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Old 10-04-2009, 07:48 AM   #1
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Double vision - Diplopia

Hello,

I'm a 37 yo male and I have horizontal binocular diplopia since about 1 1/2 yrs. My left eye started to go left. I started wearing press-on fresnel prisms. First a 5 diopter, then 7-10-12-15 and now 20 (for near vision). I had a neurological exam and MRI of the head a year ago = normal. Blood test normal also.

What concerns me is that I have never had any kind of important medical issues, head trauma, childhood strabismus and my vision is almost perfect (besides the double vision). In fact, the only reason why i'm wearing glasses is for the press-on prism. I take no medication/drugs.

Eye exercises VS prisms: I have read that the eye becomes dependant of the prisms and eye exercises would be best. I have done exercises (supervised by orthoptist) but doesn't help much. My job as an accountant requires me to work with a computer most of the day so my eyes are burned-out and I would not be able to work right now without the prism.

Eye surgery: my far vision eye deviation is not as important and apparently eye surgery would be too risky at this point. Plus, I don't want my situation to be worse after surgery.

Other symptoms I have on occasion : 1) severe eye pain behind both eyes that will last 5-10 seconds and go away 2) slurring words..very subtle but never done that before.

I was wondering if the are people out there who had a similar situation (Adult acquired strabismus). What was the outcome?

I know I have to let the doctors do there job but my gut feeling is that my diplopia is most-likely a symptom of something else that is undiagnosed for the moment.

Last edited by ddelisle; 10-04-2009 at 09:19 AM.

 
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Old 10-05-2009, 05:35 AM   #2
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Re: Double vision - Diplopia

There's not a lot that we amateurs can add to what you've said yourself. This sort of condition really does need proper diagnosis. It sounds as though you have already eliminated most of the usual strabismus causes. If you have not already seen a neuro-ophthalmologist, that would be a good move as they are trained to determine the relationship between the brain and the eyes.

 
Old 10-05-2009, 12:46 PM   #3
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Re: Double vision - Diplopia

Has sixth cranial nerve palsy been ruled out?

 
Old 10-05-2009, 04:19 PM   #4
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Re: Double vision - Diplopia

There are many different reasons why an adult might develop diplopia. Your statement about occasional slurred words suggests that you should see a neurologist or neuro-ophthalmologist.

 
Old 10-07-2009, 04:22 PM   #5
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Re: Double vision - Diplopia

When this started, I first saw my family doctor who referred me to a neurologist. He did an exam, said I had diplopia and referred me to an ophthalmologist (oh, I had to ask for the MRI). The ophthalmologist sent me to orthoptics. The orthoptist, who has been increasing my prism continuously, said that I probably had a predisposition since birth and was able to manage it until now (maybe but i'm not convinced).

My ophthalmologist happens to be the best for strabismus in my (large) city. Not sure if he is a neuro-ophthalmologist however, I will check that out and also check out sixth cranial nerve palsy. I don't know if its because of the health system here in Canada but some of the medical professionals mentionned above appeared to want to brush me off. For me, the opinion of amateurs who went through the same thing is as important.

Thank you for the responses.

 
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Old 10-08-2009, 06:01 AM   #6
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Re: Double vision - Diplopia

It is not at all uncommon to have a latent tendency to diplopia or strabismus manifest itself later in life. I used to read lots of posts about this when AAPOS (pediatric ophthalmologists) had a forum, so this could very well be the case. Of course, you want to check out all the other possibilities.

 
Old 10-08-2009, 08:10 AM   #7
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Re: Double vision - Diplopia

Hello all,

I am just thinking aloud my thoughts here....
From your medical and eye history, sounds like you are quite healthy and to have this happened out of the blue, it must be disconcerting to say the least. And then having to deal with the professionals who are supposed to have the expertise to fix the problem can also be frustrating especially when you feel like you are being brushed off.

Ok. It is possible that you may have this for a long time but were able to compensate for it until now that you are approaching presbyopia. But I am not so convinced because generally for someone with high amount of exotropia, it is impossible not to have some trace of symptoms in the past years. Also, pseudomyopia may occur as one could use the accommodative ability to compensate to eliminate the deviation/diplopia (except in suppression cases). Whether you were compensating using intra- or extraocularmuscles, I doubt it would go completely unnoticed.

Your left eye is going outward; turning to the left. My question is: Is it just staying out constantly, or you are just having hard time trying to look toward your nose? Assuming it is just out there, it indicates the paralysis of the muscle that pulls the eye inward which is the medial rectus. However, Medial rectus is innervated by the third nerve which also controls the superior rectus, inferior rectus and inferior oblique muscles. Since you are only reporting that your left eye going out and not down or with ptosis, unilateral third nerve palsy is unlikely. So now we have a possible Unilateral Left Medial Rectus Palsy. If this is a medial rectus problem, the differential diagnosis would be midbrain lesion which is extremely extremely rare (you are not reporting other symptoms), Internuclear Ophthalmoplegia (which can be ruled out by checking convergence, abducting nystagmus, and ocular tilt reaction etc). Systemic conditions such as MS or Myasthenia Gravis can also affect MR. The fact that you are not having any systemic complaints or other ocular symptoms, are these likely the "zebras"?!

So what other differential diagnosis are there? Convergence Insufficiency: may or may not be associated with accommodative insufficiency? Convergence Paralysis? When this incident first started, do you remember if you were ill? When was your last complete physical examination? I don't mean to doubt that you are not as healthy as you said, but sometimes patients do say out of purely subjective observation without actual evidence.

I hope you will be able to rule out any serious disorders. The best case scenario is that it's an adult acquired strabismus of unknown etiology. However, it is better be safe than sorry, a diagnosis of exclusion is probably the best way to get to the bottom of this. I hope you have your MRI result soon. I would see a neuro-ophthalmologist as others had suggested.

Cheers!

p/s: sorry for my longwindedness!

Last edited by earthworm88; 10-08-2009 at 09:16 AM.

 
Old 10-15-2009, 03:41 AM   #8
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Re: Double vision - Diplopia

Hi, I am 45years old and last year I had sudden severe vertical Diplopia at distance and near in all directions. I was admitted to hospital with a suspected stroke. I had CT scan in hospital which was normal and all blood tests, etc. were also normal. Was allowed out of hospital and had a stick on prism for a while. The distance vertical dv cleared up quite quickly with just very slight vertical dv now. I was left with diplopia at near. This has been very frustrating as because although I wear glasses for distance my close up eyesight has always been perfect. My optician referred me back to the hospital in March this year and I am still waiting to get to the bottom of the problem.
I had an MRI scan last year, the opthalmologist said it showed restricted blood flow which was the probable cause but the general consultant said that it was completely normal ! confused: I have been left in limbo with no definite cause. I have suffered from, vertigo, nausea, memory and speech problems... I tried to speak to my GP because with the other sypmtoms I was worried that there was some underlying problem but he said that anxiety could just as easily cause these problems. (He too now says the MRI showed nothing and yet last year he said that there were some bright spots in the white matter which indicated restricted blood flow and it could have been a small stroke).... It is probably my own fault that my gp has reacted this way because I presented all my symptoms at once and therefore came across as a hypochondriac.
An othalmologist said that it is probably decompensation of a latent squint (ie something i've always had but now can't control.
I have disputed this because it has only happened since the severe problem last year.
The othoptist says that it is now convergence insufficiency and I am trying some exercises....
It is very difficult to know where to turn next.... I have had blood tests for myasthenia and am awaiting the results but I presume they are normal because I haven't heard otherwise. I have an appointment with the specialist again in 2 weeks.
I know that my posting wont have helped you in any way, I just thought that I would let you know that I understand the frustration of the condition and having no definite diagnosis.

 
Old 10-15-2009, 08:51 AM   #9
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Re: Double vision - Diplopia

SHORTLEGS: There is an paper which is possibly relevant to your condition. Try googling: "Recently Acquired Diplopia in Adults with Long-standing Strabismus" by Burton J. Kushner, M.D. The entire paper is available for free ******** online.

Yes, I know that you had no history of childhood strabismus; neither did I, but I developed double vision (i.e., adult acquired diplopia) secondary to monovision contact lens use. I was told that it is possible to have micro-strabismus as a child, with an alignment deviation so subtle that it can only be detected by testing. (And who bothers testing kids who look normal and have no complaints?) If the onset of your double vision was preceeded by a change in your glasses prescription (possibly a switch to bifocals or progressives), then BINGO! In this case, you could try emailing Dr. Kushner to request a referral to someone competent in your area. (He was extremely helpful to me.) Otherwise, bring a copy of the above article to your first appointment with a strab specialist (seriously).

DDELISLE: If you do have adult acquired strabismus, why are you saying that surgery would be "too risky at this point"? Is that what you were told by an experienced specialist? My strab surgeon told me that there was a 75% chance that surgery would eliminate my double vision, and a 25% chance that I'd be no worse off than before surgery. I was in the lucky 75%, following an outpatient procedure which was totally painless. (A couple of hours after leaving the surgery center, I was shopping at the mall, wearing sunglasses to cover a red eye. I drove myself to the followup appointment with the surgeon the next day.)

 
Old 10-15-2009, 10:36 AM   #10
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Re: Double vision - Diplopia

JodieJ Thanks for your reply. I think I just about googled everything under the sun last year before I even realised that I had been left with the double vision for close work. The diplopia came on quickly and there had been no change in my glasses presciption or anything.
I left hospital last year with a diagnosis (if you can call it that) of opthalmoplegia - cause being investigated. At the time the diplopia was so severe that cars/buses appeared to be flying over each other!! Since then I have seen an opthalmologist 3 times and orthoptist about 4 times with no clear diagnosis. I am seeing the opthalmologist in 2 weeks time. Last time I was told to bring old photos to see if it had perhaps been a longer term condition because I was tilting my head. The opthalmologist I saw was a different one and was not interested. He just dismissed me with a see you in 6 weeks. Hopefully this time it will be the original specialist who asked for the photos and I might get somewhere.
The trouble now is that because I thought that the residual horizontal diplopia that I was left with after the problem last year would clear up I have adapted bad habits to overcome it. ie. blinking a lot or tilting and moving my head. I therefore didn't realise that the problem was as bad as it actually is by proper testing.
Hopefully I will get some sensible response at my next appointment, she specialises in diplopia, strabismus etc. The orthoptists have been very good. They think that the cause is some sort of autoimmune illness, based mainly upon how my health was when it was at its worst and now i am feeling a lot better, my eyes have improved also. Blood tests have not shown up anything though.
I am sorry to waffle on........ you will be beginning to realise that I am quite frustrated with what is happening. I wish that a doctor could give me a straight answer as to the cause and then treat me accordingly. Unless your symptoms fit into the neat little catergories then the doctors are at as much of a loss as us.....

thank you again for your input.
Joy

 
Old 10-15-2009, 06:29 PM   #11
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Re: Double vision - Diplopia

earthworm88: it's very frustrating indeed. My left eye does not stay out constantly. It tends to go left and I need to concentrate and force it straight to see only one image. At reading distance, this effort has become too hard to make, this is why I need the prism. I am in good health and have had physical examinations every 1-2 yrs. I was not ill when this started. I don't have prescription glasses and I had an MRI in august 08 (showed nothing).

shortlegs: I hope the exercises will help you, they haven't for me. Next week i'm seeing a third orthoptist. The one I was seeing had hip surgery, I saw a second one a few times, she is pregnant and leaving. It's like starting over again. Believe me, I understand your frustrations also.

JodieJ: apparently the surgery would be risky because the deviation is not big
enough. What was your deviation when you had surgery?

 
Old 10-15-2009, 10:03 PM   #12
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Re: Double vision - Diplopia

Ddelise, you previously stated that you required 20 PD for near vision. That is definitely in the "surgery" range. Prior to surgery, I was using 6 PD to correct a deviation of 14 PD. (It varied by time of day--worse late at night.) I had surgery on one eye only. I suggest that you get another opinion from an experienced strab surgeon. The minimum deviation for surgery is usually about 12 PD.

My strab surgeon gave me a computerized vision therapy program to practice with during the 3 weeks before surgery. I put a major effort into doing the exercises, and I failed some of the initial tasks more than 100 times before finally passing. I did make a little progress during the many frustrating hours I spent. After surgery I continued working on the computerized exercises, and I couldn't believe how easy they had become.

Last edited by JodieJ; 10-15-2009 at 10:14 PM.

 
Old 10-16-2009, 03:33 AM   #13
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Re: Double vision - Diplopia

ddelisle : Morning
I was thinking back to your original post about worrying about underlying cause for your symptoms. This is my worry too.
I think that you should see a neurologist to rule out any other cause.
I like you had an MRI in 2008 which was apparently normal. (mine did show some bright spots in the white matter which the opthalmologist said was restricted blood flow but the consultant said was completely normal !!!...who knows !!)
At least we know that they didn't show anything too serious up like a major stroke or tumour. They are good at detecting tumours, my husband was told 9 years ago after a CT scan that he had had a stroke, we queried this and requested an MRI which clearly showed up a brain tumour. Fortunately he then received the correct treatment having originally been sent home with asprin and statins !
I too have had speech problems together with memory problems, my gp dismissed me as anxious/stressed. I know this is not the case (although admittedly I am now a little stressed about what is wrong!) I will probably seek further testing to rule out anything else.
I wonder if it is simply that because our brains are receiving confusing images and we are battling to control them everything else is a little confused ?
The opthalmologist wants me to have glasses with a stick on prism for close work but the orthoptist says she is going to recommend against this because my eyes will rely on this instead of trying to work themselves and I will end up needing stronger and stronger prisms which will not help me as I get older.
I will have to just perservere with the exercises for now and see what the specialist says at my next appointment....

Hopefully we can both get some answers soon.


 
Old 10-16-2009, 07:27 AM   #14
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Re: Double vision - Diplopia

Shortlegs, do not give up! I have another suggestion for you. Specialists know who are the best people in their specialized area. They see them at conferences and (hopefully) read their professional publications. Ask the local specialists whom you see (or have seen) for the names of the top people in their field nationally/internationally. (Ask them who they would refer their spouse/mother/best friend to see for a second opinion if s/he had your symptoms and money/travel were no object.) Try googling these names or use the search feature at pubmed. Contact information/email addresses for these top doctors can usually be found in their professional papers. (They are usually associated with major teaching hospitals.) Email them for advice/referrals, describing your condition in detail. This strategy worked for me with an uncommon retinal problem which the local (Chicago) specialists told me was "untreatable" (see our long thread about ILM pealing). Do NOT rely on local specialists who are not helping you.

Addendum: Since your double vision developed suddenly, old photos may not be useful in diagnosing your condition. If you did have a latent vulnerable to binocular vision breakdown (e.g., micro-strabismus), this may not be apparent in old photos.

Last edited by JodieJ; 10-16-2009 at 09:38 AM. Reason: Added information

 
Old 10-18-2009, 04:14 PM   #15
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Re: Double vision - Diplopia

JodieJ: I'm surprised by your answer (minimum deviation of 12 for surgery). I will seek a second opinion then for sure.

Shortlegs: I was told by the orthoptist that sometimes they can increase the strength of the prism until it stabilizes and then they brings it back down. In my case it only went one way..worse. I feel exactly like you, wondering if the double vision is screwing up my brain and causing the speech problem. I'm getting really fed up of my situation and will try to find a neuro-opth in Ottawa, Toronto or even NY State.

 
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