Binocular Diplopia

[caruso]

So. The initial diagnosis is palsy to cranial nerve 6 and possibly 3 from (baro) trauma.

Cranial nerve 6 feeds the lateral rectus muscle which is responsible for "abduction" (movement away from body midline) or moving the right eye to the right. Cranial nerve 3 feeds several muscles but in your case it seems to be the inferior oblique muscle that is affected which would cause the diplopia to be worse in your diagonal fields of view, primarily upwards and outwards which is supported by what you said about your double vision however you say your diplopia is crossed indicating an "exotropic" or underconverged or "wall eye" condition but you also say that you can see normally when looking to the upper LEFT which means the right eye can turn inwards, not outwards. Those two findings are conflicting.

Right eye is not completely finishing its tract.

No clue what that means, perhaps it simply means the right eye is incapable of moving through it's full natural range of motion? The term "intractable diplopia" typically refers to an issue that cannot be improved.

At any rate the problem appears to be neural, not due to scarring or inflammation, so you're looking at up to a year for what is hopefully complete resolution of symptoms with the first 6 months being a good indicator. No treatment except for prism in the eyeglasses or perhaps experimenting with head positioning such as tilting to one side or turning your head to one side to minimize the double vision. It may not be possible now but as things improve, less movement will be necessary to compensate.

Should a doctor suggest patching one eye to temporarily eliminate the double vision I would strongly caution against doing that for reasons I can get elaborate on if the issue is raised. Speak to your doc about the possibility of a prismatic correction in the right lens in eyeglasses, or possibly splitting the prism correction between both lenses to minimize thickness and distortions, even though the right eye appears to be the issue. It won't work in all fields of vision but would probably eliminate the diplopia in straight ahead viewing and then you'd only have to turn your head more when looking to the right and down to avoid the split images. I know this because there are certain fields of view that allow you to see without double vision. There are "stick on" temporary prisms that can be used on a trial basis before grinding permanent lenses that can be a bit costly.

Finally- you really need to consider if continued diving is worth the risk of additional damage, clearly you are susceptible.

 

[Duke Dive Medicine]

Well.. they kinda did.. I was talking to the emergency line and they were pretty sure based on the info no AGE and likely no DCS .. of course the neurologist asked me what that was....I’m leaning toward some type of mask barotrauma from heavy Val salva due to congestion... which means it will almost certainly be something else..,
No mention of sinus issues but it’s been an interesting life so far...
Enroute to OD now...probably a referral on up to Dook....
Mike

Mike, this is probably not mask barotrauma. That is a barotrauma of descent that occurs if you don't exhale through your nose, and if it's bad enough to cause diplopia you'd have visible barotraumatic damage: periorbital ecchymosis, reddened conjunctiva, kind of like you'd been in the ring with Chuck Liddell. A hard Valsalva maneuver could have conceivably pressurized a sinus enough to cause some barotramatic damage - the diagram below shows the relationship of some of the cranial nerves, including CN VI, to the sphenoid sinus. This is why I asked about a bony dehiscence - normally these nerves are protected by a layer of bone but in some people, part of the bone is absent. The diagram is for another condition but it shows the anatomy reasonably well. If there was no mention of it on your CT read then you probably don't have it, but FWIW and for posterity:

https://i.pinimg.com/originals/bf/bf/e0/bfbfe0a4da24f6ff87cdba03b9b4f629.jpg

Here's another possibility:

Spontaneous subcutaneous orbital emphysema following forceful nose blowing: Treatment options

If you forced air into your orbit, it may not have shown up on CT depending on how far out from the injury you were, but it could have caused inflammatory damage, which is parallel to what @caruso was talking about. Also @caruso please feel free to add thoughts here.

Has this gotten any better since you first posted?

Best regards,
DDM

 

[Mike Campbell]

Morning all,
DDM there was no mention of a bony dehiscence. i have a dvd of both the CT and MRi but there is no discussion of findings. The oral report to me was pretty severe sinusitis and mild mastoiditis. But again, this was an ER in Georgia on a Saturday morning so that they had to call in an MRI technician, so....
It has not gotten better or worse. I have single vision out to about two feet then the diplopia takes over.
The optometrist noted that my right eye does not completely follow through when I follow movement and also that my right eye lids show more of my right eye than the other, but as far as the latter goes, since my injury and resulting semi paralysis of that side of my face in 2014 it seems to me to look the same as usual. A complete exam with dilation showed healthy internal eyes. So her thought is that this is related to a palsy of those nerves. My 7th cranial was the one damaged in the earlier incident that resulted in facial baropharesis that has pretty much resolved save the slight damage aforementioned. So I assume it reasonable to believe perhaps the same area for injury?
I have an appointment with an optic neurologist in Smithfield tomorrow morning.
The ONLY thing that I did differently this time from several hundred dives over the past couple years was the forceful val salva a number of times trying to follow students onto the Duane and Speigel. The issue presented about twenty minutes or so after two shallow afternoon dives after the deeper dives of the morning. Progressed to full binocular diplopia within 24 hours.
All those heady push the limits diving of the late 60's and 70's and drinking rum with Morgan Wells figuring out mixes I never came close to getting hurt. Been at ECU for 17 years now been hurt twice...so...Y'all keep inputting, I appreciate it....
Mike.

 

[caruso]

Nothing more to add, other than to be a bit repetitive. I'm not understanding why, given that you are walking around with constant double vision in straight ahead (and most primary gaze positions), that the optometrist didn't discuss the possibility of prismatic correction to alleviate the symptoms, regardless of the underlying causes. Were you at least checked with a prism bar, or prisms in the 'phoropter' (the big device with all the lenses in it that you look through) and asked if you see two separate objects and instructed to tell the examiner when the objects are lined up horizontally and vertically as they rotate the lenses? Because that's how the optometrist determines the amount and extent of the strabismus, which not only gives an idea of whether the angle of deviation is low enough to treat with prism, and perhaps more importantly, gives a baseline to compare to open re-examination down the line which will hopefully show improvement.

How are you functioning on a day to day basis with the double vision? Are you driving?

 

[Mike Campbell]

I’m thinking that may happen at least in discussion tomorrow. I’m set to return to the optom after then.
I walk around with one eye squinted a lot. I have one of those eye patches you mentioned but am yet to use it. Wife drives me about at this point.
It’s obvious I need to do something to alleviate some degree of the symptoms until resolution to whatever extent that occurs...

 

[Duke Dive Medicine]

Morning all,
DDM there was no mention of a bony dehiscence. i have a dvd of both the CT and MRi but there is no discussion of findings. The oral report to me was pretty severe sinusitis and mild mastoiditis. But again, this was an ER in Georgia on a Saturday morning so that they had to call in an MRI technician, so....
It has not gotten better or worse. I have single vision out to about two feet then the diplopia takes over.
The optometrist noted that my right eye does not completely follow through when I follow movement and also that my right eye lids show more of my right eye than the other, but as far as the latter goes, since my injury and resulting semi paralysis of that side of my face in 2014 it seems to me to look the same as usual. A complete exam with dilation showed healthy internal eyes. So her thought is that this is related to a palsy of those nerves. My 7th cranial was the one damaged in the earlier incident that resulted in facial baropharesis that has pretty much resolved save the slight damage aforementioned. So I assume it reasonable to believe perhaps the same area for injury?
I have an appointment with an optic neurologist in Smithfield tomorrow morning.
The ONLY thing that I did differently this time from several hundred dives over the past couple years was the forceful val salva a number of times trying to follow students onto the Duane and Speigel. The issue presented about twenty minutes or so after two shallow afternoon dives after the deeper dives of the morning. Progressed to full binocular diplopia within 24 hours.
All those heady push the limits diving of the late 60's and 70's and drinking rum with Morgan Wells figuring out mixes I never came close to getting hurt. Been at ECU for 17 years now been hurt twice...so...Y'all keep inputting, I appreciate it....
Mike.

Mike,

This is probably not related to cranial nerve VII, the facial nerve takes a different route than the ones governing the eyes, though if you have a history of facial baroparesis it might raise the index of suspicion that sinuses are involved here as well. I'm not sure decompression sickness can be completely ruled out either, although diplopia in the absence of any other symptoms along with confirmed forceful Valsalva might steer one away from that diagnosis. What's your present location? I think in addition to the ophthalmologist, you need to be evaluated by a physician trained in diving medicine. I'd also recommend you bring the DVDs of your radiologic studies to the ophthalmologist.

Best regards,
DDM

 

[Mike Campbell]

Hey DDM
I’m in Beaufort. Son in law is in Dukes 3D print section, grandsons probably need a visit, so if you will direct me to the appropriate dive medicine physician I shall be on my way...
Thanks
Mike

 

[Mike Campbell]

DDM
Is there a direct # I can use to contact you at Duke or a university system e mail I can use?
Mike

 

[Mike Campbell]

DDM
Talked to the office a bit ago and will be setting appointment after neurologist today...
Thanks
Mike

 

[Duke Dive Medicine]

Sorry, just saw this and spoke with them, understand you're getting in today. Good to hear, will be interested to hear what the MDs say.

Best regards,
DDM