To see views enlarged, click on the individual pictures...

A 67-year-old man was referred to you by his internist.  The man presented with the complaint of the sudden onset of double vision.  His doctor checked for diabetes and hypertension and found that the patient was normal in both instances.  The patient is otherwise in good health and has had no significant recent illnesses or injuries.

1.	What could this man be suffering from?
	a. acute onset of ocular myasthenia b. thyroid ophthalmopathy c. a decompensated longstanding phoria d.  acute fourth nerve palsy e. all of the above
2.	At your examination, the patient has an 8 prism diopter right hypertropia.  The deviation increases on left gaze, decreases on right gaze, and increases with right head tilt.  When he puts his chin down and tilts his head to the left and looks up to the right, he has single vision. At times he reports seeing images tilted.  The most likely diagnosis is:
	a. myasthenia gravis b. decompensated longstanding phoria c. acute fourth nerve palsy d.  thyroid ophthalmopathy e. none of the above
3.	The first thing to do for this patient is:
	a. repeat the testing for diabetes and hyypertension b. place a fully-correcting Fresnel prism and follow the patient's progress closely c. obtain thyroid studies d.  perform a Tensilon test e. order an MRI of the head

For answers to the above, click here on or after September 4, 2007.