Freeman diplopia visual field defects

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Freeman diplopia visual field defects

  1. 1. Diplopia and Visual Field Defects Fanny Freeman Senior Orthoptist Clinical Lead for Stroke (Visual Defects) Worcestershire Royal Hospital
  2. 2. Binocular Single Vision• Orthoptists specialize • Normal view in defects of binocular vision and ocular motility defects• Aim to get binocular single vision in all directions of gaze
  3. 3. Diplopia• Double Vision• Monocular or Binocular• Direction• Position of Gaze• Duration• Time of Day• Method used to prevent diplopia
  4. 4. Third Cranial Nerve Palsy• Medial rectus• Superior rectus• Inferior rectus• Inferior oblique• Levator = ptosis• Sphinter pupillae NB painful III with dilated pupil
  5. 5. Fourth 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
  6. 6. Sixth 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
  7. 7. Cranial nerve pathways• All go through cavernous sinus• Lateral rectus palsy can be a sign of raised intracranial pressure Non localising
  8. 8. Causes of diplopia• Vascular/diabetic• Neoplasic• Thyroid dysfunction• Myasthenia Gravis• Multiple Sclerosis• Parkinson• Longstanding
  9. 9. Internuclear 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
  10. 10. Midbrain Control of Eye Movements• Horizontal Gaze Centre Right and Left• Vertical Gaze Centre Up and Down• Convergence centre• Motor nerve nuclei III, IV and VI
  11. 11. Input to ocular motor centres Visual input via visual Head pathway movement via Vestibular organCortex ‘effort of will’ III Initiated in IV VI frontal cortex Innervation of EOM Brain Stem
  12. 12. Vascular 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
  13. 13. Brain stem stroke• Facial Palsy• Gaze Palsy• Skew deviation• Diplopia• Glad to be alive
  14. 14. Ocular 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
  15. 15. Treatment of Diplopia• Treatment• Improves walking• Can restore 3D vision for pouring drinks• Reading• May be able to drive again• Less nausea
  16. 16. Fresnel 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
  17. 17. Blenderm• 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
  18. 18. Abnormal Head Posture• Often seen in vertical deviations• Tilt to lower eye restores binocular single vision• Some patients not aware they are tilting their heads
  19. 19. Orthoptic Treatment • Can improve convergence with orthoptic treatment • If fails use base in prisms in reading glasses
  20. 20. BOTOX• To Extraocular muscles• Useful if surgery not an option• Can help recovery• Patients ask for the full works!
  21. 21. Squint 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
  22. 22. Vision• 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
  23. 23. Is 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’
  24. 24. Visual Field Defects• Commonly found with strokes• Glaucoma• Diabetic Retinopathy
  25. 25. Visual Field Testing• Confrontation• Formal testing in Eye Department• Driving Visual Field 120 degrees wide and 20 degrees up and down
  26. 26. Homonymous Hemianopia
  27. 27. Visual Inattention• Reading• Vision• 2 pen Test• Albert’s Test• Balloon Test
  28. 28. Balloons Test
  29. 29. Eye Movements
  30. 30. Hemianopia• 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
  31. 31. Disconnection 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
  32. 32. Patient 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
  33. 33. What to do if visual defect suspected• 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
  34. 34. Thank you for listening• My Father• born 09.09.1919• Still driving• On no medication• No eye defects• Does The Times crossword everyday

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