Q: Several years ago I had a sudden onset of diplopia. Since then, a year and a half later, I have been diagnosed with everything from a 4th nerve palsy and mini-stroke (which they now don’t believe is true) to a stress-related illness because the doctors involved “can’t explain” my symptoms. In short, the diplopia has not resolved but I have learned to live with it. Sometimes it spreads and images double when I am looking forward and also to the left. Starting last March, I began to have issues with balance that come and go. I don’t have typical vertigo (no spinning, nausea, etc.) but I have fallen when fully conscious, get back up again, and also have episodes of being off balance and have stumbled and/or staggered.
Test results have shown I have upbeat vertical nystagmus and 65% right inner ear damage. I have had two MRIs of the brain, both of which are negative for MS. There are no lesions, and a blood test for myasthenia gravis was negative. I had an EKG that was negative and the next step is that my neurologist who has interest in neuro-ophthalmology is doing an in depth eye exam at a clinic that has more extensive equipment than her regular office.
My neurologist and the MD who oversaw my ENT test results seem to feel that my symptoms aren’t severe enough for concern. Since they can’t explain what is going on, they feel I have no need to worry. I am 62 and otherwise very healthy and fit. My medications are Vesicare, Atenolol, Simvastatin, Loratadine and Fluticasone nasal spray. I also take calcium, vitamin D and fish oil. A Lyme screen was negative, as was the balance of my blood work with the exception of a vitamin D level that was slightly below normal.
I’m really at a loss as to what to do so I would be very grateful for your opinion on whether you think I should continue to pursue a diagnosis at this time or just live my life and wait to see if things get worse. Is it appropriate to see another neurologist who focuses on vascular disorders or a neurosurgeon?
A: To my way of thinking, the fact that you fall and are off balance is sufficient cause to pursue a diagnosis. Symptoms that may appear to some physicians to be “acceptable” may not be to others. You could be behind the wheel of a car, walking up a flight of stairs, crossing a busy street with oncoming vehicles, or in thousands of other uncompromising situations and have worsening symptoms surface.
Diplopia is often the result of an impairment of extraocular muscles that may be from a disorder of the neuromuscular junction of the cranial nerves, or less likely, a disorder of the supranuclear oculomotor pathways. Nystagmus causes the eyes to make uncontrolled but repetitive movements that often result in impaired vision. When this occurs, both eyes are unable to focus on any specific object. Depth perception and balance issues will occur. As a general rule, the condition occurs because of a medical problem that might include stroke, TIA, or a direct blow to the head or another eye issue that hasn’t come to light yet. This is why your neurologist performed the testing he or she did. The condition is often accompanied with head nodding and unusual head positions. Nystagmus in adults has many causes, some of which are curable. When children are concerned, some types of the disorder have been known to improve.
There are numerous medications that react with VESIcare. Your primary care physician should review the list and confirm or rule out those medications you are currently on. Beyond this, Atenolol can cause blurred vision, dizziness and lightheadedness. While not the same as diplopia, you might want to speak with your physician in this regard. Loratadine carries a side effect of ear ache and dizziness. Fluticasone test studies have reported blurred vision and intraocular pressure.
My recommendations are that you request a second opinion with a top notch neurosurgeon. You should also make an appointment with a good otolaryngologist to determine if your ears are the cause of or are contributing factors for your symptoms. Bring your MRI and your list of medications to both specialists for review and discussion.
