Double TroubleDouble Trouble

Case 1Case 1

55 year old with 3 day history of 55 year old with 3 day history of double vision.double vision.

Similar episode of diplopia about 10 Similar episode of diplopia about 10 years ago.years ago.

Diabetes for 15 years.Diabetes for 15 years. No meds or allergiesNo meds or allergies

Case 1Case 1

Case 1Case 1

Diagnosis ?Diagnosis ? Investigations?Investigations?

75 YR Man WITH DIPLOPIA75 YR Man WITH DIPLOPIA

Sudden onset 4/8/03Sudden onset 4/8/03 Optometrist found nothingOptometrist found nothing Same day headache, nausea, Same day headache, nausea,

vomitingvomiting In ER lid began to droopIn ER lid began to droop

Hospital CourseHospital Course

MRI, MRA negativeMRI, MRA negative CT, CTA negativeCT, CTA negative Discharged after 8 daysDischarged after 8 days Headache persistedHeadache persisted Referred to WEHReferred to WEH

PMHPMH

DiabeticDiabetic Atrial tachycardiaAtrial tachycardia HypercholesterolemiaHypercholesterolemia Acephalgic migrainesAcephalgic migraines Glaucoma suspectGlaucoma suspect

PAST OCULAR HISTORYPAST OCULAR HISTORY

1992-episode of “tight” feeling 1992-episode of “tight” feeling around both eyes followed by 20 around both eyes followed by 20 second episode of vertical diplopiasecond episode of vertical diplopia

Similar episode 1 month before Similar episode 1 month before where he felt like eyes were where he felt like eyes were “crossing”“crossing”

MRI normalMRI normal

MedicationsMedications

LipitorLipitor PrevacidPrevacid ClarinexClarinex

ExaminationExamination

ODOD OSOS

VAVA 20/2520/25 20/3020/30

ColorColor 8/88/8 8/88/8

VFVF FTFCFTFC FTFCFTFC

MotilityMotility

PupilsPupils

FundusFundus WNLWNL WNLWNL

NEXT STEP(S)?NEXT STEP(S)?

78 YEAR OLD WOMAN78 YEAR OLD WOMAN

PROGRESSIVELY DROOPING RUL, PROGRESSIVELY DROOPING RUL, BINOCULAR DIPLOPIA, AND BINOCULAR DIPLOPIA, AND BLURRY VISION OD FOR 2-3 BLURRY VISION OD FOR 2-3 WEEKS.WEEKS.

SYMPTOMS DO NOT VARY SYMPTOMS DO NOT VARY DURING DAY.DURING DAY.

NO EYE PAIN, HEADACHE, OR NO EYE PAIN, HEADACHE, OR TRAUMA.TRAUMA.

MEDICAL HISTORYMEDICAL HISTORY

BREAST CANCER S/P BREAST CANCER S/P LUMPECTOMY, CHEMO AND XRT LUMPECTOMY, CHEMO AND XRT 10 YEARS AGO.10 YEARS AGO.

HYPERTENSION.HYPERTENSION. DEPRESSION.DEPRESSION.

EXAMINATIONEXAMINATION

OD OS

VISION 20/60 20/40

PUPILS 7 → 6 5 → 3

COLOR 15/15 15/15

MOTILITY AS SHOWN

CVF FULL FULL

FUNDUS WNL WNL

MRI: T2-WEIGHTEDMRI: T2-WEIGHTED

MRI: T1-WEIGHTED WITH MRI: T1-WEIGHTED WITH GADOLINIUMGADOLINIUM

HOSPITAL COURSEHOSPITAL COURSE

NEUROSURGICAL CONSULTATION NEUROSURGICAL CONSULTATION → STEREOTACTIC BIOPSY.→ STEREOTACTIC BIOPSY.

FROZEN SECTION: FROZEN SECTION: GLIOBLASTOMA MULTIFORME, GLIOBLASTOMA MULTIFORME, GRADE IV.GRADE IV.

RIGHT ANTERIOR TEMPORAL RIGHT ANTERIOR TEMPORAL LOBE RESECTED.LOBE RESECTED.

RL

Aberrant Regeneration of the Aberrant Regeneration of the Third NerveThird Nerve

Congenital, trauma, tumors, aneurysm, Congenital, trauma, tumors, aneurysm, migraine.migraine.

Ischemia is exceptionally rare cause.Ischemia is exceptionally rare cause. Globe retraction in upgaze , miosis on Globe retraction in upgaze , miosis on

adduction (pseudo light-near adduction (pseudo light-near dissociation).dissociation).

MRI/MRA in all patients with non-MRI/MRA in all patients with non-traumatic cases of third nerve palsy or traumatic cases of third nerve palsy or presumed “ischemic” third nerve palsy.presumed “ischemic” third nerve palsy.

Evaluation of Isolated TNPEvaluation of Isolated TNP

Complete Partial

Pupil involved ?

No

Ischemic risk factors ?

Yes

Observe

MRI/MRA(or CTA)

Yes

Pupil involved ?

Yes No

Re-evaluate after 1 week

involvedspared

Observe if ischemic risk factors, otherwise considerImaging, LP

Modified from clinical pathways in neuro-ophthalmology , AG Lee

10 YEARS OLD MRI / MRA

20 YEARS OLD MRI / MRA, ? A-GRAM

40 YEARS OLD MRI / MRA, ? A-GRAM

60 YEARS OLD B/P, FBS, ?ESR, FOLLOW DAILY

PUPIL SPARING REPORTED IN 8-15% OF III-PALSY DUE TO ANEURYSMS

PUPIL SPARING CN III PUPIL SPARING CN III PALSYPALSY

Different scenario Different scenario

50 year old with history of 50 year old with history of intermittent “double vision” for 8 intermittent “double vision” for 8 months.months.

No headache, no vision loss.No headache, no vision loss.

Different scenario Different scenario

VA 20/20 OU.VA 20/20 OU. IOP 13mm/Hg OU.IOP 13mm/Hg OU. Normal color plates.Normal color plates. Hertel Exo OD 17 OS 18 Base Hertel Exo OD 17 OS 18 Base

100.100.

Different scenarioDifferent scenario

Pseudo Von-Graffe’s sign

Lid retraction in adduction

MRA CONVENTIONAL A-GRAM

MRA WILL PICK UP 95% OF ANEURYSMS > 3mm

MRAMRA

CTA or MRA ?CTA or MRA ?CTA MRA

Scanning time Short Longer

Patients with implanted metal

Can be used Contraindicated

Contrast Iodinated contrast Not necessary in 3D TOF and 2D TOF

Flexibility of display Superior

Evaluation of Neck vessels

Problematic Superior

Aneurysm detection 5-6 mm aneurysms can be missed

CaseCase

A 73 year old lady referred by a A 73 year old lady referred by a neurosurgeon.neurosurgeon.

History of “double vision” for 3 History of “double vision” for 3 months (horizontal and binocular) , months (horizontal and binocular) , worse when she looks to the left.worse when she looks to the left.

Has seen a neurologist , who ordered Has seen a neurologist , who ordered an MRI an MRI showed “intracranial showed “intracranial meningiomas” of the falx, and left meningiomas” of the falx, and left hemisphere.hemisphere.

MotilityMotility

CaseCase

Does not see double when she wakes Does not see double when she wakes up AM for an hour.up AM for an hour.

Patient reported that she is getting Patient reported that she is getting “tired” real quickly and unable to do “tired” real quickly and unable to do “any work in the house”. Feels her “any work in the house”. Feels her legs and arms are “heavy”.legs and arms are “heavy”.

VideoVideo

Fatigability

Case 23Case 23

Orbicularis weakness OD >OS

Always remember !Always remember !

Ocular myasthyenia gravis.Ocular myasthyenia gravis.

Imaging for isolated Non-Imaging for isolated Non-traumatic TNPtraumatic TNP

Children < 10 years : MRI/MRA Children < 10 years : MRI/MRA regardless of pupil status.regardless of pupil status.

10-50 year old with pupillary sparing 10-50 year old with pupillary sparing and no vascular risk factors: MRI/MRAand no vascular risk factors: MRI/MRA if normalif normal medical evaluation and medical evaluation and observe.observe.

If aberrant regeneration: MRI/MRA with If aberrant regeneration: MRI/MRA with contrast.contrast.

With pupillary involvementWith pupillary involvement if MRI/MRA if MRI/MRA is normal is normal Cerebral angiography. Cerebral angiography.