DIPLOPIA

e.c MIASTENIA GRAVIS

Oleh: mifta sari puspa ningrum (173601117)

Pembimbing : dr. Rahmat Syuhada Sp.M

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Patient identity

 Name : Mrs. K M
 Age : 39
 Sex : Female
 Occupation : entrepreneur
 RM Numbers : 07732211
 Hospitalized :29/06/2018

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Anamnesis

 Autoanamnesis , 29 june 2018

 Main complaint:
Patient have double vision since ± 1 week ago
o Additional Complaints:
Patiiet has both eyelids down since ± 1 week ago

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Diseases history now

since ± 1 week ago Patient have double vision and Patiet has both eyelids down since ± 1

week ago. Patient have history of Myasthenia gravis since ± 2 years ago.

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Pass diseases history

 Past eye disease history (-)

 History wearing glasses (-)
 The history of hypertension is denied
 History of diabetes mellitus is denied
 Patient have hhostory of Myasthenia gravis since ± 2 years ago.

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Faily disease history

 The history of both parents wearing glasses (-)

 The history of the disease with the same complaint in the family is denied

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Physical investigation

Patient Status
 Awareness : compos mentis
 Blood Pressure : 100/80 mmHg
 Nadi : 90x / min regular
 Temperature : 36.7 C

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Ophthalmological status

OD OS
20/30 Visus 20/30
-0,50 – 20/20 Correction -0,50 = 20/20

Ptosis (+), Hiperemis (-), Palpebra superior Ptosis (+), Hiperemis (-),
edema (-) edema (-)

Hiperemis (-), edema (-) Pallebra inferior Hiperemis (-), edema (-)
cont
OD OS

Papil (-) Conjungtiva Papil (-)

Folikel (-) Folikel (-)
palpebra
Papil (-) Conjungtiva fornices Papil (-)
Folikel (-) Folikel (-)

Injeksi (-) Conjungtiva bulbi Injeksi (-)

Fibrovaskular tissue (-) fibrovaskular tissue(--)

Injeksi (-) sclera Injeksi (-)

cont
OD OS

Clear Cornea clear

mild, pus (-) blood (-) Camera oculi anterior mild, pus (-) blood (-)

Kripta iris normal, brown color Iris Kripta iris normal, brown color

Spherical, d: 3mm, light reflex Pupil Spherical, d: 3mm, light reflex

(+) (+)

Clear Lensa Clear

Diagnosis of work

Diplopia ODS et causa

Myasthenia gravis

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DIFFERENT DIAGNOSIS

 Ambliopia
 bleparoptosis

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PROGNOSA
 Quo ad vitam : dubia ad bonam
 Quo ad functionam : dubia ad bonam
 Quo ad Sanationam : dubia ad malam
Treatment
 Medicamentosa
 Mestinon 2x1 tab
 Neurodex 3x1 tab
 C.lyteres 6 dd gttt 1 ODS
 Cefixim 2x1 tab
 Artificial tears
 Cendo lyteers 33 dd gtt 1 ods
 Non medicamentosa
o Regulary taking drug of Myathenia gravis ( mestinon)
o Do not get tired 13
Discussion

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Definition of diplopia

The term diplopia is derived from greek

-Diplous : double
-Ops : eye

-The eyes normally positioned so that the image fall exactly on the
same spot on the retina of each eye.

-Slightest displacement of either eye causes DIPLOPIA as the

image is shifted to a different position on the retina of the
displaced eye. 15
 Patofisiologi

Requirement of normal ision :

1. The retina of both eyes receives both images
simultaneously

2. Fusion : when both eyes of the retina make the

same visual impression. i.e the transmission of
idential images to the brain, 2 images of the
mixture will mingle into a single perception

3. The central nervous system is able to pick up the

stimuli coming from the two retinas and integrate
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them into a single shadow.
Classificaion of diplopia

Diplopia

Pathological Physiological

Monocular Binocular

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Evaluation of diiplopia

 Determine the nature either

• Monocuar or binocular

• Monocuar is often an ocular problem

• Binocular occuur when the mage produced by the two eyes do not absolutely match.
- so that image produced are relatively misaligned
-mainly a neurological problem

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Common cause of monocur diplopia

 Astigmatism
 Keratoconus
 Pterygium
 Cataract
 Lens dislocation
 Massa orr swelling in the ayelid
 Drry eyes
 Retinal disorder

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Common cause of binocular diplopia

 Strabiismus
 Due to waekness of extra oclar muscle of eye
 Myasttheia gravis

 Grave’s disease
 Trauma o the eye muscles

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Anamnesis
Three important symptoms should be asked
1. Is closing one eye making diplopia lost?
2. Is the deviation equal in all directions of gaze (view) or by bending and rotation
of the head in various positions ?
3. Is the second object visible horizontally (side by side) or vertically (up and
down)?

Patients should be asked specifically about the decreased visus, trauma, childhood
strabismus, amblyopia, and previous eye surgery or strabismus. It is also important to
look at the entire neurological and ophthalmic systems

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Binocular Diplopia Check

 Examination of Eyeballs, Orbits, and Eyelids

 Examination of Extraocular Muscle Movement
 Neuromuscular Junction Examination
 Examination of Extraocular Muscle Movement
 Brainstem examination
 Examination of supranuclear pathways

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Management

 The management of diplopia depends on the cause of diplopia itself. In the case of
monocular diplopia, refraction correction is made
 in chronic cases, binocular diplopia, MRI is an indication unless the etiology is clear.
Surgery or administration of medications or the use of a prism lens may reduce the
symptoms of diplopia when its aetiology has been discovered and general conditions
have been favorable

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cont

 Clinical
 closes one eye
 The stick-on occlusive lens can be applied to the glasses to minimize the handicap on the
use of the blindfold, while blurring one eye to minimize the annoying double vision.
 Prism Fresne
 Treatment of myasthenia gravis: mestinone or long-acting anticholinergic agent, as well as
corticosteroids
 Surgery

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Myasthenia gravis

 Myasthenia gravis is characterized by weakness and rapid fatigue of any of the muscles
under your voluntary control.
 Myasthenia gravis is caused by a breakdown in the normal communication between
nerves and muscles.
• Major cause of diplopia
• Dipopia is ofen intermittent, variable, not confined to single ocular motor nerve distribution
• Fluctuating ptosis my be present
• Diagnosis:
 - IV edophonium inj -> reversall of eyelid or eye muscle weakness
 -antibodies against AH rreceptor or MuSK protein

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Prognosis

 as a rule of thumb, patients with multiplexed diabetic mononeuritis recover spontaneously

within 6 weeks.
 Optical causes (eg lens dislocation, corneal abnormalities) can be corrected.
 Blowout fracture has a different prognosis depending on the number of damaged tissue
 Central (neurologic) causes diplopia can have serious consequences and in the case of
primary or secondary tumors, the prognosis is ugly
 In Miastenia gravis Ocular, where the weakness in the eye settled more than 2 years, only
10-20% developed into generalized myasthenia gravis.

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