Nonsurgical treatment of neurologic diplopia

The Nonsurgical Management of Orbital Dystopia Using Refractive Lenses and Prosthetic Shells

Surgical rehabilitation of orbital dystopia can be challenging. The authors demonstrate the effective use of spectacle lenses to visually correct misalignments of the globe and the orbit. Presented is a retrospective review of 4 patients undergoing aesthetic rehabilitation through use of spectacle lenses and in a number patients a cosmetic shell.Two patients with neurofibromatosis presented with inferior dystopia of the globe and orbit. A base-down prismatic lens applied to the spectacles in conjunction with a prosthetic shell successfully visually corrected the facial asymmetry and improved patients' aesthetic appearance. One patient with a history of traumatic retinal detachment, who did not want any surgical intervention, a "plus" (hypermetropic) lens was used to magnify the perceived image of an enophthalmic and phthisical globe, to enhance appearance and improve symmetry. In the fourth patient, with Goldenhar syndrome, the appearance of a hypotropia and concurrent esotropia was successfully treated with a Fresnel prism and a prosthetic shell.This case series illustrates the successful role of various refractive lenses often in conjunction with prosthetic shells in patients with reduced vision and orbital dystopia to improve facial symmetry. This conservative treatment is especially useful when surgery is not a desired or not considered a suitable option for the patient.

Binocular diplopia in a tertiary hospital: Aetiology, diagnosis and treatment

OBJECTIVE

To study the causes, diagnosis and treatment in a case series of binocular diplopia.

MATERIAL AND METHOD

A retrospective chart review was performed on patients seen in the Diplopia Unit of a tertiary centre during a one-year period. Diplopia was classified as: acute≤1 month since onset; subacute (1-6 months); and chronic (>6 months). Resolution of diplopia was classified as: spontaneous if it disappeared without treatment, partial if the course was intermittent, and non-spontaneous if treatment was required. It was considered a good outcome when diplopia disappeared completely (with or without treatment), or when diplopia was intermittent without significantly affecting the quality of life.

RESULTS

A total of 60 cases were included. The mean age was 58.65 years (60% female). An acute or subacute presentation was observed in 60% of the patients. The mean onset of diplopia was 82.97 weeks. The most frequent aetiology was ischaemic (45%). The most frequent diagnosis was sixth nerve palsy (38.3%), followed by decompensated strabismus (30%). Neuroimaging showed structural lesions in 17.7% of the patients. There was a spontaneous resolution in 28.3% of the cases, and there was a good outcome with disappearance of the diplopia in 53.3% at the end of the study.

CONCLUSIONS

The most frequent causes of binocular diplopia were cranial nerve palsies, especially the sixth cranial nerve, followed by decompensated strabismus. Structural lesions in imaging tests were more than expected. Only one third of patients had a spontaneous resolution, and half of them did not have a good outcome despite of treatment.

Non-neoplastic lesions found only in the two-year bioassays but not in shorter toxicity studies of rats

International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) has been conducting a prospective evaluation period to validate the criteria for waiving some carcinogenicity studies in rats. Before the waiving strategy is practiced in ICH, it is crucial to elucidate whether non-neoplastic lesions are found only in 2-year rat carcinogenicity studies. To confirm possible importance of 2-year bioassays for evaluating chronic toxicity but not carcinogenicity, we retrospectively surveyed 59 pharmaceuticals approved by the Ministry of Health, Labour and Welfare (MHLW) from 2007 to 2010 in Japan for non-neoplastic lesions observed in carcinogenicity studies. Non-neoplastic histopathological lesions observed only in 2-year carcinogenicity studies but not in 6-month chronic toxicity studies using rats were compared with clinical adverse drug reactions (ADRs). Thirteen non-neoplastic lesions that may correlate with clinical ADRs were classified into three categories: Category 1, lesions not predictable from other nonclinical data except those from 2-year rat carcinogenicity studies; Category 2, lesions predictable mainly from chronic toxicity studies; Category 3, lesions predictable mainly from pharmacological actions. In the present survey, non-neoplastic lesions only found in 2-year rat carcinogenicity studies were neither significant in terms of frequency and severity nor useful for clinical risk management.

Vision concerns after mild traumatic brain injury

OPINION STATEMENT

Mild traumatic brain injury (mTBI) can manifest with visual dysfunction including deficits in accommodation, vergence movements, versions, and field of vision as well increased photosensitivity and a decline in ocular and overall health. Patients with incomitant strabismus should be referred to an ophthalmologist for intervention. Patients with mTBI who experience photosensitivity, or deficits in accommodation, versions, vergences, or field of vision may benefit from vision rehabilitation. These therapies may include spectacles with tinting and a variety of prism combinations. Patients with chronic visual dysfunction following mTBI may benefit from occupational, vestibular, cognitive, and other forms of physical therapy.