Monocular Diplopia & MG
 

I have searched for answers to this question and can find none.

I am pretty sure that I have MG. Typical (if there can be such) muscle tiredness and weakness, that gets worse through the day.

But my question is re: Monocular diplopia. This was my first alarm symptom. But Monocular diplopia is, so far as I can discover, unknown of with MG.

This is strange because my DV also worsens dramatically during the day, and recovers overnight. Has anyone else had this with MG? Or does anyone know of any other condition that could cause fatigable DV?

Thanks.

JJ, There has been a bit of discussion on this topic but no real consensus. I'll describe what I think happens to me but I may not have it quite right for you. When my MG flares I can get DV which can go away by closing one eye. For me, the double images are side by side (which means one or both of my eyes are wandering in the left-right direction).

Sometimes I have a problem with DV and it won't go away by closing an eye. In this case, it is usually not so bad and the images are up and down. It also turns out I have astigmatism in both eyes in the up-down direction. I think what happens is that my eyes get tired, have trouble focusing, and make the astigmatism more noticeable. It may even be that my eyelid gets tired, droops a bit and changes the way my eye lens sees.

If I'm right about this, my double eye DV is just 'normal' MG DV. My single eye DV is because I have astigmatism and my eyes can't focus well because they are tired. I talked to my neuro about this and was told the focusing muscles in your eyes aren't affected by MG because they are not voluntary muscles. Many people on this forum would disagree with this statement and I am one of them.

To see if this explanation holds water in your case, you might want to pay attention to lighting conditions when you sense some single eye DV. In bright light, eye defects like astigmatism won't occur because your pupils shrink and diminish the defect. In dim light, the single eye DV gets worse because your pupils open to let more light in.

I don't know if this helps. A few people here have this issue. It's not clear anyone can explain it. I have much more trouble focusing since MG appeared. My neuro can't explain it except to recommend new glasses. I have an explanation but I don't know if it is right.

Something I keep reading here is that it is possible to have two or more "conditions" causing different symptoms. This has really opened my eyes(no pun intended) :-p

It seems that many Doctors stop looking at other possible reasons/disorders after we are "diagnosed."

I have Diplopia and severe Esotropia+Ptosis only around my right eye. I take 180mg/day Pyridostigmine Bromide (Mestinon) and it REALLY helps with both my Diplopia and ESOTROPIA (crossed eye).

Although, by 6-7pm the Mestinon really putters out, so I might need to increase my dose.

May I ask, how long and how much Pyridostigmine Bromide did you take before you realized it did not help with your Diplopia?

Here is some information that really helped me understand how/why my Ocular-neurologist was able to diagnose me:
http://www.aao.org/publications/eyen...11/feature.cfm

Thanks for the suggestions.

But I have Bilateral Monocular Diplopia all the time. It starts the day with what I describe as a 2mm vertically displaced ghost. By the end of the day it can be as bad as 8mm vertically displaced and the ghost can be 90% of the real image.

The eye doctor, took the easy option. Ignored my other MG symptoms, and the fact that my DV worsens during the day, and declared it Astigmatism. When I got my new glasses, they help slightly. But by the end of the day I still have DV even with the glasses.

I have no diagnosis yet, but am experimenting with caffeine. That reduces most of my symptoms, but has least effect on my eyes.

Hi, Juliejayne. Welcome.

I believe these articles will shine some light on the situation.

Monocular DV is NOT caused by MG. There is usually another cause, even if it's "too difficult" for a doctor to figure it out! :rolleyes:

A person can have both binocular and monocular DV.

I have astigmatism. It doesn't matter which eye I close, the DV always goes away. A "fuzzy" area around an object is not DV. gr8ful, that is not true, what you said about astigmatism or your eyes being "tired."

I get a little crazy when science is ignored (by doctors). It's lazy doctoring!

I think you need to go see a neuro-ophthalmologist, if you can. They might better determine what is going on for you.

I hope you can get it figured out!

Annie


http://emedicine.medscape.com/article/1189759-overview

http://www.dartmouth.edu/~dons/part_1/chapter_4.html

http://www.aao.org/publications/eyen...11/feature.cfm

http://jnnp.bmj.com/content/75/suppl_4/iv24.full

Thanks Annie.

What I cannot find is any reference to Monocular DV, that is also fatigueable. I.E. it gets worse during the day and improves overnight.

Everything that I can find suggests that my eye problem is a refractive issue, with the Cornea, but I am struggling to find anything or anyone that can tell me IF the cornea can be deformed and recover in a matter of hours.

Because this is a moving target, it means that I cannot get glasses to correct it since the problem that they correct at 9 am will be different at 9 pm.

I think one thing that is overlooked, or can be, is nystagmus. I have an issue with this which could not initally be observed by any of the eye physicians, some considered the best in the world. A VNG discovered my eye issues and mild up beat nystagmus. Do I think it's MG? Could be, but I'm not 100 percent sure. Now my doctors can see this on my exam very slightly after me having issues since last April. I wouldn't describe mine has double vision, but more of a waviness from the images slowly swerving a bit, and my brain trying to concentrate or piece the images together. What I am describing isn't typical MG, but the medical reports say that they are not ruling out MG as a cause of this.

Well, update from the Eye doctors.
1st doctor, 1st diagnosis was astigmatism, so I was sent away to get new glasses. Doctor refused to listen to my complaints that it got worse during the day and recovered overnight.
New glasses, helped, slightly. But the problem remained even with the glasses.
2nd doctor, 2nd diagnosis, cataracts. I insisted that I didn't consider that that fitted with the symptoms that I have. Doctor ummed and ahhed. Checked further, then admitted that there was no appreciable clouding of the lens, so probably not cataracts.
The 2 of them then got their heads together, and dismissed me with, "well we can find nothing in the eye that could be causing the problem. So it must be neurological"

What a waste of effort. Why don't medical people ever want to find answers?
The neurologist has already said that it can't be neurological as it is bilateral (in both eyes). I am hoping that the blood test come back positive for MG, then I can go back to both Neuro and Eye doctors and say... hey guess what... you were wrong.

Hi JulieJayne, I noticed in a previous post that Annie suggested you see a Neuro Opthamologist. Have you done so? You say you've seen two different eye dr's.
with unsatisfactory results. If neither one was a neuro opthamologist, please consider making an appt with one. I searched for 8 years trying to find a dx. Within 10 minutes of an exam by a neuro opthamologist, he suggested that I had MG.
Sometimes we just need to keep searching for doctors that understand MG and know what to look for - not to mention, one that is willing to listen.
Good luck to you
Jan :)

Thanks, Jan. Ditto on the neuro-ophthalmologist. When the first neurologist I saw dismissed me, I saw one and, after a thorough eye exam, he said that I had MG. They have specialized tests to show double vision (which kind) and why.

I saw ophthalmologists my entire life, as we all do, and not one of them "saw" my ptosis. I've had it since birth or shortly thereafter. I was misdiagnosed at age ten with lazy eye (yes, I've had MG that long).

MG can be beyond an ophthalmologist's realm of knowledge. Which is silly, really, since it's pretty obvious when eyelids are drooping and they do know what the differential is for that!

And an N-O can also figure out the monocular issue.

If you say where you live, maybe someone can refer you to one!

Annie

I live in the Netherlands. The health system here might be different. At the moment I am waiting for the results of my MG antibodies bloodtest. That was ordered by the Internist, and hopefully, he will then be able/prepared to refer me to another Neuro and or N-O.

I will keep you posted.

Just back from the Internist. My blood work was negative for everything... apparently. I foolishly asked if they had tested for MuSK antibodies. Ice age descended. "What is that?" was his response. I tried to explain, but he had shut down and wasn't listening.

There is nothing wrong it is psychiatric... burn out. Was his final word.

I did manage to get a referral to another Neuro, but apparently we have no Neuro-ophthalmologists in the Netherlands. Or so this Internist said. If anyone knows of one, I'd be interested to hear where they are.

You need to do research when any doctor either shrugs their shoulders or says, "No." Or Nein. Or whatever other language. ;)

http://www.linkedin.com/pub/judith-v...gen/25/113/41b

http://www.umcutrecht.nl/subsite/res...vestigator.htm

http://www.eunosweb.org/

You must be able to find someone there to assist you!

And if you are short of breath, find a pulmonologist and ask for the necessary breathing tests.

Work the system!!!

Annie

OK, you are of course right. But they don't publish their contact details, as they don't want patients contacting them directly, and if I do find the details my current GP et al are going to be ****** at me for bypassing the "official channels". Has anyone tried this route and have you had success or did it cause more problems?

Do you want to be politically correct? Or do you want care that you DESERVE?

Yeah, I get that neuros can be, well, arrogant pricks. Really.

It's not going over their heads. Would your GP be willing to refer you to a neuro-ophthalmologist if you told her about one? Well, if not, then go anyway.

It's your body, not theirs. You have the right to have care. Geez, what century are we living in?! Even the doctors in BC understood the need for prompt and thorough healthcare!

Whatever you do is up to you. But then you'll have to live with the consequences of not breathing or moving if you have MG!

Annie

Did you ever find a solutioni to your monocular diplopia? I think that is what I have. I have double vision - sometimes triple vision in both eyes even with closing one I still have it in a single eye. It comes on when I'm working on my computer all day. At night it is then bad and slowly goes away as I withdrawl from the computer screen for several hours. Mine mainly manifests as car lights stacked vertically or street lights stacked vertically. Also lights appear brighter than what they should be it seems which seems to make the rest of the room appear darker.

Just curious if you found a solution.

Binocular diplopia was one of the symptoms that led my opthamologist to have me tested for MG. The first symptom was ptosis, Before eyelid surgery I had surgery for cataracts. It was after the cataract surgery that I started having DV, tunnel vision, and other weird vision symptoms. The positive test for MG stopped the plan for the eyelid surgery. My Neurologist prescribed Prednisone. It cleared up the vision issues almost overnight. More generalized MG issues have gotten worse.

A year and a half later I started having Monocular diplopia. It became progressively worse. My Neuro said 'if its monocular its not caused by MG'. I went back to the Opthamologist. He said that sometimes the lens put in after cataract surgery becomes clouded over. He used a laser treatment to cleanse the lens and my eyesight returned to the after cataract surgery levels.

Before the treatment I was convinced that it was caused by MG. My vision was worse when other MG symptoms were bad. It also got worse as the day wore on. Now I am wondering if it is just the opposite. Maybe additional muscle activity needed to focus with the clouded lens caused muscle fatigue because of the MG.

Vein777
Well as it happens, yes, though I am still not 100% sure that the Specialists are correct.
However I finally got to see a Neuro-ophthalmologist. She did the usual sort of eye tests, and realised that I was blinking more than is normal. That is called Blepharospasm. It is a neurological condition, cause unknown, no cure available. The blinking damages the tear film, and that causes double vision, that varies according to the amount of blinking. Naturally if you are tired and have spent a lot of time at the computer, that can worsen the effect.

Reducing the blinking reduces the double vision, and the normal treatment (of symptoms) is Botox. Totally not a good idea if you have or suspect MG.

However, after starting on Mestinon, the blinking has reduced dramatically from 80 per minute to 20 per minute and the double vision has improved, though not gone completely.

I think that it is worth pointing out here that if I had listened to the specialists I could have gone down the same route as Edwin.
It had already been suggested that I should have cataract surgery, and if I had agreed then I would have had needless surgery, which then fails to correct the real problem.

is a version of a statement that I have heard from too too many Neuros.
It is incorrect. If its monocular and you have other MG related symptoms, then it can be MG.
MG can cause Blepharospasm... blepharospasm can cause monocular DV.

Personally I still think that the actual answer is that MG can affect the ciliary muscles that move the lens of the eye.

I appreciate the update. I'm still having the problem and will have see it is the blinking issue you mentioned.

I do get halos a bit at night around lights - have you had that problem. I looked at a possible connection between chromium and zinc level ratios with respect to cataracts. I say that because this relationship supposedly can cause or eliminate glycation depending on that relationship. I know I am chromium deficient.

Cataracts can cause much of this. What cataracts cannot do is vary from day to day and during the day.

I am not ruling out, in fact I think it highly likely, that cataracts are part of the problem. However, any clouding of the eye in my case is minor and would not warrant cataract surgery.

Don't forget that once you have had cataract surgery, you eyesight is restricted to one focal length, and there are many many reports of people who have problems after cataract surgery, especially with double vision.

yes, I am aware of that problem. I'm trying to avoid any treatment for cataracts and attempting to find a nutritional solution. I refuse to believe that it can't be resolved through nutrition. My own physician even told me that everything is reversable but that we just don't have all the answers yet.

I am now supplementing with chromium and having my levels monitored.

Well, just as a quick update. Mestinon has now gotten most of my symptoms under control. Even the blinking which is now reduced to a normal level or 20-30 per minute instead of the 60-90 per minute that it was.

However, even with reduced blinking, the double vision persists. But it now varies in line with how much Mestinon I have taken, and with how tired I am.

Early morning. DV annoying. After first dose of Mestinon. DV not a problem. But during the day the DV comes back as the Mestinon runs out, and at the end of the day, it can be quite a problem, depending on how busy a day I have had.

I'm sorry to hear that your having this so rough. I am glad to see your getting some relief.

I didn't get relief until a friend told me about his alternative health provide that practices nutritional balancing science. I went there after I submitted a hair analysis and was blown away. Now I'm making progress but still early in the recovery.