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Developed Horizontal Binocular Diplopia. Neurological Examination Mild Impairment In Vibration Sensation In Lower Limbs. Suggest?
Question: Background history:
I'm a 58 years old man, married, with a son and daughter, highly educated, working as a psychiatrist.
Three weeks ago, I developed a sudden attack of horizontal binocular diplopia, lasting four minutes without dizziness, headache or nausea and vomiting. I noticed it occurred after a long period of working on laptop and just after change my head position.
It occurred once daily for the next 3 days, either suddenly or sometimes with change of sight from short distance to long one without any apparent precipitating cause and not even with sudden movement of neck in any direction.
I visited a neurologist who did a full neurological examination (motor, sensory and cranial nerves). Everything was ok except for a mild impairment in vibration sensation in both lower limbs. I did an MRI on the brain and it revealed nothing abnormal.
I then visited an ophthalmologist who did a full ophthalmological examination (eye pressure, ocular muscles, fundus and retina). He told me everything is OK, that it might be Spasm Of Accommodation (as I am Myopic ) and that I should wear a bifocal glasses, which I did without any apparent improvement.
Ten days ago, I developed 5 attacks of sudden vertical diplopia and the horizontal attacks disappeared. It occurs once almost daily or every other day, lasting 2-3 minutes without any accompanied symptoms. It occurs at any time of the day with not specific timing (day or night) or with fatigue or not. There are no manifestations of any muscle weakness all over the body.
I developed one mild attack of vertigo (once and not occurred again), and I visited an ENT specialist and he found no abnormal findings.
The three specialists I went to (Neuro, ophthalmology and ENT) gave no definite diagnosis and just said that we have to wait and see.
Last attack of vertical diplopia was 4 days ago, I noticed that when I wear my bifocal glasses it diminishes in frequency
Medical History:
• Diabetes Mellitus ( 6 years duration) but controlled.
• Smoker for more than 25 years (15-20 cigarettes/day)
• No history of alcohol or drug intake.
• No history of strokes, TIA's or cardiac and chest diseases.
• History of Irritable bowel syndrome and diverticulitis.
Family History: Irrelevant
Investigations:
• MRI on the brain (done on 19/8/2013) revealed no significant abnormalities with preserved major intracranial flow voids.
• Ophthalmologic and ENT examinations revealed no abnormalities.
Lab results:
• CBC within normal range.
• HbA1c ranges from 6.2-6.7%.
• Calcium and electrolytes within normal.
• Liver function tests are normal.
• Renal Function tests are normal.
• ECG is normal.
• Lipid profile is normal.
. Thyroid truncation tests including thyroglobulin antibody and microsomal antibodies are within normal
ESR is within normal
I proceeded to do acetyl choline receptor antibodies, results will be collected within 10 days
Medications used:
• Metformin 1000mg, twice daily.
• Atorvastatin (Lipitor) 20mg, once daily.
• Vitamin B1, B6, B12, one tablet, twice daily.
• Vitamin D 25,000 IU, once weekly for two months and then stopped for one month.
• Aspirin 81mg, once daily.
Cinnarizine 25 mg twice daily
Thank you for your cooperation and wishing to get a reply soon with an interpretation for my problem.
Sincerely,
I'm a 58 years old man, married, with a son and daughter, highly educated, working as a psychiatrist.
Three weeks ago, I developed a sudden attack of horizontal binocular diplopia, lasting four minutes without dizziness, headache or nausea and vomiting. I noticed it occurred after a long period of working on laptop and just after change my head position.
It occurred once daily for the next 3 days, either suddenly or sometimes with change of sight from short distance to long one without any apparent precipitating cause and not even with sudden movement of neck in any direction.
I visited a neurologist who did a full neurological examination (motor, sensory and cranial nerves). Everything was ok except for a mild impairment in vibration sensation in both lower limbs. I did an MRI on the brain and it revealed nothing abnormal.
I then visited an ophthalmologist who did a full ophthalmological examination (eye pressure, ocular muscles, fundus and retina). He told me everything is OK, that it might be Spasm Of Accommodation (as I am Myopic ) and that I should wear a bifocal glasses, which I did without any apparent improvement.
Ten days ago, I developed 5 attacks of sudden vertical diplopia and the horizontal attacks disappeared. It occurs once almost daily or every other day, lasting 2-3 minutes without any accompanied symptoms. It occurs at any time of the day with not specific timing (day or night) or with fatigue or not. There are no manifestations of any muscle weakness all over the body.
I developed one mild attack of vertigo (once and not occurred again), and I visited an ENT specialist and he found no abnormal findings.
The three specialists I went to (Neuro, ophthalmology and ENT) gave no definite diagnosis and just said that we have to wait and see.
Last attack of vertical diplopia was 4 days ago, I noticed that when I wear my bifocal glasses it diminishes in frequency
Medical History:
• Diabetes Mellitus ( 6 years duration) but controlled.
• Smoker for more than 25 years (15-20 cigarettes/day)
• No history of alcohol or drug intake.
• No history of strokes, TIA's or cardiac and chest diseases.
• History of Irritable bowel syndrome and diverticulitis.
Family History: Irrelevant
Investigations:
• MRI on the brain (done on 19/8/2013) revealed no significant abnormalities with preserved major intracranial flow voids.
• Ophthalmologic and ENT examinations revealed no abnormalities.
Lab results:
• CBC within normal range.
• HbA1c ranges from 6.2-6.7%.
• Calcium and electrolytes within normal.
• Liver function tests are normal.
• Renal Function tests are normal.
• ECG is normal.
• Lipid profile is normal.
. Thyroid truncation tests including thyroglobulin antibody and microsomal antibodies are within normal
ESR is within normal
I proceeded to do acetyl choline receptor antibodies, results will be collected within 10 days
Medications used:
• Metformin 1000mg, twice daily.
• Atorvastatin (Lipitor) 20mg, once daily.
• Vitamin B1, B6, B12, one tablet, twice daily.
• Vitamin D 25,000 IU, once weekly for two months and then stopped for one month.
• Aspirin 81mg, once daily.
Cinnarizine 25 mg twice daily
Thank you for your cooperation and wishing to get a reply soon with an interpretation for my problem.
Sincerely,
Brief Answer:
CN palsy
Detailed Answer:
Hi Dr XXXXX,
From your history it is suggestive of some cranial nerve palsy due to DM . It may be III, IV or VI CN which has resolved after a minor attack. since you have got both horizontal and vertical diplopia I believe it is more of III CN palsy which has resolved in time.Since CN palsy may be idiopathic, aneurysm and vascular ( DM and HT) it looks its more of a vascular type in your case since you have DM and MRI is normal in your case. Go to the neurologist when you have diplopia as he may do Cranial nerve examination in a proper way.
Take Care
CN palsy
Detailed Answer:
Hi Dr XXXXX,
From your history it is suggestive of some cranial nerve palsy due to DM . It may be III, IV or VI CN which has resolved after a minor attack. since you have got both horizontal and vertical diplopia I believe it is more of III CN palsy which has resolved in time.Since CN palsy may be idiopathic, aneurysm and vascular ( DM and HT) it looks its more of a vascular type in your case since you have DM and MRI is normal in your case. Go to the neurologist when you have diplopia as he may do Cranial nerve examination in a proper way.
Take Care
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Dear Dr. Away
Thanks for your reply
Regarding the visit to a neurologist, I did actually, and in one visit I had one attack of vertical diplopia for 3 minuets and he examined me during the attack and after it passed and found nothing abnormal regarding the eye movement in all directions. The same thing was done by 2 ophthalmologists with the same findings.
One neurologist asked me to do acetylene choline receptor antibodies, and I did and waiting results ( for ? ocular mythenia)
Is the vascular cause may be the main etiology even I have controlled DM for all the time, and have no other manifestations for vascular ischemia?
If it is of vascular origin what is the proper treatment, and who will prescribe it, an ophthalmologist or neurologist?
Do you think that it may be a case of spasm of accommodation as it occurs almost when I shift from near vision to far vision?
What can I do now if I did visit 2 neurologists and 4 ophthalmologists, and what are the more investigations needed?
Thanks for your patience and best regards
Thanks for your reply
Regarding the visit to a neurologist, I did actually, and in one visit I had one attack of vertical diplopia for 3 minuets and he examined me during the attack and after it passed and found nothing abnormal regarding the eye movement in all directions. The same thing was done by 2 ophthalmologists with the same findings.
One neurologist asked me to do acetylene choline receptor antibodies, and I did and waiting results ( for ? ocular mythenia)
Is the vascular cause may be the main etiology even I have controlled DM for all the time, and have no other manifestations for vascular ischemia?
If it is of vascular origin what is the proper treatment, and who will prescribe it, an ophthalmologist or neurologist?
Do you think that it may be a case of spasm of accommodation as it occurs almost when I shift from near vision to far vision?
What can I do now if I did visit 2 neurologists and 4 ophthalmologists, and what are the more investigations needed?
Thanks for your patience and best regards
Brief Answer:
Neurologist follow up....
Detailed Answer:
Hi,
You definitely have to rule out ocular myasthenia. But the signs and symptoms what you described doesn't fit into it.
Secondly it's not spasm of accommodation. Symptoms in this condition persists for long time and also you would not have both horizontal and vertical diplopia. I believe its more of vascular origin, may be transient ischaemia which is causing all the symptoms for sometime and then becoming normal.
I believe nothing can be done much other than to control DM and continue ecosprin. The fluctuation in blood sugar level has to be checked. I think better visit a neurologist who can treat you on the cause of vascular origin of your symptoms. You should need to follow up with them regularly instead of consulting new ones.
Hope this helps.
Regards
Neurologist follow up....
Detailed Answer:
Hi,
You definitely have to rule out ocular myasthenia. But the signs and symptoms what you described doesn't fit into it.
Secondly it's not spasm of accommodation. Symptoms in this condition persists for long time and also you would not have both horizontal and vertical diplopia. I believe its more of vascular origin, may be transient ischaemia which is causing all the symptoms for sometime and then becoming normal.
I believe nothing can be done much other than to control DM and continue ecosprin. The fluctuation in blood sugar level has to be checked. I think better visit a neurologist who can treat you on the cause of vascular origin of your symptoms. You should need to follow up with them regularly instead of consulting new ones.
Hope this helps.
Regards
Above answer was peer-reviewed by :
Dr. Prasad
Dear Dr. XXXXXXX
Thanks for your reply and I'm consulting now a neurologist
Best regards
Thanks for your reply and I'm consulting now a neurologist
Best regards
Brief Answer:
thank you too
Detailed Answer:
Take care and best regards to you too
thank you too
Detailed Answer:
Take care and best regards to you too
Above answer was peer-reviewed by :
Dr. Shanthi.E
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