Management of traumatic lens subluxation and dislocation
A Peyman MD Gholam, A Meffert MD Stephen, D Conway MD FACS Mandi, Chiasson Trisha in Vitreoretinal Surgical Techniques, 2019
The symptoms of a patient with a displaced lens depend on the position of the lens. The patient may complain of decreased vision caused either by acquired astigmatism and refractive shift or by acquired aphakia in cases of dislocation. Other symptoms are glare and monocular diplopia from the lens edge. A cataract will result in decreased visual acuity and contrast sensitivity (Fig. 48.1). Inflammation, glaucoma, and corneal edema can result in pain and photo-phobia. In cases of blunt injury, one must maintain a high degree of suspicion for an occult rupture. Special attention is paid to visual acuity, corneal status, degree of intraocular inflammation, and IOP. Lens subluxation is occasionally subtle. Zonular dehiscence is marked by the presence of iridodonesis and phacodonesis. The anterior chamber should be examined carefully for the presence of vitreous. The lens itself should be examined for breaks in the anterior and posterior capsule, along with the presence of cataract. One should also carefully evaluate the vitreous and retina for vitreous hemorrhage, retinal tears and detachments, and the presence of cystoid macular edema. Ultrasonography can be very helpful in evaluating the status of the retina and vitreous in eyes with opaque media, and a dislocated lens is easily diagnosed (Fig. 48.2). Computed tomography (CT) may also be helpful in evaluating the possibility of a dislocated lens.19
Eye
A. Sahib El-Radhi in Paediatric Symptom and Sign Sorter, 2019
Diplopia – simultaneous perception of two images of a single object – is less common in children than in adults because of the lower incidence of strokes and other intracranial lesions. The most common cause of diplopia in children is misalignment of the visual axes, occurring particularly in disorders affecting the cranial nerves (third, fourth and sixth) innervating the six ocular muscles. Other causes involve mechanical interference with ocular motion or disorder of neuromuscular transmission. Diplopia is either binocular (true diplopia) or monocular. The latter is caused by abnormality in the cornea (e.g. severe astigmatism, irregular curvature), in the lens (e.g. cataract, dislocated lens) or in the vitreous humour (e.g. vitreous cysts). Diplopia is often the first manifestation of many systemic muscular or neurologic disorders, some of a serious nature, so prompt evaluation is usually required. A detailed history and examination will make it possible to determine which muscles and ocular nerves are affected and what is the likely cause. Although diplopia does occur in infants, they do not usually present with diplopia and therefore the causes in infants are not included in this section.
The diagnostic evaluation and management of hyperthyroidism due to Graves’ disease, toxic nodules, and toxic multinodular goiter
David S. Cooper, Jennifer A. Sipos in Medical Management of Thyroid Disease, 2018
Although almost all patients with Graves’ disease have radiologic evidence of eye muscle involvement, only approximately 30 percent of patients have obvious clinical disease (162). Several different methods for assessing disease severity have been described, but none of the classifications are perfect. The “NOSPECS” classification is still in wide use today (Table 2.4a), as is the Clinical Activity Score, which is more quantitative (Table 2.4b) (163). In general, the most common symptoms are related to soft tissue swelling due to orbital congestion, with irritation, tearing, burning, and a gritty sensation in the eyes. Diplopia is a more unusual and debilitating problem, and only rarely is vision threatened because of corneal exposure or optic nerve involvement. Symptoms and cosmetic concerns also significantly impact negatively on the quality of life of affected patients (164).
Management of diplopia due to chemotherapy toxicity in a patient with endometrial cancer
Published in Clinical and Experimental Optometry, 2023
Katarzyna Dubas, Hanna Buczkowska, Andrzej Michalski, Marcin Mardas
Surgery with a total hysterectomy and salpingo-oophorectomy is the gold standard treatment for endometrial cancer. For women who develop metastatic endometrial cancer after surgical cytoreduction, postoperative adjuvant chemotherapy is often recommended. The most commonly used regimens are carboplatin plus paclitaxel or a combination of cisplatin, doxorubicin, and paclitaxel. All of these drugs can be toxic, causing many side effects, including those related to the visual system: ischaemic retinopathy, optic disc papilloedema, and peripheral neuropathy, including ocular motor and cranial neuropathies.3,4 The latter may lead to dysfunction of eye movement and alignment that will induce diplopia. This condition can significantly reduce a patient’s quality of life and negatively influence activities in everyday life.5
Clinical Characteristics of Acquired Diplopia in Adults
Published in Journal of Binocular Vision and Ocular Motility, 2022
The certified orthoptist plays an important role in the nonsurgical treatment of acquired diplopia due to strabismus. Orthoptists are routinely required, as a standard component of daily outpatient care, to provide non-surgical treatment options for patients with symptomatic strabismus. Binocular diplopia (double vision) is a common symptom identified in older ophthalmological and neurological patients, frequently occurring in individuals with no prior history of strabismus who then develop an ocular misalignment after visual maturity.1 But the typical patient can also be an adult or young adult with symptomatic strabismus. Etiologies are varied, and can include mechanical strabismus from prior scleral buckling, glaucoma filtration surgery or complex eye muscle procedures,1,2 restrictive strabismus from orbital diseases such as Grave’s orbitopathy,3 orbital fracture with extra-ocular muscle entrapment,4 cranial nerve paresis from intracranial ischemic, inflammatory or neoplastic processes,5 local anesthetic injury or toxicity after ocular surgery,6,7 or strabismus following endoscopic sinus surgery.8 Adults may also present with long-standing, but decompensating, symptomatic heterophoria, or a recurrent deviation following eye muscle surgery earlier in life.9
Ocular myasthenia gravis: a review and practical guide for clinicians
Published in Clinical and Experimental Optometry, 2022
OMG may present to ophthalmic clinicians with diplopia and/or ptosis, often with diurnal variability and prominent fatigability. Clinical clues to the diagnosis should be sought, including looking for patterns of weakness and fluctuations not associated with other differential diagnoses. Simple office-based testing including looking for fatigable ptosis, lid twitch, ‘peek’ sign, and the ice test can help confirm the clinical diagnosis. Investigations should include serum autoantibodies, a search for associated autoimmune disease such as thyroiditis, and a CT chest to exclude thymoma, and when necessary electrophysiological testing such as SFEMG. Management of OMG should include an initial trial of pyridostigmine, as although this can prove insufficient in some patients (especially for diplopia), this medication has considerably lesser safety concerns compared to immunosuppression. However, early treatment with corticosteroids is often necessary, and starting at low doses with slow titration upwards prior to reduction to the minimally effective dose can prove both effective and safe. In order to minimise the risks from long-term high-dose corticosteroids, use of steroid-sparing agents such as azathioprine can be considered, as can thymectomy in selected cases. Non-pharmacological options such as occlusion/patching are often used acutely to relieve diplopia. Surgical correction of stable ptosis or strabismus can also be considered in appropriate circumstances. Ophthalmic clinicians have a critical role in the recognition, diagnosis, monitoring, and symptomatic management of patients with OMG.
Related Knowledge Centers
- Abducens Nerve
- Neuromuscular Junction
- Oculomotor Nerve
- Toxin
- Trochlear Nerve
- Visual Perception
- Systemic Disease
- Extraocular Muscles
- Cranial Nerves
- Nerve