Exploring common clinical problems
Diplopia Lasting More Than 8 Months
A 56-year-old insulin-dependent, hypertensive, and moderately overweight woman is referred to you for consultation and management of her diplopia of more than 8 months* duration. She reports "laser treatment for diabetes by a retinal specialist about 7 years ago."
Examination shows best-corrected visual acuity of 20/30 in the right eye and 20/40 in the left eye. She demonstrates underaction of the left medial rectus, left inferior rectus, and left inferior oblique muscles. In the primary position at distance, she has left exotropia of 25 to 30 and left hypotropia of 6 to 8 PD. On right gaze, the left exotropia and the left hypotropia deviations increase. On left gaze, the left exotropia and left hypotropia measurements diminish slightly. Her exotropia deviation increases on near gaze. Throughout the examination, she complains of a "twisted" image out of her left eye. Double Maddox rod testing shows a left incyclotorsion of 5°.
What is your treatment plan for this patient?
Responses to Last Issue s Case
We asked our readers for comments regarding a 4-yearold girl with 3 mm of left ptosis, slight astigmatism of the left eye, and the inability to elevate the left eye above the midline. She was noted to have a 10° chin up head posture.
All respondents agreed that some form of surgical intervention was ultimately necessary. The vertical gaze limitation of the involved eye brought forth a diversity of treatment suggestions.
A slight majority of respondents felt that their primary procedure would be an anterior levator resection. A vertical strabismus correction would be considered only if there was a persistent and significant head posture following the ptosis repair. Interestingly, of those suggesting lid surgery, some felt it was necessary to prevent amblyopia and some felt it was necessary because of the cosmetics and head posturing. Only one respondent emphasized the importance of frequent cycloplegic refractions to observe and possibly treat a possible secondary anisometropia.
Slightly less than half of the comments suggested dealing with the vertical motility problem prior to performing any lid procedure. Most suggested a vertical transposition procedure with or without a contralateral inferior rectus resection. If a significant ptosis persisted following correction of the upgaze problem, surgical repair would be recommended at that time. One respondent suggested a suspension procedure if there was no Bell's phenomenon and an anterior levator resection if a Bell's phenomenon was present following the vertical repair.
One very wise respondent noted the importance of informing the parents that even after the surgery, the operated on eye will never be the same as the normal eye.
We had responses from Australia, Saudi Arabia, Turkey, and the United States. Thank you all.
Please help us to spread the knowledge by e-mailing your response to JPOS@slackinc.com, Answers will be presented in the next issue. No names will be used without prior consent. The deadline for your response is June 15, 2007, You may also submit your own cases for publication via this e-mail address. We look forward to hearing from you!