1. Diplopia due to pre-eclampsia
Aileen Guillen
Pre-eclampsia is a hypertensive disorder that occurs during pregnancy and is one of the leading
causes of both maternal and fetal deaths worldwide. It is characterized by elevated blood
pressure (>140/90 mmHg), proteinuria (>300mg/day), and neurological effects.i Visual
disturbances concern up to 25% of patients with severe pre-eclampsia and 50% of patients with
eclampsia.ii Of these possible effects is diplopia, also known as “double vision,” which is when a
person sees two copies of one object. There are two forms—optical diplopia, often due to
cataracts or corneal irregularities, and strabismic diplopia, a disorder caused by problems with
the neuromuscular junction, brainstem pathways, or ocular motor nerves. Pre-eclampsia patients
typically experience strabismic diplopia from paresis of the motor nerve. Superficially, this is
projected as ptosis of the upper eyelid and a less reactive pupil. Physiologically, this occurs due
to ischemic demyelination of the nerve, which is a resultant side effect of systemic
hypertension.iii These physiological effects are essentially the same as hypertensive retinopathy.
The only difference being that they develop much more quickly and are often transient in pre-
eclampsia patients. Though diplopia symptoms can resolve on their own within 90 days, the
overall effects of pre-eclampsia are very worrisome. Diplopia, amongst other symptoms, may be
warning signs of an approaching seizure. As symptoms worsen patients should be given
magnesium sulfate to prevent convulsions and antihypertensive drugs to reduce dangerously high
blood pressures. However, for pregnancies 37 weeks or later providers typically instead opt for
inducing labor.iv
Case Presentation:
I report the case of a woman in her mid-thirties who was referred by her obstetrician post-
delivery for diplopia. The patient had been diagnosed with pre-eclampsia while at the hospital
and labor was induced upon diagnosis. An MRI was taken at the hospital; results came back
normal. Patient stated she “just got out of labor” but had been suffering from double vision since
5 days prior. Patient described her initial symptoms as “objects seeming afar” but stated that the
next day it became worse. Upon examination the eyes themselves appeared normal. An eye
movement examination and prism test were administered. The left eye was found to be
significantly impaired. Due to the severity of the patient’s double vision, she was likely suffering
from third cranial nerve palsy in the left eye. The patient was told that preeclampsia simply takes
time to heal and was advised to buy an eye patch for the diplopic eye. Recommended follow-up
in two weeks to receive a prism insert for her glasses.
Discussion:
From this case I learned about the dangers of pre-eclampsia and saw firsthand one of the warning
signs of its severity. The timeline of the development of her symptoms revealed how rapidly they
can manifest themselves. Were I to encounter this case again, I would be very perceptive of the
symptoms and more likely to act as quickly as needed. Another interesting thing to note was how
creative Dr. Silverberg, the ophthalmologist, was in coming up with a temporary solution for the

2. patient’s visual disturbance. She had relayed discomfort with purchasing an eyepatch and so he
attempted to create a makeshift eyepatch using her prescription eyeglasses. To do so, he covered
the inside of half of the lens with tape. The patient responded positively in its effectiveness of
reducing her double vision. After discussion of the case with Dr. Silverberg, he mentioned that
although diplopia is fairly common, it is relatively rare to see it induced by pre-eclampsia.
i
Kane,Stefan C., Alicia Dennis, Fabricio Da Silva Costa,Louise Kornman, and Shaun Brennecke.
"Contemporary Clinical Management of the CerebralComplications of Preeclampsia."Obstetrics and
Gynecology International. Hindawi Publishing Corporation, 29 Dec. 2013.
ii
Samra,Khawla Abu. "The Eye and Visual System in the Preeclampsia/eclampsia Syndrome: What to
Expect?" Saudi Journal of Ophthalmology 27.1 (2013): 51-53.
iii
Trobe, J.d. "Diplopia and Strabismus." Encyclopedia of the Neurological Sciences (2014): 1001-003.
iv
"Preeclampsia." Preeclampsia. Web. 17 Mar. 2016. <http://www.preeclampsia.org/health-
information/faqs#preeclampsia-treated>.