Vertical and cyclotorsional deviations following peribulbar anesthesia

[Differential diagnosis of vertical strabismus in the elderly]

Due to the demographic changes, the number of older patients in ophthalmological practices and clinics, including those with diplopia, is increasing. Some of the patients report not only horizontally shifted double images but also or only vertically shifted double images. Vertical double vision often causes significant diagnostic problems for ophthalmologists. The underlying condition could urgently require further neurological, neuroradiological and/or internal medical diagnostics (e.g., skew deviation, 4th nerve palsy, myasthenia, Graves' orbitopathy, orbital floor fracture, orbital mass, 3rd nerve palsy) but the cause of diplopia could also be a condition in which overdiagnosis should be avoided (e.g., sagging eye syndrome, the prevalence of which significantly increases with increasing age; decompensated strabismus due to inferior oblique muscle overaction, myopia-associated vertical tropia). For some diseases early diagnosis is important for a better prognosis, e.g., tumor diagnosis, Graves' disease and stroke. This article presents an overview of the most common and most important differential diagnoses of vertical tropia in patients over 50 years of age.

Strabismus patterns after cataract surgery in adults

New-onset binocular diplopia after cataract surgery in adults is a rare but significant complication. The aim of this study was to analyze causes, risk factors, and treatment outcomes. Forty consecutive patients with new-onset binocular diplopia after uncomplicated cataract surgery were enrolled in this retrospective study at a tertiary medical center. We evaluated risk factors including type of anesthesia, preoperative presence of strabismus, and others regarding their effect on the development of diplopia after cataract surgery. We further analyzed ocular alignment and motility at presentation and during the clinical course. The majority of the patients with new-onset diplopia presented after cataract surgery on the left eye (28 of 40). Vertical strabismus occurred in 37 of 40 patients, and regional (peri- or retrobulbar) anesthesia was the main risk factor for postoperative diplopia (present in 37 of 40). There were four distinct ocular dysmotility patterns in patients with vertical strabismus: deficient elevation with (type 1a) or without over-depression (type 1b), deficient depression (type 2), or normal motility (type 3). After surgery of the right eye, most patients (6 of 9) showed type 2. After cataract surgery on the left eye, type 1a was most common (20 of 24). Three patients had horizontal strabismus due to a decompensated heterophoria or convergence insufficiency. In total, 17 patients required strabismus surgery (mean 1.3 operations, range 1-3). Regional anesthesia was the main risk factor for new-onset diplopia after cataract surgery in adults. Distinct strabismus patterns were observed for left and right eyes.d.

Torsional Diplopia

BACKGROUND AND PURPOSE

Torsional diplopia can result in failure of fusion in an individual without a measureable strabismus. When presented with a patient with complaints of binocular diplopia, physicians and orthoptists should consider cyclovertical muscle dysfunction when the source of the complaint is not readily apparent.

METHODS

A thorough review of the literature combined with the author's own personal experience in treating adult patients with strabismus was used to evaluate the different potential causes of torsional diplopia. Predisposing factors, diagnostic techniques, and strabismus diagnoses are considered.

RESULTS

The most common cause of torsional diplopia is a superior oblique palsy. Other more common causes include thyroid-related orbitopathy and skew deviations.

CONCLUSIONS

Torsional diplopia is a common cause of undiagnosed strabismus in the adult patient population. Proper consideration of the most common causes should be made.

Diplopia following sub-Tenon's infiltration of local anesthesia

A series of 3 patients with persistent diplopia following sub-Tenon's local anesthesia is presented. All 3 patients showed a pattern of vertical diplopia consistent with restriction of the inferior rectus muscle. The pathogenesis and significance of this complication are discussed.