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Freeman diplopia visual field defects
1. Diplopia and Visual Field
Defects
Fanny Freeman
Senior Orthoptist
Clinical Lead for Stroke (Visual Defects)
Worcestershire Royal Hospital
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. Diplopia
• Double Vision
• Monocular or
Binocular
• Direction
• Position of Gaze
• Duration
• Time of Day
• Method used to
prevent diplopia
4.
5. Third Cranial Nerve Palsy
• Medial rectus
• Superior rectus
• Inferior rectus
• Inferior oblique
• Levator = ptosis
• Sphinter pupillae NB
painful III with dilated
pupil
6. 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
7. 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
8. Cranial nerve pathways
• All go through
cavernous sinus
• Lateral rectus palsy
can be a sign of
raised intracranial
pressure Non
localising
10. 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
11. 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
12. Input to ocular motor centres
Visual input via visual
Head pathway
movement
via
Vestibular
organ
Cortex
‘effort of will’ III
Initiated in IV
VI
frontal cortex Innervation of
EOM
Brain Stem
13. 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
14. Brain stem stroke
• Facial Palsy
• Gaze Palsy
• Skew deviation
• Diplopia
• Glad to be alive
15. 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
16.
17. Treatment of Diplopia
• Treatment
• Improves walking
• Can restore 3D vision for pouring drinks
• Reading
• May be able to drive again
• Less nausea
18. 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
19. 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
20. 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
21. Orthoptic Treatment
• Can improve
convergence with
orthoptic treatment
• If fails use base in
prisms in reading
glasses
22. BOTOX
• To Extraocular
muscles
• Useful if surgery not
an option
• Can help recovery
• Patients ask for the
full works!
23. 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
24. 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
25. 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’
34. 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
35. 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
36. 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
37. 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
38. Thank you for listening
• My Father
• born 09.09.1919
• Still driving
• On no medication
• No eye defects
• Does The Times
crossword everyday