By: Leong Shin Yi

Noor Munirah binti Awang Abu Bakar-Optometrist-

According to International Diabetes Federation :

415 million people have diabetes in the world ◦ Almost 153 million people in the Western Pacific Region; by 2040

will rise to 215 million.

There were 3.3 million cases of diabetes in Malaysia in 2015

Estimated about 15,000 to 39,000 people lose their sight because of diabetes

About 14.6% of Non-Insulin-Dependent DM developed DR after 5 years duration of diabetic condition and 50% develop evidence of nerve damage after over 15 years of having DM.

Orbit (Orbital Cellulitis) EOM ◦ Acquired palsy◦Most commonly affected 3rd and 6th

(Thomas J. O'Donnell) Conjunctiva (Conjunctivitis) Cornea (neurotrophic ulceration) Lens (Cataract) Retinal (Retinopathy) Elevated IOP

54 /M/M on 10/3/2016 Referred from PCC clinic C/O : ◦ LE deviated inward constantly x 1 month ago associated with

binocular horizontal double vision at distance and near (D>N). ◦ It somehow bothering his daily activities esp driving. He overcame

the problem by wearing sunglasses and patch left side lens with masking tape.

◦ No AHP was noted on him. ◦ He did not bring his own glasses during the visit and he claimed that

the prescription is for distance used. He occasionally wearing the glasses.

◦ So, he came to our binocular visual clinic to seek for solution. Previous visit, he was suggested to be treated with froster occlusion and patient is keen.

Ocular History◦BE pseudophakia: Operations done in PPUKM in year 2012

◦ Still being followed up for his diabetic retinopathy and glaucoma (POAG)

◦Diagnosed with left eye 6th nerve palsy secondary to mononeuritis multiplex in January 2016.- (CT brain done: no space occupying lesion)

◦ Currently on 2 antiglaucoma drugs: G. Timolol and G. Xalatan

TESTS 2/3/2016 10/3/2016 25/3/2016 31/3/2016 8/4/2016Unaided VA OD: 6/18, PH: 6/9-1

OS: 6/18, PH: 6/12OD: 6/9.5-2

OS: 6/15-1,PH: 6/12-1

Referral letter to see ophthalmoloist

Reply letter obtained from ophthalmologist

OD: 6/18, PH: 6/9-1

OS: 6/18, PH: 6/12Hirschberg Test LE corneal light

reflected near the temporal pupil margin

LE corneal light reflected near the temporal pupil margin

Unaided CT (Dist)Unaided CT (Near)

Large LE ET with moderate recovery

Large LE ET with moderate recovery

Prism Cover Test (Dist)Prism Cover Test (Near)

20 Δ BO ET8 Δ BO ET

18Δ BO ET8 Δ BO ET

EOM Diplopia at all left gaze Abduction (-2)

Diplopia at all left gaze Left gaze Abduction (-2)

Worth 4 dots (Dist)Worth 4 dots (Near)

6 circles noted (Diplopia)

Old RX OD: -0.25/-1.00 x 90OS: Pl/ -2.00 x 90

Retinoscopy OD: -1.00 (6/6)OS: -0.75 (6/6)

Subjective Refraction OD: -1.00/-0.50 x 75 (6/6)OS: -0.75/-1.25 x75 (6/6)ADD: +2.25, N5

OD: -1.00/-0.50 x 75 (6/6)OS: -0.75/-1.25 x75 (6/6)ADD: +2.00, N5

NFV (Dist)NFV (Near)

30 BI, no recovery. Diplopia before placement of prism, not recovery

Hess Chart

RE overaction of medial rectus LE limited lateral rectus action(No deterioration or improvement seen )

2/3/2016 10/3/2016

Medical Examination CT brain scan-No space-occupying lesions

Lens OU: PCIOL stableFundus examination

OU: Moderate NPDROU: Glaucoma

Diagnosis ◦ LE 6th nerve palsy secondary to mononeuritis multiplex

(diagnosed in January 2016) Currently BE EOM is improving, lateral gaze was recovered about

90%◦ BE pseudophakia◦ BE moderate non proliferative diabetic retinopathy (NPDR)◦ BE primary open angle glaucoma

Management on 10/3/2016◦ TCA on 15/3/2016 to consider for binasal occlusion. He was

advised to bring his current glasses. To re-asses the EOM function with Hess chart

◦ Consult patient regarding monocular visual field: he was advised to turn his face in order to view at the peripheral side of occluded eye instead of eye glancing.

Management on 25/3/2016◦ Referral letter with current BV assessment findings was given

to HUKM Ophthalmologist to seek for medical report before proceed with a vision therapy programme.

Management on 8/4/2016 (Pt came for distance Rx only)◦ Distance glasses was prescribed.

◦ TCA 2/52 for BV clinic Consider giving Bangerter foil or binasal occlusion to avoid

diplopia with prescribed glasses.

◦ Advised strictly control diabetic Possibility of fluctuation on glasses power was due to diabetes. Angle of deviation and diplopia experienced was due to 6th nerve

palsy which may recover over the course of 12 months .

Mononeuritis multiplex = A painful, asymmetrical, asynchronous sensory and motor peripheral neuropathy involving isolated damage to at least one separate nerve areas

This nerve damaging disorders can be associated with many different conditions including ◦ Infection (Vasculitis)◦ Cancer-related condition (Tumour)◦ Rheumatological disorders (Rheumatoid arthritis)◦ Hematologic condition (Hypereosinophilia)◦ Chronic conditions (Diabetes mellitus)

Mononeuritis multiplex is a relatively common condition associated with diabetic neuropathy

BE POAG

BE Mod NPDR

LE 6th nerve palsy

BE cataract

The sixth cranial nerve (abducent nerve) is a somatic efferent nerve that innervates ipsilateral lateral rectus (LR) muscle to elicit eye abduction.

Sixth nerve palsy? ◦ Limited ability of the affected eye to turn out (abduct) due to 6th nerve lesion.

Why?:

It can be congenital (rare) or acquired (common). Can be unilateral or bilateral 6th nerve palsy

Ophthalmologist will do some medical examination to isolate any cranial nerve weakness. ◦ CT◦ MRI scan◦ CSF◦ HbA1C

1. Patching either eye or binasal occlusion

2. Fresnel Prism ◦ To treat diplopia and alleviate face turn. Can be tried for small eso deviations or

postoperatively if needed

3. Botolinum toxin A◦ Prevent contracture of medial rectus◦ Successful use of botulinum toxin A in the early treatment of diplopia caused by

6th nerve palsy in two type 2 diabetic patients. (Anna Broniarezyk-Loba, 2004)

4. Eye muscle surgery◦ Longstanding esotropia ~ 6 months and above

5. Control blood pressure and blood sugar◦ High sugar and blood pressure not only impact the eye but has increased risk of

stroke

Binasal occlusion◦ Type of sector occlusion◦ Not as a permanent treatment◦ Indication: Esotropia, amblyopia, diplopia, CE, DI◦ Why recommended :

Reduce double vision and direct patients to use their peripheral system, helping them to locate objects and judge distances more accurately

◦ Material : Translucent material (opaque) , clear nail polish◦ Sector size measurement:

Pt wear the glasses, focus at distant target Binasal occluder (determine the degree of nasal occlusion needed to eliminate or reduce symptoms ) is put at the centre

Further reading on binasal occlusion

www.oepf.org/sites/default/files/journals/jbo-volume-1-issue.../1-1%20Tassinari.pdf

“Fortunately, diplopia related to diabetes typically is caused by dysfunction of only one nerve at a time (and on one side), and resolves without intervention in the majority of cases within 3 to 6 months”.

“People with diabetes can reduce their chances of developing cranial neuropathy and double vision by maintaining excellent blood glucose, blood pressure, and blood lipid control”.

(Chous, 2013)

Full eye examination, ruled out other underlying causes (brain tumour by RAPD test)

Temporally patching either eye

Prescribe Prism glasses or to consider eye muscle surgery ◦ paralysis nerve is permanent

Advised strictly control DM and HPT

Advised annual medical examination

Microvascular Cranial Nerve Palsy causes, Amercan Academy of Ophthalmology, 2012.

International Diabetes Federation, Malaysia Boulton, A.J.M., MD, FRCP, Malik, R.A., MB, PHD, Arezzo, J.C.,

PHD, Sosenko, J.M., MD, MS., Diabetic Somatic Neuropathies, (2004), Amerian Diabetes Association, Vol. 27(6), Pg.1458-1486.

Tracy, J.A., MD, and Dyck, P.J.B., MD, The Spectrum of Diabetic Neuropathy,(2008), Public Medical Journal, Vol. 19(1).

O’Donnell, T. J., MD, Buckley, E.G., MD, Sixth Nerve Palsy, (2006), Vol.7(5, Pg. 215-221.

Mononeurities Multiplex, ADAM.

Broniarczyl-Loba, A., MD, PHD, Czupryniak, L., MD,PHD, Nowakowska, O., MD, PHD, Loba, J., MD,PHD., () Botulinum Toxin A In The Early Treatment of Sixth Nerve Palsy-Induced Diplopia in Type 2 Diabetes.

National diabetes registry report vol., 2009-2012 Eye Care of the patient with diabetes mellitus, American

optometric association Rinehart, W., Sloan, D., and Hurd, C., Exam cram NCLEX-RN,

4th Edition