Case Report

Recurrent Diplopia After Consuming Alcoholic Beverages

to the editor: A 67-year-old night watchman was referred to our clinic by an ophthalmologist because of a one-month history of recurrent vertical diplopia. The diplopia usually occurred after work when he was exhausted or after he had consumed sake. The diplopia always resolved spontaneously after sleeping, but this time it persisted for several weeks, and he finally consulted an ophthalmologist.

On examination, his right eye was higher than the left, which produced the vertical diplopia, but there was no facial swelling (Figure 1). Three-dimensional computed tomography showed a complete bone defect in the orbital floor and a mucocele (red) displacing the eyeball (blue) superiorly (Figure 2), which resulted in the symptom of vertical diplopia. Despite the defect in his orbital floor, the periosteum was intact. The mucocele was drained by aspiration (needle aspiration) through the gingivobuccal sulcus. After removing 20 mL of mucus, the right eye returned to the same level as the left eye, and the diplopia resolved completely. The aspirated mucus had no bacterial infection and the cytologic study showed no malignancy.

Figure 1. Patient with vertical diplopia (right eye higher than the left).

Figure 2. Three-dimensional computed tomography showing a complete bone defect in the orbital floor and a mucocele (red) displacing the eyeball (blue) superiorly.

A Caldwell-Luc surgical technique had been performed on this patient for right maxillary sinusitis 30 years earlier, but the nasoantral window for drainage had gradually narrowed. The mucosal lining of the sinus continued to produce mucus, and it became swollen during and after inflammation (consuming alcohol) and pushed the eyeball superiorly. The diagnosis was postoperative maxillary sinus mucocele.

Postoperative maxillary sinus mucocele is rare in the United states and Europe1-3; however, it is common in Japan.4.5 It typically occurs 10 to 15 years after the initial Caldwell-Luc operation and is accompanied by a swollen and painful cheek.5 Interestingly, this patient had never complained of a swollen and painful cheek. Even without those symptoms, recurrent diplopia would occur. The history of sinus surgeries is important to detect in such cases.

Currently, we are planning to reoperate on the right maxillary sinus to provide permanent drainage by an endoscopic sinus surgery. However, the patient's liver function does not permit use of general anesthesia, because of chronic hepatitis.

KOICHI TSUNODA, M.D.
naomi amagai, m.d.
masanobu housui, m.d.
Kenji kondou, m.d.
kenichirou ishio, m.d.
naonobu takeuchi, m.d.
kimitaka kaga, m.d.

Department of Otolaryngology
Faculty of Medicine
University of Tokyo
7-3-1 Hongo, Bunkyo-ku
Tokyo, Japan 113-8655

References

Is Ophthalmologic Follow-Up for Corneal Abrasions Needed?

to the editor: We read with great interest the article "Prevention and Treatment of Common Eye Injuries in Sports,"1 in the April 1, 2003 issue of American Family Physician. Overall, we found it to be a concise and informative article. However, in Table 3, the authors state that "24-hour ophthalmologic follow-up is mandatory" in the treatment of corneal abrasions.1 It has been our experience that uncomplicated corneal abrasions may be followed up appropriately by the primary care physician in the clinic, emergency department, or urgent care facility.

Although a brief literature review found various and differing recommendations for follow-up, we were not able to find any evidence (i.e., original outcome-based research) supporting these recommendations. Two of the most popular emergency medicine textbooks2,3 recommend 24-hour follow-up for patients with corneal abrasions but do not specify that this must be conducted by an ophthalmologist. A leading ophthalmologic textbook4 also does not recommend or mandate ophthalmologic follow-up.

A study5 of practices in Great Britain noted that only 50 to 60 percent of follow-up was performed by the ophthalmologic house officer. In their conclusion, they propose that "general practitioners play an increasingly active role in the diagnosis, treatment and follow-up of patients."5

In summary, while there is consensus that next-day follow-up is necessary for patients with corneal abrasions, evidence is lacking to support the need for mandatory 24-hour ophthalmologic follow-up. Our concern is that by making such a strong statement, these authors' may be contributing to the creation of a new "standard of care" without providing supporting evidence. The consensus appears to be that referral to an ophthalmologist is not indicated in the absence of complicating factors.

LEO BUNUEL-JORDANA, D.O.
DAVID C. FIORE, M.D.

University of Nevada School of Medicine
Department of Family and Community Medicine
Brigham Building, MS 316
Reno, NV 89557

References

editor's note: This letter was sent to the authors of "Prevention and Treatment of Common Eye Injuries in Sports," who declined to reply.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, fax number, and e-mail address. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.