A 55-Year-Old Woman With Double Vision

Monica Pacheco, MD; David K. Coats, MD; Kimberly G. Yen, MD

Disclosures

October 24, 2008

Clinical Presentation

A 55-year-old woman presented to the eye clinic for evaluation of double vision that had been present for 3 weeks and resolved only when 1 eye was occluded. Of significance, the patient had been found in bed unresponsive by her husband about 3 weeks prior. She was taken to the hospital and was admitted to the intensive care unit for 3 days. The patient did not recall this event, but her husband reported that they were told that "all of the salt was gone from her body." When she awoke she complained of horizontal diplopia. A brain computed tomography scan was normal per her husband's report. She did have some deficits related to this incident, including poor balance, requiring a cane to walk, and slurred speech.

A call to the patient's primary care physician completed the story. He indicated that the patient was thought to have psychogenic polydipsia that had led to severe hyponatremia. During her hospitalization, she had severe cerebral edema and seizures. The patient also had a history of an Arnold Chiari malformation.

An eye examination revealed 20/30 uncorrected visual acuity in both eyes. Motility examination revealed a 50PD exotropia at distance and a 14PD exotropia at near (Figure 1). Versions were significant for left eye adduction limitation on right gaze and right eye adduction limitation on left gaze. Dissociated horizontal nystagmus developed in the abducting eye in extremes of gaze. Mild upbeat nystagmus developed in eccentric gaze. Slit lamp and dilated fundus examination were within normal limits.

A. Patient is looking to the right; note adduction deficit of the left eye. B. Patient is looking to the left; note adduction deficit of the right eye.

Arnold Chiari malformations are associated with this type of nystagmus:

  1. Upbeat nystagmus

  2. Convergence-retraction nystagmus

  3. End-point nystagmus

  4. Downbeat nystagmus

  5. See-saw nystagmus

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All of the following are among the differential diagnosis of an adduction deficit, except:

  1. Postsurgical medial rectus muscle slip, stretched scar, or loss

  2. Partial third nerve paresis or palsy

  3. Internuclear ophthalmoplegia

  4. Acquired Brown's syndrome

  5. Myasthenia gravis

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Deficit of adduction combined with horizontal nystagmus in the abduction eye is commonly associated with:

  1. Postsurgical medial rectus muscle slip, stretched scar, or loss

  2. Partial third nerve paresis or palsy

  3. Internuclear ophthalmoplegia

  4. Acquired Brown's syndrome

  5. Myasthenia gravis

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What is the next step in this case?

  1. Brain magnetic resonance imaging (MRI) with attention to brainstem

  2. Repeat brain computed tomography (CT)

  3. Orbits CT

  4. B-scan

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