36 y/o man with longstanding strabismus, concerned that left eye "goes off" and he has trouble in social situations.
No prior eye surgery or patching. Specs for myopia.
Exam:
Va cc 20/20 ou
Rotations: Trace limitation to elevation in adduction OD
Alignment:
R gaze: LHT 8 Primary: LHT 12 L gaze: LHT 15
Double Maddox Rod: No torsion ou
Worth 4 dot: Suppresses left eye distance and near
Stereo: Nil
Displays a left head tilt ~5-10 degrees
Photos:
Questions:
Q 3.1 What is your working diagnosis? Are there additional tests that may help confirm your diagnosis?
Q3.2 What is your surgical plan?
Case 4
42 y/o woman with 2 day history of left-sided numbness (face, arm, torso, leg) and bilateral dysacusis, presents with "right eye turning in."
MRI shows 1.2 cm ring-enhancing lesion of the right pons consistent with tumefactive demyelination.
Remote history of subfoveal CNV OD secondary to ocular histoplasmosis, had submacular surgery with no recurrence.
Exam:
Va cc: 20/400 OD (central scotoma stable), 20/20 OS
Rotations: Severe limitation to abduction OD
Alignment:
R gaze: ET 45 Primary: ET 25 L gaze: ET 4
Ocular exam: Stable 2+ NS, foveal RPE atrophy; optic nerves pink and flat ou with no RAPD
Photos:
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| Upper photo: Left gaze; Lower photo: Attempted right gaze |
Representative photo from http://bingskee.hubpages.com
Questions
Q 4.1 Assuming her alignment is stable in 4-6 mos, what is your surgical plan?
Q4.1 resect right lateral rectus, recess right medial rectus
ReplyDeleteQ3.1: Leading diagnosis is DVD given the complete lack of binocularity and suppression of OS (the hypertropic eye) with either a right Brown's syndrome or overaction of the right SO. Forced ductions would help to differentiate between the latter two.
ReplyDeleteQ3.2: Inferior oblique anterior transposition OS
Q4.1: Right 6th nerve palsy with essentially no abduction OD. Would do a right medial rectus recession with a vertical muscle transposition to correct the ET and obtain some movement in abduction. Ideally, would operate only on OD given poor visual acuity; however, may need bilateral medial rectus recessions to correct full esotropia