What Happens When I Still See Double! You Cover One Eye? 1 - PowerPoint PPT Presentation

2/13/2015 The Battle for Binocular Vision No Financial Disclosures or Potential Conflicts of Interest Jonathan C. Horton, UCSF http://www.ucsf.edu/hortonlab 12 February 2015 What Happens When I Still See Double! You Cover One Eye? 1

2/13/2015 Eject! Journal of Neuro-Ophthalmology 19:1-6, 1999 Patient’s drawings of her monocular diplopia Maddox Rod 2

2/13/2015 Maddox rod over my right eye: crossed diplopia = exophoria Human Ocular Dominance Columns (Adams et al, 2007) Convergence of Monocular Inputs Generates Binocular Strabismus During Critical Period for Visual Development Cells Required for Fusion and Stereopsis Disrupts Projections onto Binocular Neurons 3

2/13/2015 A phoria is a natural property of the oculomotor plant. 5/3/67 It is overcome by a cortical drive to fuse images. Dear Dr. Kaye Your I’m very grateful for your kindness and your generous offer. Actually I’ve been wearing corneal lens’s for many years quite successfully. I carry a small pair of reading glasses for the occasional run in’s with fine print or a menu in a too dark cafe. But please know that your generous letter and of was a tremendous morale booster and something I’ll never forget. Sincerely RR Horizontal fusional amplitude: 10 to 20 prism-diopters Vertical fusion amplitude: 3 to 4 prism-diopters 4

2/13/2015 73-year-old with occasional horizontal diplopia Monovision: focus @ near left eye, focus @ distance right eye Visual acuity wearing gas permeable contact lenses: 20/20, J10 in right eye 20/60, J1 in left eye (-2.75 sphere improves to 20/20) Refraction: -10.00 + 2.00 × 130 ° right eye -10.00 + 1.75 × 60 ° left eye 2 weeks after using glasses with full distance correction in each eye 5

2/13/2015 Hirschberg ratio: 1 mm of corneal light decentration equals 7 ° of eye deviation 6

2/13/2015 Is it strabismus, or something neurological? Strabismus*: Full range of eye movements Comitant deviation Neurological: Limited eye movements Incomitant deviation l 6-month-old baby with new onset of crossed eyes *exceptions: cranial dysinervation disorders, etc. 7

2/13/2015 Left gaze, limited abduction left eye Right gaze full, centered pupil light reflexes Temporal displacement of pupil light reflex 35-year-old man with horizontal diplopia- 8

2/13/2015 9

2/13/2015 81-year-old with progressive left eye esodeviation 41-year-old with 3 months of ptosis and limited ductions OS 10

2/13/2015 58-year-old with diplopia following a stroke 2 months ago Diplopia Principles • Use muscle light or cover test to check for ocular misalignment • Is it strabismus or neurological? • Comitant or incomitant? • Ocular nerve palsy or brainstem problem? • Image the orbits along with the brain Fresnel stick-on plastic prism • Ocular myasthenia – a clinical diagnosis • Most diplopia can be fixed • Prisms – find a good optometrist • Eye muscle surgery for appropriate cases 11