Download Wong, L

Lisa Wong, OD
Vision Therapy and Low Vision Rehabilitation Resident
Southern College of Optometry
I.
Case History
 Patient demographics: 42 year-old white male
 Chief complaint: Constant diplopia, horizontal and vertical
 Ocular, medical history:
o First seen 7/10/15 for an optometric consult at a rehabilitation facility after
suffering a thalamic hemorrhage on 7/2/15.
o No previous eye examinations
o Medical history remarkable for sleep apnea, no other known conditions.
 Medications: None currently
 Other salient information:
o Inpatient at rehabilitation hospital 7/8-7/22/15, presented to SCO on 7/23/15
for visual efficiency examination.
II. Pertinent Findings
 Clinical:
o Refractive: Emmetropic with early presbyopia.
o Ocular motility:
 Horizontal eye movements: full
 Vertical eye movements:
 7/10: 30% past midline superiorly and inferiorly
 7/21: 25% inferiorly
 7/23: 10% superiorly and inferiorly
 8/20: 50% superiorly, 40% inferior
 Saccades: 5/2/5/5 on NSUCO
 Pursuits: Unable to complete test due to vertical gaze palsy, no head or
body movement
o Ocular alignment:
 7/10: 20Δ IAXT with 5 Δ right hypertropia at near
 7/21: 9 Δ right hypertropia
 7/23: 18 Δ CAXT, 10 Δ right hypertropia distance and near
 8/20: 6 Δ CAXT with 4 Δ right hypertropia at near, 4 Δ CAXT with 5 Δ right
hypertropia at distance
o Motor-Free Visual Perceptual Test-3
 Raw Score=50, Standard Score=81, percentile rank 10%
 Difficulty with figure-ground and short term memory
o Rapid Automatized Naming/Rapid Alternating Stimulus Test
 Numbers (SS=107), Letters (SS=101), 2-set (SS=107) and 3-set (SS=109):
Average
 Colors (SS=87): Below average
 Objects (SS=67): Very poor
o King-Devick: Test I: 26s; test II: 25s, Test III: 26s. Total: 77 seconds
o
Humphrey Visual Field 24-2: Scattered defect inferior OD, no defect OS.
Questionable reliability.
 Physical:
o Patent foramen ovale
o Unknown cerebral vasculature abnormality (updated medical records will be
requested)
 Laboratory studies:
o Sodium, chloride, potassium, bicarbonate, platelets, hematocrit, white blood
count, BUN: normal
o ALT: high
o Blood toxicity screen: barbiturates
 Radiology studies: MRI/CT – consistent with thalamic hemorrhage
 Others: N/A
III. Differential Diagnosis
 Vertical gaze palsy secondary to bilateral medial thalamic hemorrhage
IV. Diagnosis and Discussion
 Thalamic infarctions comprise 11% of all vertebrobasilar infarctions, and are categorized
based on the four main thalamic arterial blood supplies. Inferolateral infarcts are the
most common (45%), followed by areas supplied by the paramedian artery (35%)—
which includes the medial area—and polar arteries (12.5%). In one third of the
population, the polar artery is missing and its territory is supplied by the paramedian
artery.
 Medial thalamic infarcts are characterized by deficiencies in short term memory,
attention, intellect, and vertical gaze. Mild hemiparesis or hemiataxia may be involved,
but were not seen in this case. Unilateral thalamic lesions typically cause upgaze palsies,
while bilateral lesions cause upgaze, downgaze, or combined vertical palsies with other
abnormalities such as convergence paralysis, bilateral internuclear ophthalmoplegia,
and a Horners syndrome.
a. A study by FJ Rowe and the VIS Group in 2009 found that strabismus occurred in 16.5%
of patients after a stroke, with 24% of those attributed to insults to subcortical areas
(cerebellum, brainstem, basal ganglia, or thalamus). 64% of their study sample (n=512)
received intervention (Fresnel prism, orthoptic exercises, spectacles, total or sector
occlusion) to alleviate diplopia. Some patients may show improvement in symptoms
with little to no intervention. In patients with thalamic strokes, evidence of spontaneous
recovery of downward eye movements has been reported; however, the upgaze palsy
appears more persistent (Clark and Albers).
V. Treatment, Management
 Treatment:
o 60mm binasal occlusion with inferior sector occlusion prescribed at
rehabilitation hospital. Initially attempted 10 Δ BI OD, OS Fresnel prism, but
patient preferred binasals.
o Vision therapy with binasal occlusion began on 7/30/15
 Week 1: Thumb rotations, head rotations, vertical saccades, closed eye
rotations, vertical OKN
 Vertical OKN reflex absent
 Week 2: Thumb rotations, vertical saccades, VO star, vertically split
Marsden ball
 Unable to vertically align Marsden ball, with or without binasal
occlusion at any distance.
 Week 3: Thumb rotations, vertical saccades, VO star
 Week 4: Thumb rotations, vertical saccades, vertically split Marsden
ball, vertical OKN
 Vertical OKN response present superior to inferior OD, OS.
 Able to vertically align Marsden ball easily, with 37mm binasal
occlusion, from 6 inches to 8 feet away.
 Response to treatment:
o Patient has decreased binasal occlusion from 60mm to 37mm, with a marked
reduction in exotropia. He is able to fuse at arm’s length without binasal
occlusion.
VI. Conclusion
 Clinical Pearls:
o Vertical gaze palsies are the most common ocular motility defect in a thalamic
insult. Vision therapy can be an effective treatment to improve ocular motility
ranges.
o Binasal occlusion may help fusion in these patients with vertical diplopia.
Bibliography:
1. Adamec, I., Barun, B., Lakusic, DM., Ozretic, D., Brinar, VV., and Habek, M. “Neuro-ophthalmic
Manifestations of Thalamic Stroke.” Neuro-Ophthalmology. 2011; 35(3): 121-124
2. Afifi, AK., Bergman, RA. Functional Neuroanatomy: Text and Atlas, 2nd edition. New York: Lange
Medical Books/McGraw-Hill. 2005. Print.
3. Clark, JM., Albers, GW. “Vertical Gaze Palsies from Medial Thalamic Infarctions Without
Midbrain Involvement.” Stroke. 1995; 26: 1467-1470.
4. Jones, E. and Rowe, FJ. “Ocular motility consequences following lesions of the thalamus: a
literature review.” British and Irish Orthoptics Journal. 2009; 6: 40-46.
5. Perren, F., Clarke, S., Bogousslavsky, J. “The Syndrome of Combined Polar and Paramedian
Thalamic Infarction.” Archives of Neurology. 2005; 62(8): 1212-1216
6. Rowe, FJ and VIS Group UK. “The profile of strabismus in stroke survivors.” Eye. 2010; 24: 682685
7. Wians, FH. “Blood Tests: Normal Values.” Merck Manual Online, Professional Version. Accessed
online 24 Aug 2015. <http://www.merckmanuals.com/professional/appendixes/normallaboratory-values/blood-tests-normal-values#v8508814>