Case 6

1
Case 6
2
Presentation

• 39 year old painter and decorator presents with
  vertical double vision .
• Present for 3/12.
• Attends with his wife , who made him come about
  the problem.

3
First thoughts

• List

4

• Thyroid?
• Something orbital?
• Neurological?
• Refractive/ Glasses
• Sinus disease?
• Trauma?

5
Further history required.

• List

6
Suggested questions

• When is it noticed most?
• How much worse has it got lately.
• Are things absolutely vertical or is there a
  slope on objects?
• Vision OK in each eye ?
• Any other visual symptoms?

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Visual Examination

• list

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Examination

• Some limitation of up gaze Right eye.
• Vr 6/6 Vl6/9
• Fundi, ocular media nad.
• R pupil sluggish and slightly irregular.
• Confrontation fields full.
• Slight droop in R eyelid cf L.

9
Further history

• Worse when takes a high mark ( plays weekend
  AFL).
• No history of trauma admitted.
• Poor historian and resents wife , making him
  come.
• Thinks he will just see the optometrist.

10
Further presentation

• Double getting worse and given glasses with
  prisms by optometrist.
• Having difficulty with job on ceilings.
• CAT scan suggested and refused.
• Walks out in a huff and says he will see
  optometrist again.
• Reappears 2/12 later with thick glasses and
  requests certificate for social security as cant
  work now.
• Wife states he complains of pain in his face (
  malar region).

11
Suggestions?
12
Consents to a CAT scan of brain and orbits. Scan
NAD reported. What next?
13
Referred ophthalmologist Xrays of orbits redone
show See Xrays.
14
Blowout fractures can be missed on sagittal
views Wife remembers him having a black eye 6/12
ago. His good mate hit him accidentally and he
didnt want to mention it! Pain in face due to
infra orbital nerve involvement