Due to the demographic changes, the number of older patients in ophthalmological practices and clinics, including those with diplopia, is increasing. Some of the patients report not only horizontally shifted double images but also or only vertically shifted double images. Vertical double vision often causes significant diagnostic problems for ophthalmologists. The underlying condition could urgently require further neurological, neuroradiological and/or internal medical diagnostics (e.g., skew deviation, 4th nerve palsy, myasthenia, Graves\' orbitopathy, orbital floor fracture, orbital mass, 3rd nerve palsy) but the cause of diplopia could also be a condition in which overdiagnosis should be avoided (e.g., sagging eye syndrome, the prevalence of which significantly increases with increasing age; decompensated strabismus due to inferior oblique muscle overaction, myopia-associated vertical tropia). For some diseases early diagnosis is important for a better prognosis, e.g., tumor diagnosis, Graves\' disease and stroke. This article presents an overview of the most common and most important differential diagnoses of vertical tropia in patients over 50 years of age.
UNASSIGNED: Gemäß der demografischen Entwicklung stellen sich zunehmend ältere Patienten in der augenärztlichen Praxis und Klinik vor, darunter auch solche mit Diplopie. Einige der Patienten geben dabei nicht nur horizontal versetzte Doppelbilder, sondern auch oder rein vertikal versetzte Doppelbilder, teilweise mit Verkippung, an. Vertikale Doppelbilder stellen den Augenarzt oft vor erhebliche diagnostische Probleme. Ursächlich kommen einerseits Krankheitsbilder infrage, die eine dringende weitere neurologische/neuroradiologische und/oder internistische Abklärung benötigen (z. B. Skew Deviation, N.-trochlearis-Parese, Myasthenie, endokrine Orbitopathie, Orbitabodenfraktur, orbitale Raumforderung, N.-oculomotorius-Parese), andererseits Erkrankungen, bei denen eine Überdiagnostik vermieden werden sollte (z. B. Sagging-Eye-Syndrom, dessen Prävalenz mit zunehmendem Lebensalter deutlich zunimmt; dekompensierter Strabismus sursoadductorius, Myopie-assoziierte Vertikaltropie). Für manche Krankheitsbilder ist eine frühzeitige Diagnosestellung für eine bessere Prognose wichtig, z. B. Tumordiagnose, endokrine Orbitopathie oder Schlaganfall. Wir geben hier eine Übersicht über die häufigsten und die wichtigsten Differenzialdiagnosen der Vertikaltropie bei Patienten im Alter über 50 Jahren.

UNASSIGNED: To study the rare and unusual causes of monocular elevation deficit.
UNASSIGNED: Five patients presenting to us with diplopia and elevation deficit were thoroughly examined and were found to have monocular elevation deficit due to rare causes.
UNASSIGNED: All five were found to have different underlying etiologies - iatrogenic, sphenoid wing meningioma, cysticercosis, sarcoidosis and mid brain infarct, and were managed appropriately.
UNASSIGNED: Monocular Elevation Deficit can occur due to a variety of causes. Having a high index of suspicion for the more serious etiologies is of utmost importance. Thorough clinical examination and imaging help clinch the diagnosis.

BACKGROUND: The ability of physical therapists (PTs) to accurately identify and reliably measure phoria/tropia is critical in the differential diagnosis of individuals with acute vestibular syndrome and concussion/mild traumatic brain injury.
OBJECTIVE: To determine if PTs may reliably measure phoria and to determine the reliability of two dissociating tests of phoria, the prism neutralized Maddox rod test and modified Thorington method, in normal adults with artificially created phoria.
METHODS: Thirty adults (mean age 24.87 ± 4.74 years) were randomly assigned to wear trial lenses (1, 2, 4, or 6 pd prism left, plain glass right) to create phoria. In sitting and supine, phoria was measured using prism neutralized Maddox rod test and modified Thorington method. Mean, SD, and range of first neutral endpoint were calculated for each examiner. Percentage of trials in agreement (≤ 2 and 4 pd); comparisons within the linear mixed effects regression model; and inter-rater reliability between examiners was calculated with the intra-class correlation coefficient (ICC).
RESULTS: Participants underwent 20 measurements by each examiner. Trial agreement between examiners was 74% (range 13%-100%) in horizontal and 91% (range 63%-100%) in vertical plane. Maddox rod test had significantly different means between two examiners (P < .05). Modified Thorington test had no significant difference. The Maddox rod test had a significant examiner main effect, examiner 2 always scored lower. Inter-rater correlation coefficient for each test was significant at level of P < .01 (ICC ≥ 0.67 ≤ 0.94) except for modified Thorington test in supine, horizontal plane with P < .05 (ICC ≥ 0.38).
CONCLUSIONS: PTs may reliably measure artificially created phorias using prism neutralized Maddox rod test and modified Thorington method.

UNASSIGNED: To evaluate the success of combining ipsilateral inferior and superior oblique muscle surgery in young children with congenital unilateral superior oblique under action who present in infancy with a large socially noticeable head-tilt.
UNASSIGNED: A consecutive retrospective case series of young children was analysed. The success of surgery in eliminating the head-tilt was evaluated by pre- and post-operative ocular motility assessment focusing on the vertical misalignment in primary position and downgaze, the magnitude of the head-tilt in degrees and the status of the superior oblique tendon.
UNASSIGNED: Five children had a mean age at first surgery of 41 (range 25-63) months, a mean primary position vertical deviation of 26 (25-30) prism dioptres, a head-tilt of 30 (20-35) degrees and a mean post-operative follow up of 24 (8-43) months. While there was a uniform surgical plan, nonetheless each operation required individualisation based on a spectrum of per-operative superior oblique tendon findings. The head tilt was eliminated in 40% and reduced in the remainder, to a mean of 7 (0-18) degrees and with a mean post-operative primary position vertical misalignment of 3 (range 0-10) and of 10 (range 0-40) prism dioptres in downgaze.
UNASSIGNED: Combined, ipsilateral oblique muscle surgery reduced the severe head tilt and primary position alignment to a psychosocially and functionally acceptable level. For the majority, the outcome was stable or associated with further decremental improvement. A persistent downgaze vertical tropia occurred in children with macroscopically abnormal superior oblique tendons but these cases were not identifiable clinically pre-operatively.

UNASSIGNED: To evaluate the outcome of orbital decompression, strabismus and/or eyelid surgery in patients with moderate to severe thyroid-associated orbitopathy, when combined approach is preferred.
UNASSIGNED: Retrospective, comparative, non-randomized review of 45 patients operated on from 2015 to 2018. Simultaneous decompression, eyelid and/or strabismus surgery was performed in 34 eyes of 20 subjects (group 1). Patients with multi-step procedures were used as control groups: group 2 included patients with staged decompression and eyelid retraction surgery (15 cases, 19 eyes); group 3 included patients with staged decompression and vertical strabismus surgery (10 cases, 13 eyes). Mean follow-up was 2.9 ± 1.8 years. Mann Whitney two-tailed test was used for paired data, and Fisher\'s exact test for categorical data; p <.05 were considered statistically significant.
UNASSIGNED: Changes in margin reflex distance were not significantly different among patients of subgroup 1A (11 patients, one-step decompression/eyelid surgery) and group 2 (p >.05). Improvement in postoperative diplopia were not significantly different among patients of subgroup 1B (9 cases, one-step decompression/strabismus/eyelid surgery) and group 3 (p >.05). One patient of group 1 had recurrent dysthyroid optic neuropathy that recovered with steroid treatment. No other complications occurred in the one-step surgery group.
UNASSIGNED: Simultaneous orbital decompression, strabismus and/or eyelid surgery resolved dysthyroid optic neuropathy, decreased proptosis, improved diplopia and eyelid position with a range comparable to that of a multi-step technique. If confirmed in prospective controlled studies, a one-stage approach might be advised to reduce the costs and time needed for rehabilitation in selected patients.

OBJECTIVE: To report a case of sudden onset vertical diplopia, blurred vision, and muscle spasms.
METHODS: This is a case report of a 57-year-old female who presented to the accident and emergency department with a one day history of vertical diplopia and a two week history of lower limb spasticity secondary to muscle spasms.
RESULTS: The patient had no significant medical or ocular history. Orthoptic investigation initially revealed a left inferior rectus (IR) underaction. Possible diagnoses at this point were thought to be isolated IR weakness, myasthenia gravis or skew deviation. An urgent MRI scan was arranged and blood tests were taken. MRI showed no abnormalities. Blood tests were normal, however, the acetylcholine receptor antibody serum test (ACH-R) was 0.43 nmol/L, which is at the high end of normal. At the follow-up visit, the IR weakness had deteriorated and the patient had also developed gaze-evoked nystagmus. An appointment with the neurologist and neuro-ophthalmologist was expedited. When the patient returned, she reported that her neurologist had diagnosed her with stiff-person syndrome (SPS). The patient had also developed a laterally alternating skew deviation and reported that she had undergone a course of intravenous immunoglobulin (IVIG). The patient was prescribed diazepam and gabapentin. Due to the lack of recovery, persistent diplopia and oscillopsia, monthly IVIG have been prescribed.
CONCLUSIONS: There is currently a paucity of literature relating to ophthalmic problems with SPS and how they are best treated. Previous reports have established that there is a link with myasthenia gravis, with many patients going on to develop myasthenia. Treatment of SPS is lacking large evidence-based studies. However, treatment with muscle relaxants and anticonvulsants has provided a good outcome for some. Further research is required to develop an evidence-based approach to treating the ophthalmological problems patients with SPS experience. This case report highlights the importance and value of orthoptists in investigating and monitoring patients with stiff-person syndrome.

Acute diplopia is a rare chief complaint with a broad differential diagnosis; key historical and physical characteristics aid with emergency management. This case report discusses the important findings, imaging, and multidisciplinary interaction between emergency medicine, ophthalmology, and neurology regarding the approach to addressing acute painless vertical diplopia. A 51-year-old male presented to the emergency department (ED), reporting that he was seeing \'two of everything,\' since awakening. Although the patient had a history of ischemic stroke, he had never experienced this sensation of diplopia. His ED workup was essentially unremarkable; he was admitted for evaluation of the possibilities of a fourth cranial nerve (CN IV) palsy, acute Parinaud syndrome, or ischemic stroke. Ultimately the patient was sent home one day after admission with the diagnosis of CN IV neuropathy. Highlighted is an approach to undifferentiated diplopia with an included discussion of the pathophysiology of a CN IV palsy and Parinaud syndrome. Understanding basic pathophysiology and anatomy allows for a proper history, physical exam, and appropriate consultation. With these tools, emergency physicians can improve their approach to patients with acute diplopia when arriving at the ED.

Aberrant regeneration of the third nerve occurs as a result of synkinetic \'miswiring\' of the third nerve following its injury, such as in third cranial nerve palsy due to tumor, trauma, or aneurysm. The case presented is an elderly woman with new vertical diplopia, which led to a diagnosis of a third cranial nerve palsy, thought to be caused by a 5 mm blister aneurysm of the posterior communicating artery. However, neuro-ophthalmological evaluation diagnosed aberrant regeneration of the third nerve, with the cause of her new vertical diplopia being an ipsilateral fourth nerve palsy. The patient underwent endovascular treatment of her aneurysm using stent-assisted coiling. This procedure was complicated by an episode of air embolism, from which the patient made a good recovery. This patient\'s presentation demonstrates that the cause of any diplopia must be established, and presents a novel, semi-schematic illustration of aberrant regeneration of the third nerve that should aid clinicians in its recognition.

We present a 26 year old Pakistani lady with first presentation of a demyelinating event, presenting as Parinaud\'s syndrome. The video demonstrates a convergence-retraction nystagmus on upgaze and failure of accommodation, and her brain imaging confirms a corresponding pre-tectal contrast enhancing T2 hyperintense lesion suggestive of demyelination. A review of the literature is presented.