Amitriptyline overdose-an uncommon cause of acute transient exotropia presenting to the emergency setting: a case report.

BACKGROUND: Acute presentations of acquired exotropia or divergent alignment of either or both eyes are commonly observed following intracranial vascular events, trauma, orbital, and endoscopic sinus surgeries. CASE PRESENTATION: The reported case is about a 16-year-old previously healthy Tamil female who presented to the emergency department with a few hours of reduced responsiveness. With the only clue in the history being about a family conflict the previous day, the examination revealed a noticeable exotropia along with a constellation of anticholinergic findings: a low Glasgow Coma Score, mydriasis, tachycardia, floppy limbs, exaggerated reflexes, and a palpable urinary bladder. Amitriptyline overdose leading to significant neurological involvement was suspected, and she was immediately offered urine alkalinization. Resources for urine and blood toxicological studies were not available. The patient gained consciousness 24 hours later and confirmed an overdose of ten amitriptyline tablets. Exotropia, a unique manifestation of this patient's neurotoxicity, spontaneously resolved in 36 hours. DISCUSSION AND CONCLUSIONS: The reported case is about an uncommon clinical finding of exotropia seen in a common toxicological emergency: acute amitriptyline overdose. The importance of having a wide knowledge of various clinical presentations of drug toxicities is highlighted here, as any delay in diagnosis or initiation of life-saving measures could have resulted in fatal consequences.

Convergence excess consecutive esotropia associated with 0.01% atropine eye drops usage in patients operated for intermittent exotropia.

To report convergence excess esotropia (CEET) following 0.01% atropine eye drops (Low dose atropine [LDA]). Children who developed CEET that resolved promptly after discontinuation of LDA are described. Three myopes aged 5.3 ± 1.2 years and mean sphere -4.5D were included. All were operated for intermittent exotropia earlier. Mean esotropia was +28.3PD for near and 10.6PD for distance. LDA induced high AC/A ratio and fusion normalized in 3 weeks after discontinuation of LDA. LDA should be used with caution in patients with esophoria or previously operated for intermittent exotropia. Any evidence of the emergence of a CEET should warrant discontinuation of LDA.

Large exotropia after retrobulbar anesthesia.

A 67-year-old woman complained of horizontal diplopia shortly following bilateral cataract surgery with intraocular lens implantation performed under retrobulbar anesthesia. Retrobulbar anesthesia was administered at an inferotemporal injection site using 1 cc lidocaine hydrochloride 2% mixed with bupivacaine hydrochloride 0.5%. The initial ophthalmologic evaluation showed a 12-prism diopter (PD) exotropia, and ocular motility evaluation revealed marked limitation of adduction without vertical limitation. One year after cataract surgery, the exodeviation increased up to 60 PD. The patient underwent an 8.0-mm recession of the right lateral rectus and a 6.0-mm recession of the left lateral rectus. Both lateral rectus muscles were biopsied, and biopsy revealed dense fibrous connective tissue without viable muscular cells. The lateral rectus muscle might be injured by retrobulbar anesthesia, and it could induce large exotropia.

Ocular dysmotility after intra-arterial chemotherapy for retinoblastoma.

We report the case of a 15-month-old boy with retinoblastoma who developed exotropia secondary to a right medial rectus infarct after intra-arterial chemotherapy. He had unilateral sporadic group C tumor (International Classification of Retinoblastoma) and was treated with intra-arterial melphalan. One week after the first session of intra-ophthalmic arterial melphalan chemotherapy, he was noted to have orbital congestion, exotropia, and right adduction limitation. Magnetic resonance imaging was suggestive of a right medial rectus infarct. The tumor showed a good response to intra-arterial chemotherapy but the exotropia persisted.

[Permanent consecutive exotropia in children treated with botulinum toxin]. / Exotropía consecutiva permanente en niños tratados con toxina botulínica.

BACKGROUND: Congenital esotropia is the most frequent type of strabismus. Botulinum toxin is a treatment option with variable results. We undertook this study to determine the frequency and associated factors with consecutive permanent esotropia in patients diagnosed with congenital esotropia treated with botulinum toxin. METHODS: A retrospective review was achieved in patients with congenital esotropia treated with botulinum toxin and who remained in esotropia after a minimal follow-up of 6 months. Pre- and postnatal background, cycloplejia, magnitude of the pre-application deviation, injected dose and number of applications were analyzed. RESULTS: A total of 84 patients were included. Of all patients,12 (14.28%) remained in consecutive esotropia (six males and six females). Age range was from 5 months to 2 years (average: 10.75 months). Initial esotropia ranged from 20-50 prism diopters (PD) with an average of 37.9 ± 9.64 PD. One patient had variability in the magnitude of the deviation prior to treatment. During the maximum follow-up, the magnitude of the esotropia was from 10 to 40 (average, SD 18 ± 8.01 PD). In five subjects a variability was observed in the magnitude of the angle of deviation by a range of 10-40 PD, and in seven subjects the deviation was stable with an average of 20 PD. Eleven subjects had some degree of psychomotor delay (91.66%) and one subject had a non-significant history. CONCLUSIONS: In patients with consecutive permanent esotropia after application of botulinum toxin, the most prevalent characteristic is neurological.

Variable angle of strabismus related to timing of opiate ingestion.

Heroin (diamorphine) is a highly addictive opiate with potential for misuse. A small number of reports have linked the commencement of heroin misuse to acute exotropia with diplopia and subsequent withdrawal to esotropia in individuals without previous symptoms.(1-5) We describe a young adult who sought strabismus surgery to correct a large-angle exotropia. Detailed patient history and orthoptic measurements at different times of the day revealed a fluctuating angle of divergence relating to the timing of opiate ingestion, rendering surgery inappropriate. We suggest that opiate misuse, which may not willingly be disclosed by patients, should be specifically asked about before acquired-strabismus surgery is undertaken in adults.

Relative abuse liability of gamma-hydroxybutyric acid, flunitrazepam, and ethanol in club drug users.

OBJECTIVES: Despite the increasing concern about gamma-hydroxybutyric acid (GHB) toxicity, there are few studies examining the clinical pharmacology of GHB and its abuse potential. To evaluate GHB-induced subjective and physiological effects, its relative abuse liability and its impact on psychomotor performance in club drug users. MATERIALS AND METHODS: Twelve healthy male recreational users of GHB participated in 5 experimental sessions in the framework of a clinical trial. The study was randomized, double-blind, double-dummy, and crossover. Drug conditions were a single oral dose of GHB (40 or 60 mg/kg), ethanol (0.7 g/kg), flunitrazepam (1.25 mg), and placebo. Study variables included vital signs (blood pressure, heart rate, oral temperature, pupil diameter), psychomotor performance (digit symbol substitution test, balance, Maddox-Wing), subjective effects (a set of 13 visual analogue scales, Addiction Research Center Inventory-49 items, and Evaluation of the Subjective Effects of Substances with Potential of Abuse questionnaires), and pharmacokinetics. RESULTS: All active conditions induced positive effects related to their abuse potential. The administration of GHB produced euphoria and pleasurable effects with slightly higher ratings than those observed for flunitrazepam and ethanol. Gamma-hydroxybutyric acid induced a biphasic time profile with an initial stimulant-like effect related to the simultaneous rise of plasma concentrations and a latter sedative effect not related to GHB kinetics. Gamma-hydroxybutyric acid increased blood pressure and pupil diameter. Ethanol induced its prototypical effects, and flunitrazepam produced marked sedation. Gamma-hydroxybutyric acid and flunitrazepam impaired psychomotor performance, digit symbol substitution test, and balance task, whereas ethanol, at the dose tested, induced only mild effects exclusively affecting the balance task. CONCLUSIONS: Our results suggest a high abuse liability of GHB and flunitrazepam in club drug users.

Management of nonresolving consecutive exotropia following botulinum toxin treatment of childhood esotropia.

OBJECTIVE: To study motor and sensory results of surgery for exotropia following botulinum toxin A injection to correct childhood esotropia. METHODS: The medical records of 2445 patients treated with botulinum toxin bimedial injection were retrospectively reviewed to select patients operated on after 1 year of consecutive exotropia. We recorded age at onset of deviation, retinoscopic refractive error, visual acuity and age and dosage at the time of botulinum toxin injection. Retinoscopic refractive error, visual acuity, deviation angle, and stereoacuity before surgery for consecutive exotropia were also recorded. Families were contacted to obtain retinoscopic refraction, visual acuity, deviation angle, Bagolini test, vectography, and stereoacuity data 1 to 8 years after surgery. RESULTS: A total of 5 children with acquired esotropia and 2 with infantile esotropia were included. A high dose of the toxin per injection might increase the risk of consecutive esotropia. Preoperative mean exotropic deviation was 15.42 prism diopters (PD) (range, 10-25 PD), and stereoacuity was not measurable before surgery. Postoperative mean deviation was 6 PD (range, 4-8 PD), and mean stereoacuity was 447.14 arc seconds. In 2 patients, suppression of the nondominant eye was detected. Three children had poor stereoacuity. CONCLUSION: Surgery for exotropia following botulinum toxin injection in children is effective from a motor and sensory point of view.

Impairment of contrast sensitivity in long-term lorazepam users.

RATIONALE: Oculomotor balance and contrast sensitivity are known to be impaired after an intake of a single dose of lorazepam. To the best of our knowledge, these effects have not been explored in long-term users of lorazepam, despite the potential importance of such deficits in everyday life. OBJECTIVE: We tested the ophthalmological effects and contrast sensitivity for static stimuli in long-term lorazepam users. MATERIALS AND METHODS: There were 15 lorazepam users and 15 sex-, age- and education level-matched control subjects tested, using a simple blind procedure. RESULTS: The ophthalmological effects were scarce, with a discrete exophoria. Visual acuity was preserved. Contrast sensitivity, however, was more markedly impaired, consistent with the effects of an acute dose of lorazepam. The effects were not correlated with anxiety or sedation. CONCLUSIONS: The results are discussed in terms of their possible impact on everyday life. As visual acuity does not allow the detection of the impairments that are observed in the present study, it is suggested that a more systematic exploration of contrast sensitivity be carried out in long-term users of benzodiazepines.