Diplopia

Diplopia: Excerpt from In A Page: Pediatric Signs and Symptoms

Diplopia of sudden onset is more related to neurologic disease than to ocular disease. Other than space-occupying orbital lesions, most diplopia can be related to a neurologic disorder. The first causes that should come to mind are undiagnosed or poorly controlled diabetes and myasthenia gravis. A good general rule is to assume neurologic disease until proven otherwise.

Differential Diagnosis

• Monocular diplopia
  –Rare, usually associated with the cornea, lens, vitreous, or refractive anomalies such as high uncorrected astigmatism
  –May occur in lens implant dislocation
  –Neurologic disorders may present as monocular diplopia with repetitive images

• Binocular, decompensated phoria with
• concomitant strabismus, nonpathologic
  –Recent ocular surgery
  –Ocular myasthenia (may be transient)
• Binocular with proptosis, gaze restriction
  –Thyroid disease, orbital pseudotumor, cavernous sinus thrombosis or fistula
• Binocular with isolated third nerve
  –Atherosclerosis, hypertension, diabetes, tumor, aneurysm
• Binocular with isolated sixth nerve
  –Trauma, atherosclerosis, hypertension, diabetes, tumor, increased intracranial pressure, sinus disease
• Binocular with isolated fourth nerve
  –Trauma, stroke, thyroid eye disease, atherosclerosis, hypertension, diabetes
• Binocular with multiple muscle weakness in one eye
  –Cavernous sinus lesion
• Binocular with multiple muscle weakness in both eyes
  –Progressive supranuclear palsy, CPEO, acute postinfectious disorders
• Adduction weakness or abducting nystagmus
  –Inner nuclear ophthalmolplegia (INO), brainstem disease, stroke, MS, posterior fossa mass
• Vertical diplopia with no fourth or third palsy
  –Stroke, multiple sclerosis, posterior fossa mass

Workup and Diagnosis

• History
  –Temporal history of the symptoms, including past incidences and transience of defect
  –Establish whether monocular (one eye covered) or binocular (both eyes open)
  –History of recent trauma or ocular surgery
  –Status of known systemic diseases, e.g., hypertension, diabetes, thyroid disease

• Physical exam
  –Obtain visual acuity and confrontation visual fields
  –Pupillary evaluation
  –Observe for head tilt or torsion
  –Observe for proptosis
  –Extraocular muscle evaluation to isolate affected muscle
  –Observe for other neurologic signs or symptoms
  –Perform a dilated fundus evaluation to rule out associated retinal and/or optic nerve disorders
  –Perform Tensilon test for myasthenia

• Workup for medical issues such as diabetes, hypertension, atherosclerosis, stroke, thyroid disease
• Workup with imaging for MS, orbital and intracranial tumor, aneurysm, orbital pseudotumor, cavernous sinus lesions
• Neurologic or neuro-ophthalmological consultation is in order

Treatment

• If monocular, first consider a refractive cause or an ocular media compromise
• If binocular, critical to find the underlying cause
• Assess control of diabetes and other systemic concerns and remedy
• If diagnosis of myasthenia, manage systemically with Mestinon
• Neurologic or neurosurgical intervention may be necessary depending on cause
• Relatively benign causes resolve on their own in 3 months, but patching or prism in glasses may be necessary
• Prism in glasses or interventive strabismus surgery may be necessary in recalcitrant cases

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

More About Vision Impairment

• Back to disease: Vision Impairment: Introduction
• Next Book Extract About Vision Impairment: Vision Loss (In A Page: Pediatric Signs and Symptoms)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: Vision Loss (In A Page: Pediatric Signs and Symptoms)

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