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Suggest Treatment For Downward Diplopia

Posted on Wed, 25 May 2016

Question: HI
SPOKE TO YOU RECENTLY
HAD HESSES TEST DONE
CONFIRMED SUPERIOR OBLIQUE ON RIGHT SIDE IE OPPOSITE SIDE OF OLD TRAUMA FRACTURES.
LAST YEAR AUG 31 HAD VERY MINOR MVA HIT UP THE REAR WHILE I WAS PARKED,BUT CAUSED BAD HEADACHES,SOME MINOR CONCUSSION? AND WHEN DOWNWARD GAZING IE USING THE PHOTOCOPIER HAD DIFFICULTY FOCUSING OR USING THE MACHINE
AMONTH LATER I HAD A FALL DOWN SOME STEPS AGAIN ON DOWNWARD GAZING I SAW TWO STEPS SLIGHTLY CRISS CROSSED ,TOOK THE WRONG STEP.
AT THAT TIME I DID NOT RECOGNIZE MID LOWER CENTRAL DIPLOPIA

Answered by Dr. N K Mishra (3 hours later)

Brief Answer:
Possibility of surgery

Detailed Answer:
My dear,
Thanks for sending your query to us.
This downward diplopia can be very disturbing. Since it has been 7 months chances of of recovery on its own are minimal. MRI will show if there is tucking of the muscle, which probably is easier to manage ,but it needs intervention.
surgical management is needed, and you have to have a very specialized center for this type of manipulation.
My further query in this regard please do get back to me.

Above answer was peer-reviewed by : Dr. Raju A.T

Follow up: Dr. N K Mishra (5 hours later)

what do you think the cause may be?

Answered by Dr. N K Mishra (7 hours later)

Brief Answer:
Superior oblique injury

Detailed Answer:
My dear,
Thanks for getting back to me.
Either there is a muscle injury, which as time passes may improve, or there may be a small entrapment of muscle in a fracture.
The superior oblique is a unique muscle. It goes from back of eye to upper part of nose ,through a pully goes back to the eye ball .That pully may be damaged.
The management of the problem is dependent on the cause.
Next step is imaging of the region and then management.

Above answer was peer-reviewed by : Dr. Yogesh D

Follow up: Dr. N K Mishra (9 hours later)

It is confusing trying to work out what side is the problem
History of fractures 2006 la fortte2 left side of face
Hit in face further fracture septum etc 2012
MVA x3 2008
MVA 2013
Very small whiplash 2015 when shortly there after noticed vision upset had a fall down some steps
Blood sugar probably higher then should. Be avg about 10 also
When tilt head to right image splits
Turning head extending head also
Different people say one side others say the opposite??

Answered by Dr. N K Mishra (2 hours later)

Brief Answer:
Outer image on paralysed side.

Detailed Answer:
My dear,
Thanks for getting back to us.

For the doctor it is easy to pin point the side of lesion You can also do it.When you see an object there are two images,one inner and one outer.Now close one eye at a time,one image will disappear. The outer image belongs to the paralyzed side.

Control of sugar levels is always helpful. The condition known as diabetic ophthalmoplegia improves after control of sugar levels.

Any further questions in this regard please do get back to me.

Above answer was peer-reviewed by : Dr. Arnab Banerjee

Follow up: Dr. N K Mishra (34 minutes later)

Remember I vertical diplopia
superior oblique
when I close eye eye vision goes back to normal on both sides

some say if laterally flex the head to either side
the side in which the image splits is the side of the muscle problem??
As i gaze down with my finger the top image is the false one
As i go down steps the images are vertical and twisted about 40 degrees displaced .

As to prior if wear a patch all ok except visual field is reduced substantly

Answered by Dr. N K Mishra (1 hour later)

Brief Answer:
Superior oblique paralysis

Detailed Answer:
My dear,
Good of you to get back to me.

Your observations are absolutely correct. As a rule head tilt is towards the side of muscle paralysis. That head tilt is pointer to the side of muscle paralyzed.

Other than head tilt as I said earlier, the outer image belongs to the paralyzed side. Of these two images, by closing the eyes alternately , the eye which gives you the outer image is the paralyzed side.

Regards

Above answer was peer-reviewed by : Dr. Arnab Banerjee

Follow up: Dr. N K Mishra (1 hour later)

Some more confusion..
Head tilt Vs lateral flex ion of head
Normally at present head is laterally flex to the left as to compensate for muscle damage
Head lateral flex towards left shoulder brings images togeather near normal
Lateral flex head to right shoulder separates images vertically and twisted and to right so slightly
So which do u think?
Regards

Answered by Dr. N K Mishra (1 hour later)

Brief Answer:
Superior oblique paralysis

Detailed Answer:
my dear,
Head tilts are crude indicators. It is the eye movement which is supposed to diagnose the exact muscle involvement. As a rule the head is turned towards the paralysed side to compensate for loss of movement. By tilting the head body automatically compensates for the loss of movement on the affected side.

Above answer was peer-reviewed by : Dr. Sonia Raina

Follow up: Dr. N K Mishra (1 hour later)

Sorry still confused
So with what I have told you
Which do you think

Answered by Dr. N K Mishra (1 hour later)

Brief Answer:
Superior oblique paralysis

Detailed Answer:
My dear,
I will get you two facts straight. Probably it will make things less confusing. Of the two images which you see the outer is from affected eye.
Head tilt is to compensate the paralysed muscle. Outer image points to the effected eye.
This is in nutshell crux of the matter. These details are shown on the Hess's chart.

Above answer was peer-reviewed by : Dr. Sonia Raina

Follow up: Dr. N K Mishra (32 minutes later)

How can u have a outer image if have one image above the other

Answered by Dr. N K Mishra (52 minutes later)

Brief Answer:
Superior oblique paralysis

Detailed Answer:
my dear,
Here the outer image is the lower image, lower being outer,peripheral image for us.

Above answer was peer-reviewed by : Dr. Deepak