Migraine as an organic cause of monocular diplopia

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					                                                            CASE         REPORT
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    MILES E. DRAKE, Jr., M.D.

    Migraine as an organic
    cause of monocular diplopia
    Diplopia generally represents a failure of binocular                         The general physical examination was unremarkable.
    fusion of vision, with the double image caused by a                        Ophthalmologic examination indicated normal visual acuity
    different location of the retinal image in either eye.                     and fields, no demonstrable diplopia, and no evident ana
    Such diplopia is binocular, and clears when monocular                      tomic cause for diplopia. Neurologic examination was nor
    vision is used and only one retinal image is seen.                         mal except for mild left hyperreflexia. The CBC, platelet
                                                                               count, coagulation studies, blood chemistry, urinalysis,
    Diplopia during use of only one eye is less frequently
                                                                               ECG, and chest roentgenogram were normal. Thyroid
    encountered, and may rarely represent organic in
                                                                               function tests had proved normal a few weeks earlier during
    volvement     of the visual     system      but more    often   is         an evaluation by the family physician.
    functional in origin. This report concerns a patient with                     An EEG showed infrequent and transient bitemporal ac
    monocular     diplopia   that was not of functional       origin           tivity, but was within normal limits. Routine and enhanced
    but represented migrainous involvement of the occipi                       computed tomographic (CT) brains scans were normal. The
    tal lobes.                                                                 patient had been placed on aspirin and dipyridamole, and
                                                                               was given propranolol for headaches and hypertension.
    Case report                                                                She has since reported no further episodes of monocular
    A 40-year-old woman noted the abrupt development of                        diplopia.
    episodes of diplopia. These occurred infrequently, lasted up
    to 30 minutes, were usually Vertical but occasionally hori                 Discussion
    zontal in nature, and were unrelieved by her covering either               This patient          had a well-defined   personal   and family
    eye. The double vision was occasionally associated with                    history of migraine. She later developed monocular
    initial or subsequent blurring of vision bilaterally, but with no          diplopia involving either eye in association with mi
    other neurologic Symptoms. The diplopia improved gradu                     graine attacks. No ocular disease was demonstrated,
    ally after approximately 30 minutes, and was succeeded by                  and there was no indication of a potential neurologic
    severe generalized throbbing headache, sometimes asso                      cause for diplopia other than migraine. It is likely that
    ciated with nausea and vomiting. Her medical history was
                                                                               this case represents an infrequently   encountered    or
    remarkable for generalized throbbing headaches with nau
    sea and vomiting, which had previously been considered to                  ganic cause of monocular diplopia, namely bilateral
    represent migraine, and for hypertension, treated with a                   occipital dysfunction owing to migraine.
    diuretic. There was a family history of atherosclerotic car                   Monocular diplopia and polyopia is most frequently
    diovascular disease, stroke, and migraine.                                 of functional origin) Unilateral diplopia involving one
                                                                               eye only may occur on the basis ofocular disease in the
    Dr. Drake is assistaniprofessor in the department of neurology             involved eye, chiefly cataracts, corneal opacities, astig
    at the Ohio State University College of Medicine. Reprint                  matism of severe degree, and dislocation of the lens.2
    requests to him there, 46 7 Means   Hall,    410 West 10th A ye.,          Bielschowsky3 described a patient with long-standing
    Columbus, OH 43210.                                                        convergent        strabismus    and amblyopia    of the left eye,

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who developed monocular diplopia in that eye after           vious accounts have not distinguished between monoc
loss of the right eye. This was ascribed     to divergence   ular and binocular diplopia, but it is likely that most
between the true macula ofthe left eye and the previous      diplopia was of the more common binocular variety.
false macula in that amblyopic eye.                          Lance and Anthony'° found visual involvement, in
   Monocular diplopia in only a specific eye is occa         cluding obscuration ofthe type reported by our patient,
sionally encountered inamblyopic patients, on account        in association           with diplopic      episodes,      in 32.8% of all
of presentation of dissimilar targets on refraction, or      migraine patients. Symptoms referable to brain stem
soon after the initial establishment of a dominant           dysfunction, including diplopia that was not further
macula.2 Cass4 encountered monocular diplopia in 33          classified, were reported             in 24.4%.
of 70 patients with strabismus. This was ascribed to a         Three of the twelve patients studied by Swanson and
disparity in retinal images caused by incongruity of the              I experienced        diplopia.     One     of   these     manifested
false macula in the squinted eye with the true macula in     definite binocular diplopia in association with abdu
the normal eye; such monocular diplopia was likewise         cent-nerve palsy. The monocular or binocular character
confined to the squinted eye. Unilateral monocular           of the diplopia in the other two patients was not
diplopia has also been reported5 in patients with a          specified. Such patients have often been reportedt2 to
refractive difference between upper and lower portions       have various nonspecific EEG changes, and it is likely
of the retina, resulting in vertical displacement of the     that our patient with intermittent bitemporal activity
images with the fainter one above.                           could be included in this group of migraine sufferers.
   Bilateral monocular diplopia has been described in          Evidence of diminished cerebral blood flow during
association with visual-field defects and abnormalities      the migrainous aura clearly suggests a vascular basis for
of fixation that conduce to the formation of a false         these symptoms,'3 and raises the possibility of fixed
macula, and in association with tumors of the occipital      neurologic deficits after an attack. Cerebral infarctions
lobe.6 Gordon and Bender7 encountered monocular              and edema have been demonstrated in migraine pa
diplopia and polyopia along with oscillating visual          tients with neurologic                deficits    associated        with        their
disturbances in multiple sclerosis patients having in        attacks,'4 and this underscores the importance of recog
volvement of the medial longitudinal fasciculus.             nition      and treatment           of complicated           migraine           syn
  Benders also studied   four patients     with monocular    dromes. Although monocular diplopia independent of
diplopia or polyopia with use of either eye. He found a      the eye's being used is most often a functional symp
consistent pattern of scotoma in one eye; visual dis         tom, our case indicates that such complicated migraine
turbance in the field affected by the scotoma that           syndromes may present in this fashion.               0
involved obscuration, fluctuation, or extinction; and
the presence of optical illusions or spatial disorienta
tion. Two ofthe patients had suffered occipital injuries,     1. Bender MB: Neuro-ophthalmotogy, in Baker AB, Baker LM (eds): Clinical
one had diffuse cerebral dysfunction including occipital         Neurology. Hagerstown, Md. Harper and Row. 1976, vol 1. pp 38, 115.
                                                              2. Pincus MH: Monocular diplopia. Am J Ophthalmol 24:503-506. 1941.
involvement after encephalitis, and one had a defect in       3. Bielschowsky A: Ueber monokular Diplopie ohne physikalische Grund
visual fixation oft@ncertain etiology but presumed occi         age nebst Bemerkungen ueber das sehen Schelenden. Arch Ophthalmol
                                                                44:143, 898.
pital origin. Bender' has proposed that bilateral mon         4. Cass EE: Monocular diplopia occurring in cases of squint. Br J Ophthal
ocular diplopia represents a disturbance in visual inte         mol25:565-577, 1941.
                                                              5. Fincham EF: Monocular diplopia. Br J Ophthalmol 47:705-712. 1956.
gration on the basis of occipital disease, and that such      6. Walsh FB, Hoyt WF: Clinical Neuro-ophthalmology. ed 2. Baltimore,
diplopia of organic origin can be recognized by in               Williamsand Wilkins, 1969, vol 1. p 140.
                                                              7. Gordon RM, Bender MB: visual phenomena in lesions of the medial
volvement of homonymous portions of the visual field             longitudinal fasciculus. Arch Neurol 15:238-240, 1966.
in both eyes, proximity of the involved area to an area       8. Bender MB: Polyopia and monocular dsplopia of cerebral origin. AMA
                                                                 Arch Neurol Psychiatry 54:323-338, 1945.
of visual-field defect in each eye, and increase in           9. Bickerstaff ER: Basilar artery migraine. Lancet l:15-17, 1961.
diplopia when observing moving objects. Although our         10. Lance JW, Anthony M: Some clinical aspects of migraine. Arch Neurol
                                                                15:356-361, 1966.
patient had no evidence by EEG or CT brain scan of an        11. Swanson JW, Vick N: Basilar artery migraine. Neurology 28:782-786,
occipital lesion, it is most likely that her bilateral          1978.
monocular diplopia was of the cerebral type, and rep         12. Smyth VO. Winter                        Electroencephalogr
                                                                                   AL: The EEG inmigraine.                 Gun
                                                                 Neurophysiol 16:194-202, 1964.
resented occipital involvement by migraine.                  13. Lance JW: Mechanism and Management of Headache. ed 4. London.
                                                                Butterworth,    1982, pp 155-156.
   Diplopia has been described in migraine, particular       14. Gala LA. Mastà gliaFL: Computerised axial tomographic findings in
ly in vertebrobasilar- or basilar-artery migraine.9 Pre         patients with migrainous headaches. Br Med J 2:149-150.           1976.

NOVEMBER 1983 VOL 24@NO 11                                                                                                                    1027

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