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

crossword everyday