Diplopia: Difference between revisions
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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 defect
*Evalulate for Visual Acuity
*Evaluate 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]]
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*[[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===
===Binocular===
*Third nerve palsy: eye is down and out
*[[CNIII palsy|Third nerve palsy]]: eye is down and out
**Always needs CTH/CTA to r/o aneurysm given that nerve runs under PCA
**Always needs [[CT head|CTH]]/CTA to rule out [[Posterior Communicating Artery (PCOM) Aneurysm|aneurysm given that nerve runs under PCA
*Fourth nerve palsy
*[[trochlear nerve palsy|Fourth nerve palsy]]
**These are tough to catch and can be referred to optho outpt for prisms
**These are tough to catch and can be referred to optho outpt for prisms
**No imaging needed unless other deficits present
**No imaging needed unless other deficits present
*Sixth nerve palsy: eye can't track laterally
*[[abducens nerve palsy|Sixth nerve palsy]]: eye can't track laterally
**Children need imaging to r/o tumor
**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
**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
**If other nerves/deficits noted, consider MRI and further wu
 
*Other potential studies also include:
*Other imaging studies also include:
**[[CT head|CTH]] with and without contrast ± CTA neck to rule out dissection and intracranial mass
**CTH with and without contrast ± CTA neck to rule out dissection and intracranial mass
**MRV or CTV to eval for [[cavernous sinus thrombosis]]
**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)
**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 + DWI to if concern for [[CVA]]
**MRI ± MRA if unable to classify intracranial process on initial contrast CT with contrast
**MRI ± MRA if unable to classify intracranial process on initial contrast CT with contrast
**MRI if concerned for MS
**MRI if concerned for [[MS]]
**[[LP]] if concern for [[meningitis]]
**Metabolic workup to rule out diabetes or cause of mononeuropathy


==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 follow-up 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 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>


==See Also==
==See Also==

Revision as of 18:38, 28 September 2019

Background

Eye movements by extra-ocular muscles and cranial nerve innervation
Capture2.PNG

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

  • Determine monocular vs binocular
  • Evaluate for visual field defect
  • Evaluate visual acuity
  • Assess cranial nerves
  • Check extraocular muscle function
    • Entrapment will show extraocular muscle restriction with extremes of gaze
  • Sudden 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
  • 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 myasthenia gravis

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
    • These are tough to catch and can be referred to optho outpt 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

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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