Diplopia

• Third nerve palsy (vertical and horizontal diplopia)
  –Compressive lesions (especially if pupil is involved), including aneurysm, cavernous sinus or orbit tumor, pituitary apoplexy, and uncal herniation
  –Ischemic microvascular disease (e.g., diabetes mellitus, hypertension)
  –Midbrain infarct
  –Giant cell arteritis
  –Herpes zoster
  –Leukemia
  –Meningitis
  –Subarachnoid hemorrhage
  –Ophthalmoplegic migraine
  –Trauma
• Fourth nerve palsy (vertical diplopia): Etiologies include trauma, ischemic microvascular disease, congenital, multiple sclerosis, and other causes as above
• Sixth nerve palsy (horizontal diplopia): Etiologies include ischemic microvascular disease, trauma, increased ICP (bilateral palsy), tumor, multiple sclerosis, post-LP, sarcoidosis/vasculitis, pontine infarct, and other causes as above
• Myasthenia gravis
• Orbital disease (e.g., Graves’ orbitopathy, orbital inflammation, tumor)
• Cavernous sinus or superior orbital fissure syndrome (multiple CN involvement)
• Postocular surgery
• Trauma
• Brown's syndrome (restriction of superior oblique tendon)
• Internuclear ophthalmoplegia (MS, CVA)
• Vertebrobasilar insufficiency (vertigo)
• Botulism
  Monocular diplopia
• Refractive error (high astigmatism)
• Corneal opacity or irregularity
• Cataract
• Dislocated lens or lens implant
• Extrapupillary openings
• Macular disease
• Retinal detachment
• Nonphysiologic

Workup and Diagnosis

• History, neurologic, and ocular examinations
  –Note onset, duration, associated symptoms (e.g., eye or orbit pain, headache, erythema), trauma, and past history (e.g., diabetes, HTN, CVA, infection, thyroid disease)
  –Complete neurological exam: Note focal neurological deficits, cranial nerve involvement, cerebellar signs, and symptoms of demyelination (e.g., abnormal Romberg)
  –Ocular exam: Vision, pupil size and reaction, eye motility ductions and versions, ptosis, fundus exam (optic nerve edema or pallor), visual field defect, proptosis, and ice test (myasthenia gravis)

• Consider ophthalmology consultation
• If suspect CNS lesion, MRI is usually the test of choice
• If suspect orbital etiology (e.g., trauma, thyroid), CT is usually superior
• MRI/MRA (and/or angiography) is indicated immediately in cases of pupil-involving third nerve palsy, if age <50 (to rule out demyelinating disease), if no improvement over 3 months, aberrant regeneration, multiple cranial nerve or systemic neurologic involvement exists
• Further testing may include Tensilon test and acetylcholinesterase receptor antibodies to rule out myasthenia gravis, fasting blood glucose and HgbA1C to rule out diabetes, ESR or CRP to rule out giant cell arteritis (urgent temporal artery biopsy is indicated if arteritis is strongly suspected), thyroid function tests and orbital ultrasound or CT for Graves’ orbitopathy
• Lumbar puncture may be necessary (after head CT is done, to rule out increased intracranial pressure)

Treatment

• Treat the underlying etiology
• Patch one eye (usually the involved eye) as necessary
  –In children <10 years old, avoid patching and monitor for development of amblyopia
• Document magnitude of ocular deviation and/or diplopia to determine improvement or stability between exams (measured with prisms by ophthalmologist)
• Prisms in glasses for small stable deviations
• Strabismus surgery for symptomatic diplopia in primary and reading positions if deviation is stable for more than 6 months, for manifest head tilt, or for improving appearance

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

Other Book Chapters Related to Double vision

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Double vision

• Back to symptom: Double vision: Introduction (review 192 causes)
• Next Book Extract About Double vision: Vision Loss (In A Page: Pediatric Signs and Symptoms)
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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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