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Diplopia
From WikEM
Contents
Background
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
- Eye Musculature Dysfunction
- Cranial Nerve Dysfunction
- Brainstem or Intracranial process
Clinical Features
Exam
- Determine Monocular vs Binocular
- Eval for Visual Field Defect
- Evalulate for Visual Acuity
- Determine if there is a Cranial Nerve Deficit
- Check extraocular muscle function
- Entrapment will show extraocular muscle restriction with extremes of gaze
- Multiple cranial nerve involvement suggests an intracranial process or cavernous sinus involvement
- Sudden painful or non painful onset suggest a vascular cause such as thrombosis, dissection, ischemia, or vasculitis
- 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
Monocular Diplopia
- Cataract
- Lens Dislocation
- Macular Disruption
Binocular Diplopia
- Basilar Artery Thrombosis
- Posterior Communicating Artery (PCOM) Aneurysm
- Vertebral Artery Dissection
- Myasthenia Gravis[3]
- Lambert-Eaton Syndrome
- Botulism
- Cavernous Sinus Thrombosis
- Brainstem Mass
- Intracranial Mass
- Miller Fischer variant Guillain-Barré[4]
- MS
- Hyperthroid Proptosis
- Basilar Meningitis
- CVA
- Muscular Entrapment from Trauma
- Third nerve palsy
Evaluation
Monocular
- Slit Lamp Exam
- Assess for Cataract
- Lens Symmetric
- Posterior Orbital Mass
- Macular Dysruption
- Consider Ophthalmology Consult
- Consider Ocular Ultrasound
Binocular
- CT brain with and without contrast ± CTA neck to rule out dissection and intracranial mass
- 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.
Management
- Neurology or Neurosurgical consult is warranted if evidence of an Intracranial bleed, Aneurysm or CVA
- Metabolic workup to rule out diabetes or cause of mononeuropathy
- If concern for basilar meningitis perform Lumbar Puncture
Disposition
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:
- CVA
- Guillain-Barre
- Botulism
- ICH
- Meningitis
- Intracranial Mass with edema or shift
- Aneurysm causing compression
- Multiple Cranial Nerve Involvement
- 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
- ↑ Coffeen P, Guyton DL: Monocular diplopia accompanying ordinary refractive errors. Am J Ophthalmol 1988; 105:451
- ↑ Rucker JC, Tomsak RL: Binocular diplopia. A practical approach. Neurologist 2005; 11:98-110
- ↑ Kusner LL, Puwanant A, Kaminski HJ: Ocular myasthenia: Diagnosis, treatment, and pathogenesis. Neurologist 2006; 12:231-239
- ↑ Bushra JS: Miller Fisher syndrome: An uncommon acute neuropathy. J Emerg Med 2000; 18:427-430
- ↑ Sanders SK, Kawasaki A, Purvin VA: Long-term prognosis in patients with vasculopathic sixth nerve palsy. Am J Ophthalmol 2002; 134:81-84
Authors
Daniel Ostermayer, Ross Donaldson, Tom Fadial, Kevin Lu, Neil Young
