For the most part, patients with monocular diplopia do not warrant a neurologic evaluation since a careful ophthalmic evaluation will reveal the cause (see Table . 4 days ago Objective: To present a report of the ocular motility disorders, treatment and outcomes of myasthenia gravis (MG). Material and method: A. Monocular diplopia is double vision in one eye only, and is much less common than binocular diplopia. A diplopia 1 monocular pode ser causada, entre outras.
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A year-old man presented with a 2-day history of acusas onset painless left ptosis. He had no other symptoms; importantly pupils were equal and reactive and eye movements were full. There was no palpable mass or swelling. He was systemically well with no headache, other focal neurological signs, or symptoms of fatigue.
CT imaging showed swelling of the levator palpebrae superioris suggestive of myositis. Acute ptosis may diplppia serious pathology. A careful history and examination must be taken. Orbital myositis typically involves the extraocular muscles causing pain and diplopia. Isolated levator myositis is rare. Acute ptosis may indicate a serious underlying pathology and a careful history and examination must be taken to monicular decisions on the type and urgency of appropriate investigations and treatment.
A year-old man was referred to the emergency eye clinic by his optician with a 2-day history of acute onset painless left ptosis. He did not report any double vision, blurred vision or headache.
Prior to idplopia he had not had any eye problems and was not a contact lens wearer. His medical history included cardiomyopathy and arrythmogenic right ventricular tachycardia for which he had an implantable cardioverter defibrillator ICD fitted and was awaiting ablation. He felt diplopix and well, with no preceding viral dplopia, no headache, and no symptoms of malaise or fatigue. He was without fever.
Apart from its position the lid was normal in appearance with no mechanical cause for the ptosis such as swelling, palpable mass or subtarsal abnormality.
Visual acuity was normal at 0. Cover test showed no deviation and eye movements were full with no diplopia elicited. There was no proptosis and both eyes were white and quiet with normal symmetrical intraocular pressures and healthy funduscopy. Cranial nerve examination was normal. The patient underwent blood tests, with normal full blood count, urea and electrolytes, liver function tests, thyroid function tests, glucose, lipids, C reactive protein and erythrocyte sedimentation rate.
Autoimmune screen was normal including thyroid antibodies, antineutrophil cytoplasmic antibody and cauaas antibody. Serum ACE was normal and acetylcholine receptor antibodies were negative.
An orthoptic assessment and HESS chart confirmed the above findings with full eye movements and an isolated ptosis. An urgent CT angiogram was requested to rule out the possibility of a posterior communicating artery aneurysm MRI was dippopia because of his ICD.
This showed a normal cerebral appearance, causa retro-orbital mass and no aneurysm. There was ill-defined enlargement of superior rectus with mild thickening of adjacent levator palpabrae superioris, with stranding of fat around the left superior rectus to the upper border of the lateral rectus.
The remainder of the extraocular muscles were normal, with no optic nerve compression, no dilation of the superior ophthalmic veins and symmetrical cavernous sinuses. These finding were in keeping with an inflammatory process of the superior rectus and levator palpabrae superioris. Involvement of the whole muscles without tendon sparing suggested orbital myositis rather than thyroid eye disease figure 1 A, B CT scan at presentation.
This presentation of isolated unilateral ptosis was not typical of a neurogenic cause. A partial third cranial nerve palsy would typically involve the superior, inferior and medial recti to some degree causing diplopia. Compressive lesions, including a posterior communicating artery aneurysm, classically involve the pupillary fibres which are most vulnerable to compression in their location at the periphery of the third nerve, and cause pupil dilation.
However, pupil sparing, as in this case, is not a reliable sign and an aneurysm must be considered and excluded. The typical associated headache may also be absent. The most common cause of a partial third nerve palsy is microvascular and is associated with diabetes mellitus, hypertension, dyslipidaemia and smoking.
There are however case reports of isolated ptosis caused by aneurysmal compression 1—3 so this must be investigated appropriately. This can be subtle and must be carefully examined. The diagnosis can be confirmed with pharmacological testing with topical apraclonidine, causing dilation of the affected pupil due to denervation hypersensitivity of the iris dilator muscle. Myogenic causes of ptosis include myasthenia gravis.
The patient may not exhibit symptoms of systemic muscle fatigue if they have ocular myesthenia but variable diplopia is often present. Negative acetylcholine receptor antibodies does not exclude the diagnosis.
Ptosis may be asymmetric but is usually bilateral. Miller-Fischer syndrome and Guillain-Barre syndrome may initially present with ptosis following a preceding illness but there would be progressive signs. Orbital infection is an important differential of orbital myositis, and patients presenting with more diffuse symptoms and signs are commonly treated with intravenous antibiotics and closely monitored before the diagnosis of idiopathic orbital inflammation is made.
However, in this systemically well patient with absent orbital signs, no erythema, pain or swelling and normal blood markers we did not feel treatment with intravenous antibiotics was indicated at presentation.
Orbital myositis is a subtype of non-specific inflammation of the orbit primarily involving the extraocular muscles. It most commonly affects young to middle-aged adults with a female predominance. Patients typically present with orbital pain exacerbated by eye movement, with conjunctival injection over the affected muscle, oedema, diplopia due to impaired function of the inflamed extraocular muscle and in some cases mild proptosis.
It is usually acute and unilateral and most commonly affects the medial recti, followed by the superior and lateral recti and rarely the obliques and inferior recti. In this case the CT scan showed involvement of the superior rectus but function was not impaired on examination. Siatkowski et al 13 reviewed 75 patients with orbital myositis and found the function of the extraocular muscles affected changed over the course of the disease.
Our patient presented early in the disease process which likely explains the normal function of the superior rectus. The most common differential diagnosis for orbital myositis is thyroid eye disease. Imaging modalities include ultrasonography, CT and T2-weighted MRI, showing enlarged muscle bellies with thickened tendons vs tendon sparing in thyroid eye diseasewith low internal reflectivity on ultrasound and enhancement with contrast on CT 8 and MRI.
Treatment with systemic corticosteroids is the mainstay of therapy, with rapid resolution of symptoms, 4 6 although spontaneous remission may occur, and in two of the previous case reports the ptosis resolved without treatment.
Evaluation and Management
Further investigations to exclude other inflammatory, neoplastic, vasculitic or infectious conditions are advised in this situation. Provenance and peer review: Not commissioned; externally peer reviewed. National Center for Biotechnology InformationU. Published online Jan 5.
Jennifer Helen Court 1, 2 and David Janicek 1. Author information Article notes Copyright and License information Disclaimer.
Diplopia: Diagnosis and Management: Evaluation and Management
Correspondence to Jennifer Helen Court, moc. Accepted Dec This article has been cited by other articles in PMC. Abstract A year-old man causss with a 2-day history of acute onset painless left ptosis.
Background Acute ptosis may indicate a serious underlying pathology and a careful history and examination must be taken to inform decisions on the type and urgency of appropriate investigations and treatment. Case presentation A year-old man was referred to the emergency eye clinic by his optician with a 2-day history of acute onset painless left ptosis. Investigations The patient underwent blood tests, with normal full blood count, urea and electrolytes, liver function tests, thyroid function tests, glucose, lipids, C reactive protein and erythrocyte sedimentation rate.
Open in a separate window. Differential diagnosis This presentation of isolated unilateral ptosis was not typical of a neurogenic cause.
Discussion Orbital myositis is a subtype of non-specific inflammation of the orbit primarily involving the extraocular muscles. As indicated in the piece, prior history of illness is important, in my case ventricular tachycardia. The initial monoculzr I experienced made me anxious that I may have had a stroke. Painless isolated ptosis should lead to consideration of serious life-threatening disorders with timely and appropriate investigations before diagnosing orbital myositis.
Orbital myositis is an idiopathic inflammatory condition diagnosed by history, examination and appropriate imaging. Oral steroids are the mainstay of treatment. Orbital myositis is a rare cause of isolated ptosis but should be considered in the differential diagnosis in the absence of pupil abnormalities and confirmed with appropriate investigations.
Ptosis as the sole manifestation of compression of the oculomotor nerve by an aneurysm of the posterior communicating artery. J Clin Neuroophthalmol ; Pseudomyesthenia resulting from a posterior carotid artery wall aneurysm: Ptosis as partial oculomotor nerve palsy due to diplopix by infundibular dilatation of posterior communicating artery, visualised by three-dimensional computer graphics: Neurol Med Chir Tokyo ; Curr Allergy Asthma Rep ; 9: Curr Opin Rheumatol ; 9: Idiopathic orbital myositis and review of literature.
Internet J Ophthal Vis Sci ; 8. Recognition and differential diagnosis of enlarged extra ocular muscles in computed tomography. Am J Ophthalmol ; Ophthal Plast Reconstr Surg ; 4: Acute isolated levator palpebral myositis. Rinsho Monoculwr ; Wheatcroft S, Elston J. Unilateral ptosis due to isolated involvement of the levator muscle in acute orbital myositis.
Br J Ophthalmol ; Dee ptosis due to isolated levator myositis. J Korean Ophth Soc ;