Diplopia in children

Dr Hilde Deconinck in children is rare z Critical period of visual development J Visual acuity J z Sensory adaptation : J Pathologic suppression and ARC develop only in the immature visual system Symptoms of diplopia in children

z Torticollis z Rubbing in one eye z Closing one eye z “I see two daddies” Conditions for binocular single vision

z Simultaneous use of both eyes with bifoveal fixation z Normal routing of visual pathways with overlapping visual fields z Binocularly driven neurons in the visual cortex z Normal retinal correspondence Conditions for Binocular Single Vision

z Accurate neuromuscular development so that visual axes are directed at and maintain the fixation on the object of regard z Approximately equal image clarity and size for both eyes

5 titel 29-11-2011 Development of binocular vision z Bifoveal fixation z Fusion of 2 retinal images into a single image in the mind J Sensory fusion: Corresponding retinal points project to the same cortical locus where the input is integrated into one image J Motorfusion : maintenance of motor alignement of the eyes to sustain bifoveal fixation. (driven by retinal disparity) Development of binocular vision

z Stereopsis : J Stereopsis is bridge between fusion and diplopia

retinal disparity is to great to permit simple superposition of the two visual directions but to small to elicit diplopia

7 titel 29-11-2011 Binocular Single Vision

z Each fovea fixates identical point

z Corresponding retinal points horopter

z 3- dimensional space : Panum’s area

8 titel 29-11-2011 Manifest deviation of the eyes

z Diplopia: J Image on the fovea in one eye and a nonfoveal corresponding point in the other eye of one object z Confusion : J perception of two different objects on corresponding retinal points

9 titel 29-11-2011 Sensory adaptations to z Su p p r essi on : J The image of one eye is inhibited to reach consciousness during binocular activity J Central suppression (fovea) : confusion J Peripheral suppression : diplopia z : with constant unilateral foveal suppression of one eye J non alternating strabismus Sensory adaptations to strabismus

z Abnormal Retinal Correspondence J Condition where the fovea of the fixating eye has acquired an anomalous common visual direction with a non foveal point in the deviated eye J Allows some binocular vision in the presence of heterotropia

11 titel 29-11-2011 Case report 1 z Girl 7 y z intermittent diplopia since one week z General history : excellent schoolresults, no complaints, normal activity z Anxious because of double sight z Ophtalmological and orthoptic examination: perfectly normal z Diagnosis : physiological diplopia Physiological diplopia z Occurence depends on the attention paid to double images z Normally retinal rivalry prevents image to reach the conscious mind (physiologic suppression) z double vision : outside Panum’s area z fingertest Case report 2 Boy 4 y z Sudden convergent squint, closing one eye z Positive history in family for strabismus and hypermetropia z Visual acuity : 0.4 logMar both eyes z CT : esotropia OD, can alternate fixation z M : RF=LF :+18° Syn : RF=LF :+21° z No motility restrictions or incommitance z Convergence normal z Cycloplegic refraction +5.5 ODS Optical treatment

z Full correction +5.5 ODS z Alternating occlusion untill optic correction available z One week later cc esophoria, Lang – z After 7 months correction : recurrent diplopia z Stronger glasses +6.5 ODS z Continues to close one eye with full correction, mentions diplopia Surgery : 5 mm recession of both medial recti

z No diplopia z Does not want to wear correction z Visual acuity : J OD : 0,9 sc J OS : 0,7 sc z Bagolini test : BSV-ARC z CT : no movement to microexotropia ? z Stereoscopy : 400” titmus test

16 titel 29-11-2011 conclusion

z Acute concommitant strabismus with diplopia z latent hypermetropia z Probably underlying ARC z Recovered after surgery z Carefull follow up and occlusion left eye 1h/day

17 titel 29-11-2011 Case report 3 z Girl 15 y J Agresssion in the metro J Hospitalisation with retrograde amnesia and mutism J Alternating esotropia, with diplopia and photophobia, dilated pupils (medical) J No motility restriction J Eyefundus normal Ophthalmological work-up 2 days later

z Known latent hypermetropia :+ 4 z Partial correction at home z Treatment : optical correction z Net regression of diplopia, and no diplopia after 2 days z Controle 6 months later : no complaints , no correction anymore Stress on visual system with accommodative anomaly

z Rupture of sensory fusion secundary to stress z Diplopia z Relief of “overaccommodation” with partial correction z Normalisation of fusion Girl 6 years z Deep amblyopia OS secundary to partial congenital cataract and microdivergent strabismus z Operated and pseudophake : with optimal correction 0,2 z Excentric fixation treatment

z Optical correction with addition for near z Total occlusion during 3,5 months : visual acuity of 0,4 z During 6 months occlusion 8-18h : 0,5

z Reduction of occlusion since complaints of diplopia

z Cave intractable diplopia

22 titel 29-11-2011 Conclusion

z Physiological diplopia z Sudden concommitant strabismus z Disruption of fusion by accommodative spasm z Diplopia after occlusion treatment

23 titel 29-11-2011