Diplopia w/ Exertion

30 something year old white male.  Normal height and weight.  Borderline high blood pressure 130/90, controlled to 120/75 with 25 mg Atenolol once daily.  I had this problem before I developed HBP.  Otherwise good health per physical results (cholesterol and blood sugar in normal limits). Experiencing periodic horizontal binocular diplopia with exertion (always), coffee (sometimes), alcohol (always), stress (sometimes).  As the distance to the object increases, the doubled images are further apart.  Eyes sometimes feel sluggish.  Occasional headache.  If I sit down and cool off forehead and eye area with something cold like ice, the problem is resolved within a few minutes.  Visited regular doctor, ophthalmologist, and neuro- ophthalmologist.  Several MRIs of brain and eyes with and without contrast were normal (spaced about 4 years apart).  Eye exam is normal (vision is 20/20 uncorrected).  Tests for Horners, MS, MG were negative.  These doctors are stumped.  This started about 5 years ago with infrequent episodes, but now the frequency has increased.  Any assistance would be appreciated.

[CCF-Neuro-M.D.-CS]

Based on your I would think a disorder such as myasthenia gravis is likely. You have not specified which tests you had, but with occular MG, many of the common MG test can be negative. If all the regular testing was negative, including anti-bodies to the acetylcholine receptor, then a single fiber EMG is reasonable. This is a special muscle test, during which a doctor will examine several muscles around your eye. Not all doctors perform this, and it is typically done in academic centers. I hope this helps. Good luck.

[Camcm]

dear crossfire, it is interesting to me to read your post, since I have been experiencing something very similar--although my diplopia is vertical. I too have it come on early in my morning exercise routine (jogging), particularly if I start out very fast. Caffeine and nervousness also seem to be triggers. Mine however resolves on its own within minutes and does not recur again in the day, even if I indulge in additional exercise. How long does your diplopia last? I too have had MRIs and other testing to exclude MS, MG.  Have you had an MRA to check the condition of your cranial arteries and rule out an aneurysm? That might be very important to exclude. Have you had a lumbar puncture? Or visual evoked potentials? Bloodwork to exclude other things such as thyroid, B12, etc.?
I was referred to a prominent neuro=opthal at Penn and actually had an episode in his office. But he was unable to provoke me (Valsalva, etc.) into having it again, and concluded whatever it was was not a serious threat to my vision. He suggested superior oblique myokymia (which is aggravated by caffeine I think), but in other respects it doesn't match my symptoms (I have no nystagmus). I feel that my condition somehow has a vascular component, since it comes on during times of increased respiration and raised blood pressure. I hope you get some answers. Perhaps it will be reassuring for you to hear that I have had this off and on for years. After experiencing it daily for the past 2 years, it now seems to be resolving.
But I understand that it can really be frightening. Best of luck to you!

[crossfire]

I would be interested in seeing the same doctor if he/she is still in practice.  I have seen the premiere doctors in DC, and I was going to next try John's Hopkins, but if this doctor has already seen a similiar case, then perhaps he/she can start drawing some informed conclusions.  Please e-mail me at borkowsky at alumni.ncsu.edu.  Thanks.

[Camcm]

Hi again,
Steven Galetta at Univ.of Penn. Somewhat eccentric, but very thorough.
good luck!

[lil sunshine]

I have vertical double vision too. I noticed it a couple of years ago that {usually} when lying down and looking at the clock about 10' or so from bed I saw twin images, one on top of the other . I could read both well at 42 I still have 20/20 vision. I do have nystgmus{sp} and had a horrible time with facial/eye twitching that went away after I had what I thought was a small stroke. Turns out it was a seizure, I 'm on meds now.
Sometimes I don't have to be lying down, say at church when all the people to the right of me{we always sit on the far left side of church} have 2 sets of facial features. I don't watch TV while lying down anymore, it's awful to try to sort out how many actors there really are.
I have only 3 lesions in brain but no DX yet.I do have Hashimotos and have had positive ANAs with rash but no Lupus DX either.
Bonnie

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