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Show j 19 h Ra en rre5~, cw Y rk Edit Mon cular Diplopia ears < go, mon) "Ldilr diplopi. Wil cunsidered to b a hv, t ricalor flln ti nal - Il11ptom. In uther word ,\.~'hen p ti"nt tated that wh n 10 king d ",,,n th highwa, h aw two ar c min ll al him-and en wh n h ver d hi right e. h till aw two ars when th r wa - really ani n -it wa a' um d that thi IIIl1S1 b Y h - I i al r n n rgani problem. It \ a. sub equ ntly I arn d, how v r, that thi conclu i n wa u uall 1/0/ true, and th t the v t majorit. of pati nt with mono ular diplopia had the 111plaint n a r fra tive or ptical ba i . B iar lh m t mm n cau f m n cular dipl pia i v r I early in ipi nt ataract, and the pro f that th probl m i optic I, four m fr m doin a ar full. p rf rm d pinh Itt. If th m nocular dipl pia di ppe r wh n 10 kin thr ugh a t n peic aperture, that pr th pr bl m is optical. r fra ti , r in lh media, and on can then di ount th n d for 10 kin further. from dia n tic point of vi w. In thi i u f th Journ I, Lepor and < rian report a pati nt wh wa an intelli nt 011 ge pr f or, with double vi ion a on of hi c m-plaint. Th author w re impr - d with th fact that imm diatel aft r la er treatm nt of ma ular Ie ion in hi I it e, his vi ual c mplainL di appear d; h n ,th Y nt in thi p P r illu trating m n ular dipl pia of retin I rigin. )"', all of thi e m inno ent nough until y u s what h pp n d when th ap r went )ul for I.:di-tori I r view! Th fir t r vi w r, who name will be \ ith-held- alth ugh h might e call d "th Kin 01 lh MaCLtla"-v t d t turn th p P r down. H comm nl d, "Thi r port of a c ntr ver.ial matt r, mono ular dipl pi n th ba i of iundus pathol gy, pr nl th ob rvation by one patient of thi ph nom non. Th author did littl to docum nt more pr ci I th natur f the pati nl' omplaint- nor did the attempt an I me _ Us'; ure to - if th c uld alt r hi ob rvation. II/we II XI"eal I"dllclallce 10 (lccept thi cn e IIdory n . all I'XIlIllP/c O· 'olllt!lll/llg Ihal I halle lIever seen lIIysel /II a s/II«le Pili/CIII." • 0\ ,our diloriaJ polic, i that when a pap r i nt ut r revi wand r je ted by th fir 1 r - vi \ r, it 1- nt t an th r review r f r a c nd opin) n. I r I ted ag tn, lh pap r oe r a third revi \\' to br ak th Ii. Th paper went ut to a c nd "heavv hitt r" ",h name wiII be \ ithheld. (H i n'w writm th fourth dition of lh maj r t xt in thi fi Id.) H r pli d, "Thi i a weJl-writt n paper that d crib a ina] ca e f m n cular diplopia appar ntly cau ed b. retinal di e e. Th dipl pia J ar d when th di a e wa tr at d ucce fully with la r phot coagulation. I a~r with the author that whil r tinal di ea -e i an e trem Iv unu ual cau f m n cular diplopia (I JUH'e 100 (11~1'~ tJ 11l0llllClIlllr d/plopilllll Illy 'ilc:~ Illld /lol 0111' 11'11: c/lIIsl'd by rci1lI111 disease), it i nev rlhele a pot ntially tr atable au . I b Ii \ that th paper d -erves publi ation. I am mwhat c n rn d, hH\' ver, bout Tabl 1. he on pi that .upra ellar tumor, ccipital I be le-in, and :Ii 'ocia[j\'e Ie -i n f th h mi phere hould be giv n equal - n -id ration a cau f m nocular dipk pia with 0 ular cau i quite mi le.lding. I th r som wa) that either the Ii t an retl ct thi - or the auth r can f tnote the pe-cific rd r nce- which (to nl\' mind) \.. r not that 'onvincing e cept ior patie~lt \ ith - v r intramnic I di e f:' or (( mplicated mi rain." Finall , this re\'i \\ cr add d a -h rt hand'vvritt n n t stating, "I h ven't n a tru c f thi !" W II. w no\ had two pinion -a "na "and a ". ea"-' it wa d ided t "pull out all the 5t p_" and end the paper t tlte h a I hitt r of the tat! H r pond d, "] don't bj ct t publi hin this a e. I b lie that L p r kn v \ h n hi - P lient i de ribing m n cular dublin and that we ha t beli ve him.] dmit I d n't EDITORIAL: MONOCLlLAI\ DIPLOPIA 1~5 understand wlw ... but that's mv problem. Tilc fact that I 11I1(1c IIC,'l'/' rcco.'\/li:cd a CI1~C i~ 110 I'l'a~o/l /0 clailll Lcporc'~ oll~l'/'('t/tio/l i~ IIII/rIlC, I admit that I don't know how a suprasl'Il,H tumor C,1I1 ,lccount for monocular dllubling. \Vh,lt arl' 'dissoci,ltive lesions between frontal ,md occipit,ll eve fields'? How in tl1t' world do these aCClllll1t for ;llOnocular doubling? I han' seen a Illt of patients with l1t'mispheric lesions but nl)IW with monocular doubling." To me, that seemed tll m,lke this l'ditllrial imperative. I called Dr. Lepore ,md asked if he had dllne a pinhole test lln the patient in the first place, and he honesth' replied, "No." Obviously that would have been impl)rta nt in fllrma tilln. Hllwever, I believe the point can be clarified as follows. First, three internationallv respt'cted consultants all (101Im/ cercd th.a tilcii ilad /lC,'l'/' ~CC/l a ca~c of truc retinal 1/l011l1cul.lr diplopia, I think this can be explained by a h~'pothetical case of a patient whose chief complaint was that when he looked across the room at his sister she appeared to have two heads, and that this still seemed to be the case even when the patient's right eye was covered. In this case it is implied that both heads were distinct (neither was a fuzzy or "ghost" image), both heads were the same size (one was not smaller than the other), and both heads were of proper shape (one did not have bent, slanting, or sloping boundaries)-in other words, on(lI double vision not associated with ghost image, micropsia, or metamorphopsia. The reason all the "New York doctors" initially considered the complaints of Lepore's patient typical of retinomacular disease was that this patient had not one but three monocular complaintsdoubling, but with a ghost image; micropsia; and metamorphopsia. It would be quite consistent to have this packa:?e of symptoms due tll a retinomacular lesion and to have it clear after laser therapy or clearing of the macular problem. The point to the clinician sitting out in Ohio, however, is that true monocular diplopia, by itself, demands a carefully performed pinhole test. This requires at least a 2-mm aperture, preferably among a series of pinholes rather than a single one, and preferably in a trial frame. Often the patient's head must be in a headholder, and it helps to put up a single letter or number on the projectoscope at about the 20/70 Iewl, make sure the patient can see this through the pinhole, and then evaluate for clarity or doubling. The patient may have to turn his or her head ever so slightly to find this; this test is extremely important and usually gives the answer. Another reason for this editorial is that the reviewers just didn't buy suprasellar tumors, occipital lobe lesions, and the like as a bona-fide cause for monocular diplopia. One really couldn't help but think "deep down" that if a carefully performed pinhole test had been done on those patients with the intracranial lesions, the symptom would have cleared. At any rate, to you, gentle reader, the answer is clear-get an exact history when a patient has diplopia. Don't ask just the three primary questions about diplopia (is it horizontal or vertical, greater at distance or near, and greater to right or left), but also ask what happens to the doubling when you cover one eye. If you find the patient has true monocular diplopia, ask three more questions (are both objects just as distinct or was one "fuzzy" or a "ghost image," were the objects the same size, and was one bent or distorted in any way). Then, to clear things up completely, do a careful pinhole test. When all is said and done, true isolated monocular diplopia is still refractive/optical until proven otherwise, and when proven otherwise it still appears to be refractive/ optical. Finally, I want to give a hearty personal "thanks" to all editorial reviewers for the TournaI of Clinical Nel/I'o-ophthalllloiosy. They take much time at their own expense, answer promptly, and always give careful consideration to the manuscripts. I can never thank them enough. I think the editorial Cllmments are usually in strong agreement, but when there is a reasonable or major difference, publication of the paper with an accompanying editorial is warranted, as in this case. J. Lawton Smith, M.D. I C/III 1'1(,""'-01'"1/",/"'01, Vol, 6. No, 3. 1986 |