Diplopia charting

HELPFUL FOR STUDENTS.

1. DIPLOPIA CHARTING ANUJA DHAKAL BOVS II YEAR

2. LAYOUT ETIOLOGY OF DIPLOPIA INTRODUCTION OF DIPLOPIA CHARTING PRINCIPLE OBJECTIVES PRECAUTIONS METHOD & PROCEDURE INTERPRETATIONS & ANALYSIS SEQUENCE DIPLOPIA CHARTING IN CNIII,IV,VI PARALYSIS

3. ETIOLOGY OF DIPLOPIA ACCORDING TO LATERALITY Monocular Binocular ACCORDING TO COMITTANCY OF STRABISMUS ORIENTATION OF DIPLOPIA CENTRAL FUSION DISRUPTION SYNDROME

4. INTRODUCTION Diplopia charting is the subjective method of double vision test in which the recording of the separation of double or diplopic images is made in the primary position as well as other cardinal gaze. It is a common ophthalmic procedure employed in helping with diagnosing ophthalmoplegia .

5. If the single extra ocular muscle is affected, diplopia charting gives an accurate result, but it may be difficult to pinpoint the more affected muscles in the case of multiple muscle paresis or palsy. Diplopia chart gives a symbolic or pictorial record of double vision.

6. PRINCIPLE The diplopia chart is based on the haploscopic principle(superimposition), foveal projection, Hering’s Law of Equal Innervation, and Sherrington’s Law of Reciprocal Innervation. T he concept is each retinal point has its own value of direction in gazes.

7.   Diplopia principle: One target, dissociation achieved with different colour glasses. Haploscopic principle: Two target, one target pointed and patient has to superimpose it with other 

8. OBJECTIVES Detection of Incomittancy . Subtle nerve Paresis. Monitor the course of nerve palsy.

9. DISADVANTAGES It is only quantitative and hence cannot comment on minor changes. The test requires intelligent patient to comment on separation of images. Not possible to perform in colour blind. Not of use in congenital palsies & long standing onset.

10. The chart may give false interpretations if the paresis unmasks a latent deviation or the patient starts maintaining fixation with the paretic eye, especially if the paralyzed eye has better visual acuity.  Never judge the diplopia chart in isolation. The single method can’t fulfill the requirement of clinical practice due to the variability of diplopia

11. MATERIALS REQUIRED LIGHT SOURCE – PREFERABLY LINEAR ANAGLYPHS RED GREEN MARKER & PAPER

12. HISTORY   1. When and how did the double vision started ? 2. Whether diplopia disappears or persists after closing one eye ? 3 . Associated symptoms with double vision if any ? 4. Is it constant in all gazes or more in a particular gaze? 5 . Is it more for far or near fixation?

13.  6.Whether the images are horizontally, vertically or obliquely separated? 7 . Is the diplopia constant, intermittent or variable? 8.Whether diplopia worsens at the end of the day ? 9. History of any trauma to eye, face, head or any history of ocular surgery recent or in past. 10 . Detailed history of systemic diseases like diabetes mellitus, hypertension, thyroid disorders, myasthenia gravis should be taken.

14. PROCEDURE The patient should be comfortable with his head erect and should preferably be still throughout the examination. The test is preferably carried out in a dark room. Red glass is put in front of one of the eyes (red in front of right, R for R, is a convention).

15. The examiner holds the torch or retinoscope at around ½ m or 1 m at the level of patient’s eye. This source of light could be horizontal if the complaint is of vertical separation of images and viceversa .

16. Two METHODS : L R 1) Patient’s view 2) Examiners view R L

17. The light is moved from primary position to all other 8 directions of gaze. For each direction , patient is asked to comment on the position,brightness,and separation between the red and green images. Modified test of F ranchchetti

18. COMMON MISTAKES: POSITIONING OF PATIENT PROPER DISTANCE NOT MAINTAINED AS MENTIONED ON CHART. MISTAKING PATIENT AND EXAMINER VIEW POINT.

19. LEADING QUESTIONS In which direction of gaze are the images maximally separated? Is there any tilt in the light streak seen? To which eye does the “outer” image belong? Is diplopia relieved on tilting head?

20. RESTRICTIVE V/S PARETIC?? FORCE DUCTION TEST?

21. INTERPRETATION & ANALYSIS ALWAYS REMEMBER: ALL RECTI MUSCLE PRODUCES CROSSED DIPLOPIA EXCEPT LATERAL RECTUS, OBLIQUES ALWAYS PRODUCES UNCROSSED DIPLOPIA.

22.   Predominant face turn= horizontal muscles Predominant chin up/down= vertical recti, pattern strabismus Predominant tilt = Obliques

23. CROSSED V/S UNCROSSED DIPLOPIA

24. NORMAL BSV : L R patient’s view

25. 1) RIGHT LATERAL RECTUS PALSY 1st step : identification of action of muscle.( Dextroversion ) 2nd step: find yoke muscle of right lateral rectus.(Lt.MR) 3 rd step: ask the patient about farthest image and what colour is it? ( LR always produces uncrossed image so farthest will be red colour light in dextroversion )

26. L R

27. 2)RIGHT MEDIAL RECTUS L R

28. 3)RIGHT SUPERIOR RECTUS L R

29. 4)RIGHT INFERIOR OBLIQUE L R

30. 5) LEFT INFERIOR RECTUS L R

31. 6) LEFT SUPERIOR OBLIQUE L R

32. DIPLOPIA CHARTING IN CN PALSIES:

33. 1) ABDUCENT NERVE PALSY ( CN VI)

34. CLINICAL FEATURES Esotropia . Face turn . Diplopia . Vision loss. Pain. Hearing loss

35. LEFT LATERAL RECTUS PALSY: L R

36. 2) TROCHLEAR NERVE PALSY( CN IV)

37. CLINICAL FEATURES OF CNIV PALSY Patient reports DIPLOPIA. It is worse on downgaze & gaze away from the side of affected muscle. Bielschowsky head tilt test is extremely useful. 30 – 100 degree excyclotorsion . unilateral IV CN palsy. > 100 excyclotorsion . Bilateral IV CN palsy

38. L R ???

39. RIGHT SUPERIOR OBLIQUE PALSY

40. 3) OCCULOMOTOR NERVE PALSY ( CN III) INVOLVEMENT OF MEDIAL RECTUS SUPERIOR RECTUS INFERIOR RECTUS INFERIOR OBLIQUE

41. CLINICAL FEATURES OF CNIII PALSY: Eye looks downwards and outwards in primary position.  Diplopia mixed horizontal and vertical, binocular. Ptosis of varying degrees . Glare due to pupil dilatation .

42. https:// www.researchgate.net/publication/336736295_Acute_isolated_medial_rectus_palsy_due_to_infarction_as_a_result_of_hypercoagulable_state_A_case_report_and_literature_review . https:// www.researchgate.net/publication/353315791_Diplopia_After_Migraine_Surgery . https:// www.researchgate.net/publication/351693293_Binocular_Diplopia_After_A_Snakebite .

43. ANY QUESTIONS??

44. REFERENCES AAO- NEURO-OPHTHALMOLOGY, 2004-2005. CLINICAL NEURO-OPHTHALMOLOGY,WALSH &HOYT VOLUME 1, 3 RD EDITION 1969. THEORY OF SQUINT AND ORTHOPTICS- AK KHURANNA. STEP BY STEP CLINICAL MANAGEMENT OF STRABISMUS, ZIA CHAUDHURI . THEORY AND MANAGEMENT OF STRABISMUS, GUNTHER K.VON NOORDEN https:// www.eophtha.com/posts/diplopia-and-hess-charting

45. THANK YOU