more questions regarding vertical diplopia

[Camcm]

hello. Have posted earlier regarding transient episodes of binocular vertical diplopia: sudden onset 8 years ago when I was having awful allergic symptoms involving eyes and rubbed them excessively. Have appt with top neuro-opthal soon, but curious whether it's time to think outside the box. Diplopia comes on during morning exertion--jogging or sometimes simply straining (e.g.,on the toilet) or bending down for the newspaper or taking out the recycling; weight-lifting too. Lasts from few seconds to few minutes. No headache. I can resolve it by looking up. Most dramatic during morning exercise, with greatest divergence of images (generally downgaze and to the right). Does not occur when exercise later in the day or in the evening, even with very vigorous workouts. Have had brain MRI w & w/o contrast, c-spine MRI, VEPs, LP, MRA and extensive bloodwork to rule out many things, incl. myasthenia--all negative. Neuro sees nothing wrong with eyes. No history of severe head trauma. What does pattern of morning symptoms suggest? intracranial pressure? vascular problem? (LP did not test for pressure changes, just for oligoclonal bands). I experience it 4-5 times a week; not sure if has increased or just that I'm more sensitized to how often I'm on the threshold of having it. Otherwise, am healthy, fit, thin 48-year old woman; history of anemia, now resolved after hyst. & ooph last year. Also have allergies & asthma, well controlled. Any ideas? Is it safe for me to exercise? Neuro doesn't know. Friend who is doc suggested cardiac work-up? I have excell. chol & low BP. many thanks!

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

Unlikely to be caused by increased intracranial pressure as this would have other accompanying symptoms especially as it's been going on for so long and so "routinely" with respect to time and activity. The occurrence of symptoms in the morning also make Myasthenia gravis unlikely as the problems usually come out later in the day or when fatigued. Has anyone actually seen you when you have the vertical diplopia? It would be helpful to the physician if you could reproduce your symptoms in the office. One consideration is a superior oblique palsy which is a muscle that controls one of the eye movements.  If there is a problem with this nerve then the patient has diplopia on looking down and horizontally (to which side depends on which eye is affected). However, this is more of a constant phenomenon rather than episodic.

As for whether or not you can exercise, I cannot of course "clear" you to do anything medicolegally as I have never seen you personally nor reviewed your diagnostic studies. But the fact that you don't have any symptoms when you perform rigorous exercise in the evenings is somewhat reassuring that physical exercise in itself is probably not what's causing your symptoms.  So with that in mind, you can make your own decision. Talk to your doc about perhaps only exercising in the afternoon or evening. Finally, cardiac workup would only be helpful if stroke is a consideration. Good luck with your upcoming appointment.

[Camcm]

Hi,
I don't know if you read the comments, but just in case, thanks for your advice. Yes, my husband has seen my diplopia and says my left eye focuses on him, but my right eye is straying. I have not been asked to try to reproduce this in the doctor's office, but I know from having tried on my own that I can't do it at will. I guess my neuro and PCP simply take my word. I am not an hysteric. Frankly, my neuro still suspects MS, although there is no "hard" evidence of it. I have tingling down my neck and into my middle back in certain positions, which I believe is related to computer use; also have a herniated disk in my neck. the specialist I've been referred to is tops in his field, so if he can't find anything, I'll give up and be perfectly happy.