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Diplopia Shouldn’t be a Dirty Word Kyle Smith, MD Question: How do you respond when your technician says... “Your next patient is a 76 year-old woman complaining of double vision? 1. Great! This will be a quick one. 2. Quick, send her to the ER. 3. OK. Somebody go find those #@!! prisms. 4. Oh #@!!... There goes the rest of my day. 5. Cool. I’ll go see someone else while you try to get a neuro-ophthalmology consult set up for her. Diplopia really shouldn’t be a dirty word. Prism Purgatory Diplopia is all about pattern recognition. Objectives... • Monocular diplopia • Pattern Recognition in binocular diplopia • The 10 most common causes of binocular diplopia • Diplopia evaluation pearls • Brief Quiz Monocular Monocular Diplopia Diplopia Monocular Diplopia • Differentiating monocular and binocular diplopia is the FIRST and MOST IMPORTANT issue. • Monocular Diplopia = Poorly focused image • Causes • • • • Refractive error Surface irregularity Lens opacity Post-concussive syndrome (cortical injury - not focus problem) Monocular Diplopia Diagnostic Pearls • “Does it disappear when you close one eye or the other?” • If not sure give the patient “homework” and reschedule. • Retinoscopic reflex • Ghost images A Pattern Recognition in Binocular Diplopia Pattern Recognition • Patient characteristics: Who is this? • History: 4 Critical Questions • Examination: 3 Critical Exam Findings Patient Characteristics • Age • Medical History • • Diabetes • Parkinson’s Disease • Multiple Sclerosis • Malignancy • Thyroid disease Head trauma The 4 Critical Questions • Did it start suddenly or gradually? • Have you had pain around one eye? • Are the images separated horizontally or vertically? • Is the double vision worse at distance or at near? The 3 Critical Exam Findings • Orbital Signs: • • • Enophthalmos Lid Signs: • • • Proptosis Ptosis Lid retraction Limited Ductions Diplopia Pattern Recognition • Patient Characteristics • Who? • History • Onset? • Pain? • Horizontal or vertical? • Worse at distance or near? • Orbital signs • Lid signs • Limited ductions • Exam 10 Most Common Causes of Binocular Diplopia Think Anatomically Neuromuscular Junction Brain Cranial Nerve Extraocular Muscle Brain Problems that cause Diplopia Brain • Convergence Insufficiency • Divergence Insufficiency • Skew Deviation • Internuclear Ophthalmoplegia • Decompensated Phoria Convergence Insufficiency • Subnormal convergence reflex that causes an exotropia when viewing near objects • Causes intermittent difficulty reading • Progresses over time Convergence Insufficiency • Who? Elderly, Parkinson’s • Onset? Gradual • Pain? No • Horizontal or vertical? Horizontal • Worse at distance or near? Near • Orbital signs None • Lid signs None • Limited ductions None Divergence Insufficiency • AKA: Age Related Distance Esotropia (ARDE) • Subnormal divergence reflex that causes an esotropia when viewing distant objects • Anatomical correlate unknown • Very common cause of intermittent diplopia at distance • Progresses over time Divergence Insufficiency • Who? Elderly • Onset? Gradual • Pain? No • Horizontal or vertical? Horizontal • Worse at distance or near? Distance • Orbital signs None • Lid signs None • Limited ductions None Skew Deviation • Abnormal vestibular input to the cranial nerve nuclei that results in a vertical strabismus • Abnormal ocular tilt reaction • Caused by brainstem or cerebellar pathology • Often associated with INO Skew Deviation • Who? Elderly vasculopath • Onset? Sudden • Pain? No • Horizontal or vertical? Vertical • Worse at distance or near? No • Orbital signs None • Lid signs None • Limited ductions None Internuclear Ophthalmoplegia (INO) • Abnormality of the MLF (medial longitudinal fasciculus) that results in an inability to adduct on eye • Brainstem pathology (stroke or MS) • Often accompanied by a skew deviation Internuclear Ophthalmoplegia Internuclear Ophthalmoplegia • Who? Any age • Onset? Sudden • Pain? No • Horizontal or vertical? Horizontal (eccentric gaze) • Worse at distance or near? No • Orbital signs None • Lid signs None • Limited ductions Limited Adduction INO: Other Diagnostic Clues • No diplopia in primary gaze • If exotropic (and diplopic) in primary it is likely bilateral INO (WEBINO). Decompensated Phoria • Phoria: an abnormal resting alignment of the eyes that can be overcome with effort to maintain fusion • May decompensate with age or fatigue • May become a constant tropia over time • May be horizontal or vertical Decompensated Phoria • Who? Any adult • Onset? Gradual • Pain? No • Horizontal or vertical? Either • Worse at distance or near? Either • Orbital signs None • Lid signs None • Limited ductions None Cranial Neuropathies Brain Cranial Nerve • IIIrd nerve palsy • IVth nerve palsy • VIth nerve palsy Extraocular Muscle IIIrd Nerve Palsy • Injury to CN III • ischemic (most common) • compressive (aneurysm) • May be partial or complete • No pupil involvement = ischemic • Usually very painful IIIrd Nerve Palsy IIIrd Nerve Palsy • Who? Diabetic, Vasculopath • Onset? Sudden • Pain? Yes - severe (usually) • Horizontal or vertical? Both (typically down and out) • Worse at distance or near? Neither • Orbital signs None • Lid signs Ptosis • Limited ductions All but abduction IVth Nerve Palsy • Injury to CN IV • ischemic (most common) • traumatic • congenital • Vertical diplopia • Never painful IVth Nerve Palsy IVth Nerve Palsy • Who? Diabetic, Vasculopath, Trauma • Onset? Sudden (unless decompensated congenital) • Pain? No Pain • Horizontal or vertical? Vertical • Worse at distance or near? Neither • Orbital signs None • Lid signs None • Limited ductions None VIth Nerve Palsy • Injury to CN VI • ischemic (most common) • traumatic • Purely horizontal incommitant diplopia • Sometimes mildly painful VIth Nerve Palsy VIth Nerve Palsy • Who? Diabetic, Vasculopath, Trauma • Onset? Sudden • Pain? Minimal • Horizontal or vertical? Horizontal • Worse at distance or near? Neither • Orbital signs None • Lid signs None • Limited ductions Abduction deficit Myasthenia Gravis Neuromuscular Junction Brain Cranial Nerve Extraocular Muscle Myasthenia Gravis • Autoimmune disease characterized by antibodies directed at the acetylcholine receptor at the neuromuscular junction • Characterized by variability over time • Almost any pattern of eye movements • Diplopia usually accompanied by ptosis Myasthenia Gravis • Who? Old men and young women • Onset? Variable • Pain? Painless • Horizontal or vertical? Either or Both • Worse at distance or near? Neither • Orbital signs None • Lid signs Ptosis • Limited ductions Variable Thyroid Eye Disease Brain Cranial Nerve Extraocular Muscle • Thyroid eye disease • Orbital fractures & trauma • Orbital tumors • Orbital inflammation Thyroid Eye Disease • Autoimmune disease characterized by antibodies directed toward orbital muscle and fat causing swelling and fibrosis • Symptoms & Signs • Dry eye • Lid retraction • Periorbital edema • Diplopia • Proptosis • Diplopia usually from hypotropia and/or esotropia Thyroid Eye Disease Thyroid Eye Disease Thyroid Eye Disease Thyroid Eye Disease • Who? Adults • Onset? Gradual • Pain? Minimal • Horizontal or vertical? Either or Both • Worse at distance or near? Neither • Orbital signs Proptosis • Lid signs Lid retraction, periorbital edema • Limited ductions Limited elevation and abduction Diplopia Evaluation Pearls Don’t overlook these... • Aneurysm causing IIIrd nerve palsy • Potentially life threatening • If pupil involved need urgent MRI/MRA • Malignant brain tumor • May cause cranial neuropathy (III, IV, or VI) • Usually accompanied by persistent headache • Look for papilledema • Giant Cell Arteritis • Consider if age >55 and possible ischemic lesion • Ask about GCA symptoms • Lab: ESR, C-Reactive Protein, Platelets What not to do... • Don’t order an MRI for • Convergence / Divergence insufficiency • Decompensated phorias • Diabetic cranial neuropathies • Don’t shotgun the work-up Therapeutic Pearls • Don’t treat (other than patching) unless you have a diagnosis. • Don’t tell the patient to switch the patch from one eye to the other. • Use Fresnel prisms if the condition is likely to evolve with time. • If uncertain about the diagnosis or treatment - refer. Final Quiz 83 y/o female with diplopia... • • • Painless Gradually progressive Vertically separated images 80 y/o female with diplopia... • • • Painless Intermittent symptoms Horizontal and vertically separated images 13 y/o boy with diplopia... • • • History of head injury Sudden onset Horizontally separated images 39 y/o woman with diplopia... • • • Found unconscious beside her car Sudden onset Severe headache Summary Diplopia Evaluation • There is no need to panic since most cases are relatively benign. • Think first and avoid prism purgatory. • Diagnosing diplopia is simple pattern recognition • Who are you treating? • History: Ask the right questions. • Exam: Look for orbital and lid signs. • Don’t overlook the bad stuff (aneurysm, tumor, GCA) • Don’t stop until you have a diagnosis. Thank You! Any Questions?
