A curious case of double trouble
by Jennifer Du, Specsavers
History
86 year old female presented for a routine check
Reason for visit: routine eye examination, no other problems reported.
General health: unremarkable
Medication: Magnesium tablets
POH: bilateral IOL 2 years previously
FOH: none
Examination
Pupils: PERRLA
Motility – full and smooth
Refraction: R -0.25/-0.75 x 105 L: plano / -0.25 x 5
Add: +2.25 n5
Ocular examination – nothing abnormal detected
Diagnosis
Management
- New bifocals prescribed. Px returned for follow up 2 /52 later c/o headaches with her new bifocals
- No dispensing error noted
- No changes in her refraction
- During the exam, the patient said she was intermittently seeing double while reading the letter chart
- Subsequently noted 10PD esophoria that was breaking down into esotropia
- 6 Prism BO in the right eye was found at the end of the test
Differential diagnosis
- Thyroid eye disease
- Myasthenia gravis – normally vertical diplopia noted.
- Symptoms worsen at end of day, ptosis noted
- Orbital inflammation – Usually presents with pain, proptosis
- No trauma reported
- VI nerve palsy – most likely diagnosis
Provisional diagnosis
- Microvascular CN VI palsy – causes intermittent horizontal diplopia with no other symptoms
Optometrist management
- Px referred urgently to ophthalmology to investigate sudden onset diplopia
Ophthalmology management
Ophthalmologist’s findings:
- 6PD esotropia with bilateral LR weakness
- Further questioning revealed that the px’s GP had asked the patient to stop taking cholesterol meds owing to musculoskeletal side effects 6 months previous
Diagnosis
- Microvascular CN VI palsy
Follow-up
- Reviewed by optometrist 6/52 later
- Diplopia had resolved spontaneously
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