title: [Intermittent diplopia after prolonged downward gaze to the right: what is the differential diagnosis?].
abstract: In general, intermittent diplopia evokes suspicion of ocular myasthenia gravis. However, other etiologies such as Brown syndrome or myokymia of the superior oblique may provoke intermittent diplopia. We present a case of intermittent diplopia due to a tumor in the cavernous sinus. A 59-year-old patient reported intermittent diplopia after prolonged downward gaze to the right. All other gaze directions failed to provoke symptoms. In 1992, the diagnosis of inactive macroadenoma of the pituitary gland was established and the patient underwent surgery and radiation therapy. At physical examination, prolonged downward gaze to the right of about 2 minutes provoked paresis of abduction, slight ptosis, and restriction of elevation on the left side, corresponding to sixth nerve palsy and palsy of the superior branch of the third nerve on the left side. MRI showed a relapse of the macroadenoma with infiltration of the cavernous sinus on the left side. The patient underwent surgery then focal radiation (gamma-knife). The clinical course was favourable and at the follow-up examination six months later, no diplopia was reported.
authors.affiliation: Department d'Ophtalmologie, Hôpital Universitaire, Inselspital, Bern, Suisse. rene.mueri@insel.ch
authors.forename: R M
authors.initials: RM
authors.lastname: Müri
authors.forename: E
authors.initials: E
authors.lastname: Klimmeck
authors.forename: P
authors.initials: P
authors.lastname: Imesch
mesh_terms: D020434:Abducens Nerve Diseases / Q000209:etiology; D000236:Adenoma / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D001932:Brain Neoplasms / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D002426:Cavernous Sinus; D003937:Diagnosis, Differential; D004172:Diplopia / Q000175:diagnosis / Q000209:etiology*; D005403:Fixation, Ocular / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination; D016634:Radiosurgery