Binocular Diplopia

[Mike Campbell]

Subject: Me
Issue: Binocular Diplopia
Discussion reason: For academic research
Event: After 3 days diving with University field school within minutes of last dive quickly presenting binocular diplopia. Unresolved 2 days on.
The Dives: 9 in three days . 4 in excess of 100 feet . All others 50 maximum with average 30 feet. Nixtox 30 on deep dives all within air tables no decompression, minimum 5 minute stops on deep dives.
Medical Intervention: called DAN. ER visit with CT scan and MRI both negative save sinusitis and minimal mastoiditis. Opthomologist tomorrow. Treatment so far antibiotics and steroids.
Diver background: 68yoa, 50+ years diving, Instructor for various agencies, NOAA trained in all extended range diving skills, paramedic/tactical EMT, single previous barotrauma partially resolved facial baropharesis , good health, active.
Considerations: sinus issues causing unusual use of Val salva to clear ( causative issue in my opinion)

Opinions?

I will update progress
Mike

 

[caruso]

Off the top of my head I'm thinking one possibility is that the sinus infection is causing periorbital swelling and restricting the movement of one or more of the extraocular muscles. Is the diplopia worse at distance or near? Can you recall ever having an issue with binocular vision, even going back many years, something along the lines of losing place when reading, focus lag when looking from close to far or the other way around, or even one or more incidences of intermittent double vision after prolonged nearpoint visual tasks?

Here's something for you to try. Grab a pen or other pointy object to use as a fixation target. Hold it directly in front of you and note the amount of diplopia, and if there is a vertical component to it, or if it's just horizontal. Next, close one eye and then the other and determine if its "crossed" diplopia- meaning the image on the side opposite the closed eye disappears or is it the image on the same side? If it's "crossed" diplopia then fixate on something further away and try the same test and see if the objects are closer- they should be.

Next move the fixation target in a large circle and note if the amount of the diplopia changes or remains the same in different positions of gaze. If it's worse in one position, note what that position is, and if there is a position that eliminates the double vision.

Post the findings here.

 

[Mike Campbell]

Sorry... got busy as you might expect.
It’s crossed.
Circular movement of object counter clockwise double vision of hand held object begins about 240 degrees reaches max at about 100 degrees . Clears from about 10 degrees to 240.
Looking forward right lower quadrant is the issue it seems.
Headed to OD this morning for Duke referral.
Thanks for your input!
Mike
Ps
No past Diplopia. Shrapnel to face, various facial skin cancer, 7 th cranial nerve over pressure to right side of face ( dive related), IIIR, facial reconstructive surgery....

 

[Mike Campbell]

Should be , clears from about 240 to 10 counter clockwise....

 

[Duke Dive Medicine]

Subject: Me
Issue: Binocular Diplopia
Discussion reason: For academic research
Event: After 3 days diving with University field school within minutes of last dive quickly presenting binocular diplopia. Unresolved 2 days on.
The Dives: 9 in three days . 4 in excess of 100 feet . All others 50 maximum with average 30 feet. Nixtox 30 on deep dives all within air tables no decompression, minimum 5 minute stops on deep dives.
Medical Intervention: called DAN. ER visit with CT scan and MRI both negative save sinusitis and minimal mastoiditis. Opthomologist tomorrow. Treatment so far antibiotics and steroids.
Diver background: 68yoa, 50+ years diving, Instructor for various agencies, NOAA trained in all extended range diving skills, paramedic/tactical EMT, single previous barotrauma partially resolved facial baropharesis , good health, active.
Considerations: sinus issues causing unusual use of Val salva to clear ( causative issue in my opinion)

Opinions?

I will update progress
Mike

Mike, you mentioned your CT was negative... did it say anything about a bony dehiscence (i.e. an area where bone is missing) anywhere in the sinuses? If it presented quickly as you describe it seems like it's pressure-related. Sorry if this is an obvious question given that you visited an ED, but they did rule out decompression sickness, correct?

Best regards,
DDM

 

[Mike Campbell]

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

 

[caruso]

Sounds like paralytic strabismus of an oblique muscle probably due to pre-existing scar tissue and nerve damage and further complicated by a minor ischemic event during your recent dive causing further damage that exceeded your remaining fusion reflex. Surgery not indicated - you’ll likely end up with prismatic correction in eyeglasses. There’s a fair chance this will resolve on its own. Any improvement will be within 6 months with a slim chance of further improvement up to 1 year.

 

[Mike Campbell]

So. The initial diagnosis is palsy to cranial nerve 6 and possibly 3 from (baro) trauma. Right eye is not completely finishing its tract.
While it’s hard to say exactly where the damage is without MRA it is likely in the same area damaged arresting the ascent of a student in 2014 (details of that posted then in accidents topics). That damaged nerve 7 and it has never fully resolved.
First impression is that it will resolve on its on though no schedule.
Optic neurologist appointment Wednesday.
The saga will continue...

DDM there should be a file opened up yesterday at the DAN medical...my # is 123632. 25 years ago I knew everyone including former students who worked at DAN but most have aged out...
Mike

 

[chillyinCanada]

Wishing you a speedy and good result.

 

[Mike Campbell]

Thank you Chilly and all those who’ve added to the answer to the puzzle!
Mike