Nonsurgical management of diplopia

Occupational therapists' perspectives on binocular diplopia in neurorehabilitation: A national survey

BACKGROUND

Oculomotor dysfunction affects a significant number of adults with neurological conditions and binocular diplopia is a common symptom which impacts an individual's ability to participate in meaningful daily activities. Occupational therapists use partial and complete occlusion to minimize binocular diplopia, however a review of the literature reflected a lack of standardized protocol for each intervention technique. The purpose of this study was to examine occupational therapists' perspectives on the use of partial and complete occlusion and the clinical reasoning process used.

METHODS

An electronic survey was distributed to occupational therapists working in a variety of practice settings. The survey contained questions relating to demographics, the selected occlusion technique, and clinical reasoning for that selection.

RESULTS

More than half of the 106 respondents used partial occlusion more frequently than complete occlusion. There was no correlation between respondent experience and self-report of competence in managing binocular diplopia. Respondents based their clinical reasoning on available evidence, client factors, and clinical expertise.

CONCLUSION

Respondents offered conflicting perspectives on each occlusion technique. Future studies are required to examine which occlusion technique benefits clients.

Vorapaxar and diplopia: Possible off-target PAR-receptor mismodulation

Vorapaxar, a novel antiplatelet thrombin PAR-1 inhibitor, has been evaluated in the successful TRA2P trial and the failed TRACER trial. The drug is currently approved for post myocardial infarction and peripheral artery disease indications with concomitant use of clopidogrel and/or aspirin. The FDA ruled that the vorapaxar safety profile is acceptable. However, both trials revealed excess diplopia (double vision) usually reversible after vorapaxar. The diplopia risk appears to be small (about 1 extra case per 1,000 treated subjects), but real. Overall, there were 10 placebo and 34 vorapaxar diplopia cases (p=0.018) consistent for TRACER (2 vs 13 cases; p=0.010) and for TRA2P (8 vs 21 cases; p=0.018). Hence, we review the FDA-confirmed evidence and discuss potential causes and implications of such a surprising adverse association, which may be related to off-target PAR receptor mismodulation in the eye.

[Orbital decompression : Indications, technique, results]

Orbital decompression is an effective surgical procedure to reduce intraorbital pressure. Causes may diseases leading to rapid pressure increases, e. g., bleedings, and those causing slower, progressive pressure increases, e. g., tumors or Graves' orbitopathy. During fat tissue decompression, peri- and retrobulbar adipose tissue is removed; in bony decompression, one or more bony orbital walls are removed (one-, two-, or three-wall decompression). In many cases the procedures are combined. Recent developments are the transconjunctival approaches for removing parts of bony orbital walls. Complications include double vision, which occurs in up to 30% of cases depending on the approach, hemorrhage, infections, development of chronic sinusitis, and iatrogenic skull base lesions with consecutive meningitis. In the hands of an experienced rhino- and head and neck surgeon, the intervention has low complication rates.