Diplopia: Difference between revisions

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==Background==
==Background==
[[File:Extraocular muscle actions and innervation.png|thumb|Eye movements by extra-ocular muscles and cranial nerve innervation]]
[[File:Extraocular muscle actions and innervation.png|thumb|Eye movements by extra-ocular muscles and cranial nerve innervation]]
[[File:Capture2.PNG|thumbnail]]
[[File:Capture2.PNG|thumbnail|Right eye]]
===Monocular Diplopia===
===Monocular Diplopia===
*Double vision that persists when one eye is closed
*Double vision that persists when one eye is closed
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*Related to a problem with visual axis alignment<ref>Rucker JC, Tomsak RL: Binocular diplopia. A practical approach. Neurologist 2005; 11:98-110</ref>
*Related to a problem with visual axis alignment<ref>Rucker JC, Tomsak RL: Binocular diplopia. A practical approach. Neurologist 2005; 11:98-110</ref>


'''3 Main Causes Binocular Diplopia'''
===3 Main Causes Binocular Diplopia===
*Eye Musculature Dysfunction
*Eye musculature dysfunction
*Cranial Nerve Dysfunction
*[[cranial nerve palsies|Cranial nerve dysfunction]]
*Brainstem or Intracranial process
*Brainstem or intracranial process


==Clinical Features==
==Clinical Features==
===Exam===
===Exam===
*Determine Monocular vs Binocular
*Determine monocular vs binocular
*Eval for Visual Field Defect
*Evaluate for [[visual field defects]]
*Evalulate for Visual Acuity
*Evaluate [[vision loss|visual acuity]]
*Determine if there is a Cranial Nerve Deficit
*Assess [[cranial nerves]]
**Multiple [[cranial nerve palsies|cranial nerve involvement]] suggests an intracranial process or cavernous sinus involvement
*Check extraocular muscle function
*Check extraocular muscle function
*Entrapment will show extraocular muscle restriction with extremes of gaze
**Entrapment will show extraocular muscle restriction with extremes of gaze
 
*Sudden [[eye pain|painful]] or non painful onset suggest a vascular cause such as thrombosis, dissection, ischemia, or vasculitis
 
*Other neuro deficits should raise suspicion for a [[CVA]] or [[MS]]
*Multiple cranial nerve involvement suggests an intracranial process or cavernous sinus involvement
*Systemic illness is more likely with [[meningitis]] involving the brainstem
*Sudden painful or non painful onset suggest a vascular cause such as thrombosis, dissection, ischemia, or vasculitis
*Bilateral symptoms are more likely with neuromuscular problems such as [[guillain-Barre|Miller Fischer syndrome]], [[botulism]], or [[myasthenia gravis]]
*Other neurodeficits should raise suspicion for a CVA or MS
*Systemic illness is more likely with meningitis involving the brainstem
*Bilateral symptoms are more likely with neuromuscular problems such as Miller Fischer syndrome, Botulism, or Myesthenia


==Differential Diagnosis==
==Differential Diagnosis==
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===Monocular Diplopia===
===Monocular Diplopia===
*Cataract
*Cataract
*Lens Dislocation
*[[Lens dislocation]]
*Macular Disruption
*Macular disruption


===Binocular Diplopia===
===Binocular Diplopia===
*Basilar Artery Thrombosis
*Basilar Artery Thrombosis
*[[Posterior Communicating Artery (PCOM) Aneurysm]]
*[[Posterior Communicating Artery (PCOM) Aneurysm|Posterior communicating artery (PCOM) aneurysm]]
*Vertebral Artery Dissection
*[[vertebral and carotid artery dissection|Vertebral artery dissection]]
*[[Myasthenia Gravis]]<ref>Kusner LL, Puwanant A, Kaminski HJ: Ocular myasthenia: Diagnosis, treatment, and pathogenesis. Neurologist 2006; 12:231-239</ref>
*[[Myasthenia Gravis]]<ref>Kusner LL, Puwanant A, Kaminski HJ: Ocular myasthenia: Diagnosis, treatment, and pathogenesis. Neurologist 2006; 12:231-239</ref>
*[[Lambert-Eaton Myasthenic Syndrome |Lambert-Eaton Syndrome]]
*[[Lambert-Eaton Myasthenic Syndrome |Lambert-Eaton Syndrome]]
*[[Botulism]]
*[[Botulism]]
*[[Cavernous Sinus Thrombosis]]
*[[Cavernous sinus thrombosis]]
*Brainstem Mass
*[[Intracranial mass]], brainstem mass
*Intracranial Mass
*Miller Fischer variant [[Guillain-Barre]]<ref>Bushra JS: Miller Fisher syndrome: An uncommon acute neuropathy. J Emerg Med 2000; 18:427-430</ref>
*Miller Fischer variant Guillain-Barré<ref>Bushra JS: Miller Fisher syndrome: An uncommon acute neuropathy. J Emerg Med 2000; 18:427-430</ref>
*[[Multiple Sclerosis (MS)| MS]]
*[[Multiple Sclerosis (MS)| MS]]
*[[Hyperthyroidism | Hyperthroid]] Proptosis
*[[Hyperthyroidism | Hyperthyroid]] Proptosis
*Basilar Meningitis
*Basilar [[Meningitis]]
*[[Stroke (Main) |CVA]]
*[[Stroke (Main) |CVA]]
*Muscular Entrapment from [[Maxillofacial Trauma |Trauma]]
*Muscular Entrapment from [[Maxillofacial Trauma |Trauma]]
*[[Third nerve palsy]]
*[[Third nerve palsy]]


==Diagnosis==
==Evaluation==
'''Monocular'''
===Monocular===
*[[Slit Lamp Exam]]
*[[Slit Lamp Exam]]
**Assess for Cataract
**Assess for Cataract
**Lens Symmetric
**Lens symmetry
**Posterior Orbital Mass
**Posterior orbital mass
**Macular Dysruption
**Macular dysruption
*Consider Ophthalmology Consult
*Consider ophthalmology consult
*Consider Ocular Ultrasound
*Consider [[ocular ultrasound]]


===Binocular===
*[[CN III palsy|Third nerve palsy]]: eye is down and out
**Always needs [[CT head|CTH]]/CTA to rule out [[Posterior Communicating Artery (PCOM) Aneurysm|aneurysm given that nerve runs under PCA
*[[trochlear nerve palsy|Fourth nerve palsy]]: head tilt down and away from side of lesion
**These are tough to catch and can be referred to ophtho outpatient for prisms
**No imaging needed unless other deficits present
*[[abducens nerve palsy|Sixth nerve palsy]]: eye can't track laterally
**Children need imaging to r/o tumor
**In > 50, m/l ischemic and can get MRI outpt or just watch, assuming no papilledema as it can cause isolated CN VI palsy
**If other nerves/deficits noted, consider MRI and further wu
*Other potential studies also include:
**[[CT head|CTH]] with and without contrast ± CTA neck to rule out dissection and intracranial mass
**MRV or CTV to eval for [[cavernous sinus thrombosis]]
**CT orbits w/ contrast to eval for orbital apex syndrome (like CST above, but with CN II involvement)
**[[Brain MRI|MRI]] + DWI to if concern for [[CVA]]
**[[Brain MRI|MRI]] ± MRA if unable to classify intracranial process on initial contrast CT with contrast
**[[Brain MRI|MRI]] if concerned for [[MS]]
**[[LP]] if concern for [[meningitis]]
**Metabolic workup to rule out diabetes or cause of mononeuropathy


'''Binocular'''
===Imaging Guide===
*CT brain with and without contrast ± CTA neck to rule out dissection and intracranial mass
{| {{table}}
*MRI + DWI to if concern for CVA
| align="center" style="background:#f0f0f0;"|'''Clinical Situation'''
*MRI±MRA if unable to classify intracranial process on initial contrast CT with contrast
| align="center" style="background:#f0f0f0;"|'''Suspected Diagnosis'''
*MRI if concerned for MS.
| align="center" style="background:#f0f0f0;"|'''Imaging Study'''
|-
| Diplopia & cerebellar signs and symptoms||Brainstem pathology||MRI brain
|-
| 6th CN palsy & papilledema||IIH or CVT||CT/CTV brain
|-
| 3rd CN palsy||PCA or ICA aneurysmCompressive lesion||CT/CTA brain
|-
| Diplopia & thyroid disease & decreased visual acuity||Optic nerve compression||CT orbits
|-
| Intranuclear ophthalmoplegia||Multiple sclerosis||MRI brain
|-
| Diplopia &  trauma||Fracture causing CN disruption||CT head without contrast
|-
| Diplopia & multiple CN involvement & numbness over CN5 (Unilateral, decreased visual acuity)||Orbital apex pathology||CT orbits with contrast
|-
| Diplopia & multiple CN involvement & numbness over CN5 (Uni- or bilateral, normal visual acuity)||Cavernous sinus thrombosis||CT/CTV brain
|-
|}


==Management==
==Management==
*Neurology or Neurosurgical consult is warranted if evidence of an Intracranial bleed, Aneurysm or CVA
*Treat underlying cause
*Metabolic workup to rule out diabetes or cause of mononeuropathy
*Neurology or neurosurgical consult is warranted if evidence of an [[ICH]], [[Posterior Communicating Artery (PCOM) Aneurysm|aneurysm]] or [[CVA]]
*If concern for basilar meningitis perform Lumbar Puncture


==Disposition==
==Disposition==
Depends greatly on the cause of the diplopia
*Depends greatly on the cause of the diplopia
*Monocular Diplopia - can generally have opthalmology followup unless there is evidence of an open globe,
 
*Binocular Diplopia
Neurology or Neurosurgery consult is useful depending on the cause of diplopia
 
*Admit if:
*Admit if:
**[[CVA]]
**[[CVA]]
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**[[Meningitis]]
**[[Meningitis]]
**Intracranial Mass  with edema or shift
**Intracranial Mass  with edema or shift
**Aneurysm causing compression
**[[Posterior Communicating Artery (PCOM) Aneurysm|Aneurysm]] causing compression
**Multiple Cranial Nerve Involvement
**Multiple cranial nerve involvement
 
*Isolated [[Third Nerve Palsy|Cranial Nerve III]] and VI palsy can be discharge if close neurology follow-up and cause due to [[diabetes]], microvascular ischemia and intracranial process ruled out<ref>Sanders SK, Kawasaki A, Purvin VA: Long-term prognosis in patients with vasculopathic sixth nerve palsy. Am J Ophthalmol 2002; 134:81-84</ref>
*Isolated [[Third Nerve Palsy|Cranial Nerve III]] and VI palsy can be discharge if close Neurology followup and cause due to [[diabetes]], microvascular ischemia and intracranial process ruled out<ref>Sanders SK, Kawasaki A, Purvin VA: Long-term prognosis in patients with vasculopathic sixth nerve palsy. Am J Ophthalmol 2002; 134:81-84</ref>


==See Also==
==See Also==
*[[Third Nerve Palsy]]
*[[Third Nerve Palsy]]
==External Links==
*[http://ddxof.com/diplopia/ DDxOf: Differential Diagnosis of Diplopia]


==References==
==References==
<references/>
<references/>


[[Category:Ophtho]]
[[Category:Ophthalmology]]
[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Symptoms]]

Latest revision as of 19:27, 7 May 2021

Background

Eye movements by extra-ocular muscles and cranial nerve innervation
Right eye

Monocular Diplopia

  • Double vision that persists when one eye is closed
  • Related to intrinsic eye problem[1]

Binocular Diplopia

  • Double vision that resolves when the other eye is closed
  • Related to a problem with visual axis alignment[2]

3 Main Causes Binocular Diplopia

Clinical Features

Exam

Differential Diagnosis

Algorithm for the Evaluation of Diplopia

Monocular Diplopia

Binocular Diplopia

Evaluation

Monocular

Binocular

  • Third nerve palsy: eye is down and out
    • Always needs CTH/CTA to rule out [[Posterior Communicating Artery (PCOM) Aneurysm|aneurysm given that nerve runs under PCA
  • Fourth nerve palsy: head tilt down and away from side of lesion
    • These are tough to catch and can be referred to ophtho outpatient for prisms
    • No imaging needed unless other deficits present
  • Sixth nerve palsy: eye can't track laterally
    • Children need imaging to r/o tumor
    • In > 50, m/l ischemic and can get MRI outpt or just watch, assuming no papilledema as it can cause isolated CN VI palsy
    • If other nerves/deficits noted, consider MRI and further wu
  • Other potential studies also include:
    • CTH with and without contrast ± CTA neck to rule out dissection and intracranial mass
    • MRV or CTV to eval for cavernous sinus thrombosis
    • CT orbits w/ contrast to eval for orbital apex syndrome (like CST above, but with CN II involvement)
    • MRI + DWI to if concern for CVA
    • MRI ± MRA if unable to classify intracranial process on initial contrast CT with contrast
    • MRI if concerned for MS
    • LP if concern for meningitis
    • Metabolic workup to rule out diabetes or cause of mononeuropathy

Imaging Guide

Clinical Situation Suspected Diagnosis Imaging Study
Diplopia & cerebellar signs and symptoms Brainstem pathology MRI brain
6th CN palsy & papilledema IIH or CVT CT/CTV brain
3rd CN palsy PCA or ICA aneurysmCompressive lesion CT/CTA brain
Diplopia & thyroid disease & decreased visual acuity Optic nerve compression CT orbits
Intranuclear ophthalmoplegia Multiple sclerosis MRI brain
Diplopia & trauma Fracture causing CN disruption CT head without contrast
Diplopia & multiple CN involvement & numbness over CN5 (Unilateral, decreased visual acuity) Orbital apex pathology CT orbits with contrast
Diplopia & multiple CN involvement & numbness over CN5 (Uni- or bilateral, normal visual acuity) Cavernous sinus thrombosis CT/CTV brain

Management

  • Treat underlying cause
  • Neurology or neurosurgical consult is warranted if evidence of an ICH, aneurysm or CVA

Disposition

  • Depends greatly on the cause of the diplopia
  • Admit if:
  • Isolated Cranial Nerve III and VI palsy can be discharge if close neurology follow-up and cause due to diabetes, microvascular ischemia and intracranial process ruled out[5]

See Also

External Links

References

  1. ↑ Coffeen P, Guyton DL: Monocular diplopia accompanying ordinary refractive errors. Am J Ophthalmol 1988; 105:451
  2. ↑ Rucker JC, Tomsak RL: Binocular diplopia. A practical approach. Neurologist 2005; 11:98-110
  3. ↑ Kusner LL, Puwanant A, Kaminski HJ: Ocular myasthenia: Diagnosis, treatment, and pathogenesis. Neurologist 2006; 12:231-239
  4. ↑ Bushra JS: Miller Fisher syndrome: An uncommon acute neuropathy. J Emerg Med 2000; 18:427-430
  5. ↑ Sanders SK, Kawasaki A, Purvin VA: Long-term prognosis in patients with vasculopathic sixth nerve palsy. Am J Ophthalmol 2002; 134:81-84
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