DIPLOPIA

DIPLOPIA: Excerpt from Algorithmic Diagnosis of Symptoms and Signs

Ask the following questions:

1. Is it unilateral? Diplopia that is unilateral is rare, but it can be encountered in ectopia lentis as associated with Marfan's disease, as well as in congenital double pupil, cataracts, and corneal opacities.
2. Is it intermittent? Intermittent diplopia would make one think of myasthenia gravis, but remember, Eaton-Lambert syndrome can do the same thing.
3. Is there associated proptosis? If there is associated proptosis, one should consider hyperthyroidism or pituitary exophthalmos, especially if it is bilateral. However, when it is associated with chemosis and ecchymosis, one should consider an infectious process.
4. Is there chemosis, ecchymosis, or periorbital edema? These findings should make one think immediately of cavernous sinus thrombosis, but an arteriovenous aneurysm can produce unilateral chemosis, ecchymosis, and exophthalmos.
5. Are there associated long tract neurologic signs? The findings of associated pyramidal tract or other long tract signs would make one think of a brain stem infarct or a brain stem tumor. Advanced intercranial pressure will put pressure on the sixth nerve and cause diplopia. Multiple sclerosis may cause long tract signs along with extraocular muscle palsies.
6. Is there fever or chills? Findings of fever and chills and diplopia should make one think of an orbital abscess, a brain abscess, or a cavernous sinus thrombosis. There is also the possibility of diphtheria.

DIAGNOSTIC WORKUP

An expensive diagnostic workup may be avoided by referring the patient to an ophthalmologist or a neurologist at the outset. If the diplopia is intermittent, a Tensilon test would be indicated. If there are fever and chills, one should do a CBC, sedimentation rate, possibly blood cultures, skull x-ray, and x-rays of the sinuses. However, under these circumstances, it will usually be necessary to perform a CT scan of the brain, sinuses, and orbits. If there is chemosis or ecchymosis, a cavernous sinus thrombosis is likely, and immediate admission to the hospital and administration of antibiotics after blood culture has been drawn are indicated. MRI of the brain may be necessary to diagnose multiple sclerosis and some of the brain stem infarcts.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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• Back to disease: Diplopia: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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