Horizontal Diplopia at Distance and Right Gaze

Kelly A. Malloy, OD; Jean Marie Pagani, OD


June 23, 2016

Clinical Presentation

A 38-year-old man presented with a chief symptom of horizontal diplopia for the past month. The diplopia was worse at distance and in right gaze. His vision in each eye was good, and he had not noticed any change in visual acuity.

The patient reported numbness on the right side of his face for the past 3 years. He feels that this started after eating a piece of pizza and burning the roof of his mouth. Although the numbness was initially concentrated on the roof of his mouth and the lower lip area, it seemed to slowly move upward.

About 3 or 4 months ago, he started to notice some numbness below his right eye. Also, when he tried to move his right eye to the right, he felt like there was something blocking it from moving fully. He stated that the right side of his face feels tingly and that his ability to chew has changed; he feels like he is chewing differently on each side, and this feeling has been present for the past year.

Otherwise, the patient denied any other visual or ocular symptoms. He also denied headache or any other neurologic symptoms.

One year ago, the patient saw a neurologist because of his right-sided numbness. He stated that MRI of the brain with contrast was performed and that the results were normal.

The patient's medical history is significant for postsurgical (tonsillectomy) deep venous thrombosis and pulmonary embolism. He received warfarin for 6 months but is no longer on blood thinners. His systemic history is remarkable for hypertension for 5 years, hypercholesterolemia, and possible arthritis in his knees. He is taking medication only for hypertension and hypercholesterolemia. His social history is unremarkable, and his family history is remarkable for diabetes, hypertension, and hyperthyroidism.

The findings on initial presentation were as follows:

  • Best-corrected visual acuity: 20/20 in the right eye, 20/20 in the left eye

  • Color vision (Ishihara): 14/14 in the right eye, 14/14 in the left eye

  • Pupils: equal, round, and reactive to light, with no afferent pupillary defect

  • Confrontation visual fields: full to finger-counting in both eyes; no red desaturation in either eye

  • Palpebral apertures: 8 mm in the right eye, 8 mm in the left eye

  • Exophthalmometry: 19 mm in the right eye, 20 mm in the left eye

  • Ocular motility: right abduction deficit, 70% normal (Figures 1-2)

  • Forced duction test: negative in the left eye (able to move eye out)

  • Cover test results: 4 eso in primary gaze, 35 eso in right gaze, and orthophoric in left gaze (Figure 3)

  • Slit-lamp examination: remarkable only for conjunctival injection, left eye greater than right eye

  • Goldmann applanation tonometry: 15 mm Hg in the right eye, 15 mm Hg in the left eye

  • Blood pressure: 156/96 mm Hg

Figure 1. Ductions, showing right abduction deficit.

Figures 2A-2E. Photographs showing right abduction deficit.

Figure 3. Esodeviation, which is greatest in the right gaze.

Dilated fundus examination revealed optic discs with distinct margins and no evidence of edema. There was 0.3 × 0.3 cupping in the right eye and 0.3 × 0.3 cupping in the left eye. The neuroretinal rim was intact and pink in each eye, with no evidence of pallor. The macula, retinal vasculature, and periphery were intact in each eye.

The patient was alert and oriented. Neurologic examination revealed cranial nerves VII-XII to be intact. There was facial numbness in the distribution of V2 and V3 on the right side, with no apparent involvement of V1. There was relative weakness of the muscles of mastication on the right side, as well as evident atrophy of the muscles of mastication on the right side compared with the left side (Figure 4). Motor, sensory, and coordination testing were otherwise unremarkable.

Figure 4. Marked right temporalis muscle atrophy.


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