Diplopia

Aka: Diplopia, Double Vision

1. History
   1. Monocular or binocular
      1. Does it resolve with either eye covered
         1. Test by covering each eye separately
      2. Monocular Diplopia is due to tears, Cornea or lens
         1. Emergent evaluation is not needed
   2. Timing red flags
      1. Is it new?
      2. Is it constant?
   3. Does it get worse as the day progresses?
      1. Intermittent esotropia
      2. Myasthenia Gravis
      3. Decompensated congenital strabsismus
   4. Is the Diplopia vertical, horizontal or both?
      1. Vertical
         1. Third nerve palsy
         2. Fourth nerve palsy
         3. Graves Ophthalmopathy
         4. Myasthenia Gravis
      2. Horizontal
         1. Sixth nerve palsy
         2. Congenital Strabismus
         3. Papilledema
   5. Is the Diplopia the same in all directions?
      1. Distinguishes incomitant vs comitant strabsimus
   6. Is there a childhood history of Strabismus?
      1. Untreated childhood Strabismus persists
   7. Is there a comorbid condition (e.g. Diabetes)
      1. Consider microvascular Cranial Nerve palsy
   8. Are there changes in speech or swallowing?
      1. Myasthenia Gravis
      2. Temporal Arteritis
      3. Brainstem ischemia
   9. Is there Vision Loss, Headache, or jaw pain?
      1. Temporal Arteritis
   10. Dizziness, ataxia, whooshing sound, metal taste?
       1. Increased Intracranial Pressure
2. Causes: Urgent
   1. Aneurysm (Posterior Communicating Artery)
      1. Worst Headache
      2. Third nerve palsy (Ptosis, eye is down and out)
      3. Mydriasis may be present
   2. Temporal Arteritis
      1. Fever, Night Sweats, Jaw Claudication
      2. Sixth Cranial Nerve palsy may occur
      3. Associated with Polymyalgia Rheumatica
   3. Increased Intracranial Pressure
      1. Headache, ataxia, Nausea, whooshing sound in ear
      2. Metallic Taste in mouth
      3. Esotropia or sixth Cranial Nerve palsy
      4. Causes: Mass lesions, Pseudotumor Cerebri
   4. Multiple cranial Neuropathy
      1. Brainstem cause or
      2. Cavernous Sinus process
   5. Trauma
      1. Blowout Fracture of orbit
      2. Orbital Congestion
      3. Neurological injury/lesion
3. Causes: Non-urgent
   1. Cranial Nerve palsy
      1. Third nerve palsy (Image and refer to eye and neuro)
      2. Sixth nerve palsy
         1. May be associated with Head Tilt
   2. Incomitant Strabismus (not same in all gaze directions)
      1. Graves Ophthalmopathy (restricted EOM)
   3. Comitant Strabismus (same in all gaze directions)
      1. Childhood Strabismus
      2. Increased Intracranial Pressure
      3. Intermittent exotropia
      4. Accomodative esotropia