II. History
- Monocular or binocular
- Does it resolve with either eye covered (binocular Diplopia)
- Test by covering each eye separately
- Monocular Diplopia persists regardless of whether the unaffected eye is open or closed
- Contrast with binocular Diplopia, which resolves when one eye is closed
- Binocular Diplopia is due to eye misalignment (Cranial Nerve deficit of 3,4 or 6)
- Monocular Diplopia is due to tears, Cornea or lens
- Emergent evaluation is not needed
- Does it resolve with either eye covered (binocular Diplopia)
- Timing red flags
- Is it new?
- Is it constant?
- Does it get worse as the day progresses?
- Intermittent Esotropia
- Myasthenia Gravis
- Decompensated congenital strabsismus
- Is the Diplopia vertical, horizontal or both?
- Vertical
- Third nerve palsy
- Fourth nerve palsy
- Graves Ophthalmopathy
- Myasthenia Gravis
- Horizontal
- Sixth nerve palsy
- Congenital Strabismus
- Papilledema
- Vertical
- Is the Diplopia the same in all directions?
- Distinguishes incomitant vs comitant strabsimus
- Is there a childhood history of Strabismus?
- Untreated childhood Strabismus persists
- Is there a comorbid vascular condition or Diabetes Mellitus
- Consider microvascular Cranial Nerve palsy
- Are there changes in speech or Swallowing?
- Is there Vision Loss, Headache, or jaw pain?
-
Dizziness, Ataxia, whooshing sound, metal taste?
- Increased Intracranial Pressure (may demonstrate sixth nerve palsy)
- Is there a third nerve palsy (eye looks down and out, Mydriasis, or may be subtle with mild Ptosis)?
- Emergently exclude Posterior Communicating Artery aneurysm (with CT and CTA)
- Are there other neurologic findings that are not anatomically related?
III. Causes: Urgent
- Aneurysm (Posterior Communicating Artery)
-
Temporal Arteritis (presents with transient Diplopia in 25% of cases)
- Fever, Night Sweats, Jaw Claudication
- Sixth Cranial Nerve palsy may occur
- Associated with Polymyalgia Rheumatica
- Obtain CRP, ESR
-
Increased Intracranial Pressure
- Headache, Ataxia, Nausea, whooshing sound in ear
- Metallic Taste in mouth
- Esotropia or sixth Cranial Nerve palsy
- Causes: Mass lesions, Pseudotumor Cerebri
- Multiple cranial Neuropathy (CN 2-6)
- Cavernous Sinus Thrombosis (MR Venogram or CT Venogram)
- Orbital apex syndrome (CT orbits with contrast)
- Other Posterior Circulation finding (Vertigo, Aphasia, Ataxia) or multiple adjacent Cranial Nerves
- Brainstem or posterior circulation Cerebrovascular Accident or mass
-
Trauma
- Blowout Fracture of orbit
- Orbital Congestion
- Neurological injury/lesion
IV. Causes: Non-urgent
-
Cranial Nerve palsy
- Fourth nerve palsy (Image and refer to eye and neuro)
- Sixth nerve palsy
- Most common Cranial Nerve palsy
- Exclude Increased Intracranial Pressure (fundoscopic exam, Eye Ultrasound, or LP opening pressure)
- Isolated sixth nerve palsy may be evaluated in outpatient setting with MRI Brain
- May delay imaging up to 3 months in adults, and consider MRI if does not resolve
- MRI Brain for all children with sixth nerve palsy (25% have compressive tumors)
- May be associated with Head Tilt
- May resolve spontaneously if microischemic sixth nerve palsy (esp. if age >50 with vascular risks)
- Associated with higher risk for future hemispheric stroke
- Incomitant Strabismus (not same in all gaze directions)
- Graves Ophthalmopathy (restricted EOM)
- Comitant Strabismus (same in all gaze directions)
- Childhood Strabismus
- Increased Intracranial Pressure
- Intermittent Exotropia
- Accomodative Esotropia
V. References
- Claudius, Shoenberger and Margolin in Herbert (2018) EM:Rap 18(12): 8-9
- Trobe (2012) Physicians Guide to Eye Care, AAO, San Francisco, p. 38-40