Journal of Neuro-Ophthalmology, June 2013, Volume 33, Issue 2

Dural Puncture-Induced Intracranial Hypotension Causing Diplopia

Diplopia that occurs after an epidural spinal catheter has been placed for pain control has been attributed to sixth nerve palsy nerve palsy induced by intracranial hypotension. There is sparse information about the factors that confound diagnosis in this setting. Review of 6 cases examined over a period of 5 years at a single tertiary care medical center. Six confounders to diagnosis were identified: 1) lack of awareness that an epidural spinal catheter was or had been in place; 2) delayed reporting of diplopia; 3) mild or inapparent ductional deficits; 4) lack of postural headache; 5) clinical features that suggested an alternative diagnosis; 6) neuroimaging features that did not allow exclusion of pachymeningitis. Clinicians should be aware of features that confound a diagnosis of dural puncture-induced intracranial hypotension as a cause of diplopia in the post-operative period when an epidural pain control system is or has been deployed. If these confounders are recognized and the correct diagnosis is re hed, radiologists will be less likely to diagnose pachymeningitis and clinicians will be able to avoid lumbar puncture, which may exacerbate the condition.