1. Vertical diplopia after acoustic neuroma surgery and Botox injection for protective ptosis Elaine Wong Lionel Kowal

2. YH 37 yo F PMHx Left acoustic neuroma –Excision of acoustic neuroma 05/2005 –Left facial nerve palsy with exposure keratopathy –Left upper lid botox (10U) to induce protective ptosis –Once botox worn off - noticed vertical diplopia

3. YH 37 yo F 12/2005 VAR 6/8VAL 6/18 R hypertropia 3224 404028 4014 XT 15 LIO --- LIR tight [thru- the- lid - forced- duction - test] L fundus extorted

4. YH 37 yo F 03/2006 Had Acupuncture treatment Feels diplopia has improved R hypertropia 2010 372915 3320 Exotropia 4Δ Single vision in primary and for 15˚ on upgaze and right gaze L SO ++,L IO --

5. YH 37 yo F Diagnosis ? Permanent Botox induced vertical misalignment ? Skew deviation following acoustic neuroma surgery

6. Discussion Persisting hypotropias following protective ptosis induced by botulinum neurotoxin PL Heyworth, JP Lee Eye 1994; 8 (pt 5): 511-5 3 case reports of permanent superior rectus weakness and vertical deviation Require surgical correction ? Prolonged occlusion led to breakdown of fusion ? Contracture of ipsilateral IR

7. Discussion Skew deviation following vestibular nerve surgery P Riordan-Eva, JP Harcourt, M Faldon, GB Brookes, MA Gresty Annual of Neurology 1997 Jan; 41(1); 94-9 5/18 patients develop vertical deviation following surgery 3 with manifest vertical deviation 1 with unilateral Meniere’s, 1 with bilateral Meniere’s and 1 with acoustic neuroma Diplopia lasted from 1 day to 6 months Surgical vestibular deafferentation