desmielinización, una paraventricular y la otra yuxtacortical. La TAC no fue de utilidad diagnóstica

[Our experience with surgical treatment of post-traumatic diplopia]. / Wlasne doswiadczenia w chirurgicznym leczeniu pourazowej diplopii.

On the basis of analysis of patients with posttraumatic diplopia pathomechanism, diagnostic procedure, methods of surgical treatment and its results were discussed. In the group of 1196 patients with injuries of the organ of vision posttraumatic diplopia was diagnosed in 536 (44.8%) patients, of which 331 (61.8%) underwent surgery. In this group recovery was obtained in 182 (55.0%) patients, while in remaining marked improvement was stated. Lack of knowledge in this field among specialists was pointed out and was confirmed by mistakes in diagnostics and methods of treatment. These factors markedly worsen final results of proper treatment.