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Vertical diplopia after acoustic neuroma surgery and Botox injection for protective ptosis

Vertical diplopia after acoustic neuroma surgery and Botox injection for protective ptosis. Elaine Wong Lionel Kowal. YH 37 yo F. PMHx Left acoustic neuroma Excision of acoustic neuroma 05/2005 Left facial nerve palsy with exposure keratopathy

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Vertical diplopia after acoustic neuroma surgery and Botox injection for protective ptosis

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  1. Vertical diplopia after acoustic neuroma surgery and Botox injection for protective ptosis Elaine Wong Lionel Kowal

  2. YH 37 yo F PMHx • Left acoustic neuroma • Excision of acoustic neuroma 05/2005 • Left facial nerve palsy with exposure keratopathy • Left upper lid botox (10U) to induce protective ptosis • Once botox worn off - noticed vertical diplopia

  3. YH 37 yo F 12/2005 • VAR 6/8 VAL 6/18 • R hypertropia 32 24 40 40 28 40 14 • XT 15 • LIO --- • LIR tight [thru- the- lid - forced- duction - test] • L fundus extorted

  4. YH 37 yo F 03/2006 • Had Acupuncture treatment • Feels diplopia has improved • R hypertropia 20 10 37 29 15 33 20 • Exotropia 4Δ • Single vision in primary and for 15˚ on upgaze and right gaze • L SO ++,L IO --

  5. YH 37 yo F Diagnosis • ? Permanent Botox induced vertical misalignment • ? Skew deviation following acoustic neuroma surgery

  6. Discussion Persisting hypotropias following protective ptosis induced by botulinum neurotoxin PL Heyworth, JP Lee Eye 1994; 8 (pt 5): 511-5 • 3 case reports of permanent superior rectus weakness and vertical deviation • Require surgical correction • ? Prolonged occlusion led to breakdown of fusion • ? Contracture of ipsilateral IR

  7. Discussion Skew deviation following vestibular nerve surgery P Riordan-Eva, JP Harcourt, M Faldon, GB Brookes, MA Gresty Annual of Neurology 1997 Jan; 41(1); 94-9 • 5/18 patients develop vertical deviation following surgery • 3 with manifest vertical deviation • 1 with unilateral Meniere’s, 1 with bilateral Meniere’s and 1 with acoustic neuroma • Diplopia lasted from 1 day to 6 months • Surgical vestibular deafferentation

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