Post on 07-May-2015
Diplopia and Visual Field Diplopia and Visual Field DefectsDefects
Fanny FreemanFanny FreemanSenior OrthoptistSenior Orthoptist
Clinical Lead for Stroke (Visual Defects)Clinical Lead for Stroke (Visual Defects)Worcestershire Royal HospitalWorcestershire Royal Hospital
Binocular Single VisionBinocular Single Vision
• Orthoptists specialize in defects of binocular vision and ocular motility defects
• Aim to get binocular single vision in all directions of gaze
• Normal view
DiplopiaDiplopia
• Double Vision• Monocular or
Binocular• Direction• Position of Gaze• Duration• Time of Day• Method used to
prevent diplopia
Third Cranial Nerve PalsyThird Cranial Nerve Palsy
• Medial rectus • Superior rectus• Inferior rectus• Inferior oblique • Levator = ptosis• Sphinter pupillae NB
painful III with dilated pupil
Fourth Cranial Nerve PalsyFourth Cranial Nerve Palsy
• Superior Oblique• Vertical and torsional
diplopia especially on down gaze
• Problems with stairs and reading
• Often difficult to see on OM testing
Sixth Cranial Nerve PalsySixth Cranial Nerve Palsy
• Lateral Rectus• In severe cases relatives
aware of squint• However in slight cases
may only get diplopia at distance so testing for near no defect found
• Listen to patient c/o problems with TV and driving
• Some patients get divergence weakness so diplopia for distance but no obvious LR palsy
Cranial nerve pathwaysCranial nerve pathways
• All go through cavernous sinus
• Lateral rectus palsy can be a sign of raised intracranial pressure Non localising
Causes of diplopiaCauses of diplopia
• Vascular/diabetic• Neoplasic• Thyroid dysfunction • Myasthenia Gravis• Multiple Sclerosis• Parkinson• Longstanding
Internuclear OphthalmoplegiaInternuclear Ophthalmoplegia
• Defect between horizontal gaze centre and III nerve nucleus
• Can be bilateral• May only be present
on Saccadic testing• Reading when using
saccadic movements can be difficult
Midbrain Control of Eye Midbrain Control of Eye MovementsMovements
• Horizontal Gaze Centre Right and Left
• Vertical Gaze Centre Up and Down
• Convergence centre
• Motor nerve nuclei III, IV and VI
Input to ocular motor centresInput to ocular motor centres
Cortex
IIIIVVI
Brain Stem
Visual input via visual pathwayHead
movementviaVestibular organ
Innervation ofEOM
‘effort of will’Initiated in frontal cortex
Vascular SystemVascular System
• Anterior Circulation less likely to get diplopia
• Posterior circulation mid brain, cerebellum and blood supply to cranial nerves more likely to get diplopia and OM defects
Brain stem strokeBrain stem stroke
• Facial Palsy• Gaze Palsy• Skew deviation• Diplopia• Glad to be alive
Ocular Motility TestingOcular Motility Testing
• Use Torch
• If patient gets diplopia which goes when either eye is covered then must have a manifest squint
• Follow
• Saccades
• Dolls Head
• Convergence
Treatment of DiplopiaTreatment of Diplopia
• Treatment
• Improves walking
• Can restore 3D vision for pouring drinks
• Reading
• May be able to drive again
• Less nausea
Fresnel PrismsFresnel Prisms
• Restores binocular single vision
• Useful if deviation does not vary much
• Any strength from 1^ to 40^
• Can be cut for top or bottom segment
• Patient leaves clinic very happy
BlendermBlenderm
• Best to put blenderm on lens
• Use of total eye patch reduces peripheral vision
• May have problems closing/opening eye with sticky patch
• Occlude eye with muscle palsy
Abnormal Head PostureAbnormal Head Posture
• Often seen in vertical deviations
• Tilt to lower eye restores binocular single vision
• Some patients not aware they are tilting their heads
Orthoptic TreatmentOrthoptic Treatment
• Can improve convergence with orthoptic treatment
• If fails use base in prisms in reading glasses
BOTOXBOTOX
• To Extraocular muscles
• Useful if surgery not an option
• Can help recovery• Patients ask for the
full works!
Squint SurgerySquint Surgery
• Useful in large angles• Could be done same
time as cataract surgery
• Nearly always requires a GA
• I have had patients in 80’s having squint surgery
VisionVision
• Important that correct glasses are worn
• Glasses often lost in hospital
• Label near and distance glasses
• Check have regular eye tests
• Optometrists will do home visits
Is poor vision due to cataractIs poor vision due to cataract
• Cataracts can be removed and replaced with clear focussing lens so distance glasses no longer required
• Patients say it is ‘like a miracle’
Visual Field DefectsVisual Field Defects
• Commonly found with strokes
• Glaucoma • Diabetic Retinopathy
Visual Field TestingVisual Field Testing
• Confrontation
• Formal testing in Eye Department
• Driving Visual Field 120 degrees wide and 20 degrees up and down
Homonymous HemianopiaHomonymous Hemianopia
Visual InattentionVisual Inattention
• Reading
• Vision
• 2 pen Test
• Albert’s Test
• Balloon Test
Balloons TestBalloons Test
Eye MovementsEye Movements
HemianopiaHemianopia
• Explain defect• Help with reading • Use of eye movements• Prisms• Visual Training• Advise re driving requirements• Registration as Sight Impaired• Visual Inattention harder to overcome
4% of strokes left with visual inattention
Disconnection syndromeDisconnection syndrome
• Left occipital lobe defect (RHH)
• Can write• Unable to read • Seeing part of
working right brain does not connect to language centre in left hemisphere
Patient satisfactionPatient satisfaction
• Explanation of eye symptoms
• Advice on coping strategies
• Management of defects• Follow up• Need to know in case of
stroke, that cannot overuse eyes and condition will not get worse
What to do if visual defect What to do if visual defect suspectedsuspected
• Listen to the person’s symptoms
• Observation may give an indication
• Check had recent eye test with Optician
• Refer to Eye Dept
• AT WRH in-patient refer to Orthoptist can help triage patient to decide if referral to Eye Dept is required. All stroke wards should have access to Orthoptist
Thank you for listeningThank you for listening
• My Father• born 09.09.1919• Still driving• On no medication• No eye defects• Does The Times
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