Diplopia differential diagnosis: Difference between revisions

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{{Diplopia}}
{{Diplopia}}
{{CMG}} {{AE}}
{{CMG}} {{AE}} {{HK}}


==Overview==
==Overview==


Diplopia may be caused by disorders of the orbit, extraocular muscles, neuromuscular junction dysfuntion, paralysis of the oculomotor, trochlear and abducens nerves, and injuries affecting the central nervous system (CNS). Given the various causes of diplopia, it is important to differentiate between the different causes that lead to diplopia.
Diplopia may be caused by disorders of the [[Orbit (anatomy)|orbit]], [[extraocular muscles]], [[neuromuscular junction]] dysfuntion, [[Oculomotor nerve palsy|paralysis of the oculomotor]], [[Trochlear nerve malfunction|trochlear]] and [[Abducens nerve palsy|abducens nerves]], and injuries affecting the [[central nervous system]] ([[CNS]]). Given the various causes of diplopia, it is important to differentiate between the different causes that lead to diplopia.
==Differentiating Diplopia From Other Diseases==
==Differentiating Diplopia From Other Diseases==
Diplopia may be caused by disorders of the orbit, extraocular muscles, neuromuscular junction dysfuntion, paralysis of the oculomotor, trochlear and abducens nerves, and injuries affecting the central nervous system (CNS). Given the various causes of diplopia, it is important to differentiate between the different causes that lead to diplopia. The following table differentiates between various causes of diplopia:<ref name="urlthejns.org">{{cite web |url=https://thejns.org/doi/pdf/10.3171/foc.2001.10.5.2 |title=thejns.org |format= |work= |accessdate=}}</ref>
Diplopia may be caused by disorders of the [[Orbit (anatomy)|orbit]], [[extraocular muscles]], [[neuromuscular junction]] dysfuntion, [[Oculomotor nerve palsy|paralysis of the oculomotor]], [[Trochlear nerve malfunction|trochlear]] and [[Abducens nerve palsy|abducens nerves]], and injuries affecting the [[central nervous system]] ([[CNS]]). Given the various causes of diplopia, it is important to differentiate between the different causes that lead to diplopia. The following table differentiates between various causes of diplopia:


{| class="wikitable"
{| class="wikitable"
|'''Dilopia causing disorder'''
! align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Dilopia Causing Disorder'''
|'''Subcategory'''
! align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Subcategory'''
|'''Mechanism'''
! align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Mechanism'''
|'''Distinguising Features'''
! align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Distinguising Features'''
|'''Exam Findings'''
! align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Exam Findings'''
|-
|-
| colspan="1" rowspan="4" |Orbital disorder
| colspan="1" rowspan="4" style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Orbit (anatomy)|Orbital]] disorder'''
| colspan="1" rowspan="1" |Trauma  
| colspan="1" rowspan="1" |Trauma  
|
|
* Direct injury to the orbit or eye
* Direct injury to the [[orbit]] or [[eye]]
|
|
* Ecchymosis
* [[Ecchymosis]]
* Bone fracture
* [[Bone fracture]]
* Hematoma formation
* [[Hematoma]] formation
* Altered mental status  
* [[Altered mental status]]
|
|
|-
|-
|Orbital apex mass
|[[Orbital cavity|Orbital apex]] mass<ref name="urlthejns.org">{{cite web |url=https://thejns.org/doi/pdf/10.3171/foc.2001.10.5.2 |title=thejns.org |format= |work= |accessdate=}}</ref>
|
|
* Inflitration or mass effect in the orbital apex or cavernous sinus
* Inflitration or mass effect in the [[Orbital cavity|orbital apex]] or [[cavernous sinus]]
* Compression of the oculomotor nerve  
* Compression of the [[oculomotor nerve]]
|
|
* Palsies of oculomotor, trochlear and/or abducens nerves
* [[Palsy|Palsies]] of [[oculomotor]], [[trochlear]] and/or [[Abducens nerve|abducens nerves]]
* Periorbital or facial numbness  
* Periorbital or facial [[Paresthesia|numbness]]
* Retro-orbital pain  
* Retro-orbital [[pain]]
* Proptosis  
* [[Proptosis]]
* Signs of venous congestion  
* Signs of venous congestion  
|
|
* Multi-directional horizantal and vertical diplopia
* Multi-directional horizantal and vertical diplopia
* Down and out pupil
* Down and out pupil
* Pupillary dilation  
* [[Pupillary dilation]]
* Deterioration of visual acuity  
* Deterioration of [[visual acuity]]
* Exophthamos
* [[Exophthalmos]]
* Prominent choroidal folds
* Prominent [[Choroidal|choroidal folds]]
* Optic atrophy  
* [[Optic atrophy]]
* Bone destruction  
* [[Bone]] destruction  
|-
|-
|Orbital cellulitis<ref name="pmid22346113">{{cite journal |vauthors=Chaudhry IA, Al-Rashed W, Arat YO |title=The hot orbit: orbital cellulitis |journal=Middle East Afr J Ophthalmol |volume=19 |issue=1 |pages=34–42 |date=January 2012 |pmid=22346113 |doi=10.4103/0974-9233.92114 |url=}}</ref><ref name="pmid23960899">{{cite journal |vauthors=Lee S, Yen MT |title=Management of preseptal and orbital cellulitis |journal=Saudi J Ophthalmol |volume=25 |issue=1 |pages=21–9 |date=January 2011 |pmid=23960899 |doi=10.1016/j.sjopt.2010.10.004 |url=}}</ref>
|[[Orbital cellulitis]]<ref name="pmid22346113">{{cite journal |vauthors=Chaudhry IA, Al-Rashed W, Arat YO |title=The hot orbit: orbital cellulitis |journal=Middle East Afr J Ophthalmol |volume=19 |issue=1 |pages=34–42 |date=January 2012 |pmid=22346113 |doi=10.4103/0974-9233.92114 |url=}}</ref><ref name="pmid23960899">{{cite journal |vauthors=Lee S, Yen MT |title=Management of preseptal and orbital cellulitis |journal=Saudi J Ophthalmol |volume=25 |issue=1 |pages=21–9 |date=January 2011 |pmid=23960899 |doi=10.1016/j.sjopt.2010.10.004 |url=}}</ref>
|
|
* Spread of infection from contiguous sinuses (especially ethmoidal suinus)
* Spread of [[infection]] from contiguous sinuses (especially [[Ethmoid sinus|ethmoidal sinus]])
* Culprit organisms include S. aureus and S. pneumoniae
* Culprit organisms include [[Staphylococcus aureus|S. aureus]] and [[S. pneumoniae]]
|
|
* Proptosis
* [[Proptosis]]
* Eyelid edema
* [[Eyelid]] [[edema]]
* Ophthalmoplegia
* [[Ophthalmoplegia]]
* Ocular pain
* [[Ocular]] [[pain]]
* Presence of risk factors:
* Presence of [[risk factors]]:
** Recent upper respiratory illness
** Recent [[Upper respiratory infection|upper respiratory illness]]
** Sinus infection
** [[Sinusitis|Sinus infection]]
** Younger age
** Younger age
** Retained foreign bodies within the orbit
** Retained foreign bodies within the [[Orbit (anatomy)|orbit]]
** Trauma
** [[Trauma]]
** Immunosuppression
** [[Immunosuppression]]
** Systemic infection
** [[Systemic infection]]
** Dental infections
** [[Dental caries|Dental infections]]


|
|
* Eyelid swelling  
* [[Eyelid]] [[swelling]]
* Conjunctival chemosis
* [[Chemosis|Conjunctival chemosis]]
* Axial proptosis
* Axial [[proptosis]]
* Restriction of eye movements
* Restriction of eye movements
* Retinal venous congestion  
* Retinal venous congestion  
* Papilledema
* [[Papilledema]]
|-
|-
|Thyroid-associated ophthalmopathy (Grave's disease)<ref name="pmid28405484">{{cite journal |vauthors=Şahlı E, Gündüz K |title=Thyroid-associated Ophthalmopathy |journal=Turk J Ophthalmol |volume=47 |issue=2 |pages=94–105 |date=April 2017 |pmid=28405484 |doi=10.4274/tjo.80688 |url=}}</ref><ref name="pmid26351570">{{cite journal |vauthors=Barrio-Barrio J, Sabater AL, Bonet-Farriol E, Velázquez-Villoria Á, Galofré JC |title=Graves' Ophthalmopathy: VISA versus EUGOGO Classification, Assessment, and Management |journal=J Ophthalmol |volume=2015 |issue= |pages=249125 |date=2015 |pmid=26351570 |doi=10.1155/2015/249125 |url=}}</ref>
|Thyroid-associated ophthalmopathy ([[Grave's disease]])<ref name="pmid28405484">{{cite journal |vauthors=Şahlı E, Gündüz K |title=Thyroid-associated Ophthalmopathy |journal=Turk J Ophthalmol |volume=47 |issue=2 |pages=94–105 |date=April 2017 |pmid=28405484 |doi=10.4274/tjo.80688 |url=}}</ref><ref name="pmid26351570">{{cite journal |vauthors=Barrio-Barrio J, Sabater AL, Bonet-Farriol E, Velázquez-Villoria Á, Galofré JC |title=Graves' Ophthalmopathy: VISA versus EUGOGO Classification, Assessment, and Management |journal=J Ophthalmol |volume=2015 |issue= |pages=249125 |date=2015 |pmid=26351570 |doi=10.1155/2015/249125 |url=}}</ref>
|
|
* Autoimmune
* [[Autoimmune]]
|
|
* Proptosis
* [[Proptosis]]
* Restriction of elevation and abduction of the eyes
* Restriction of elevation and [[abduction]] of the eyes
* Tachycardia
* [[Tachycardia]]
* Intolerance to heat  
* Intolerance to heat  
* Weight loss  
* [[Weight loss]]
* Insomnia
* [[Insomnia]]
* Fatigue
* [[Fatigue]]
* Diarrhea
* [[Diarrhea]]
|
|
* Dysthyroid orbitopathy (involvement of medial and inferior rectii muscles)
* Dysthyroid orbitopathy (involvement of [[Medial rectus muscle|medial]] and [[Inferior rectus muscle|inferior rectii]] muscles)
* Von Grafe's sign (lid lag on downward gaze)
* [[Von Graefe sign|Von Grafe's]] sign (lid lag on downward gaze)
* Joffroy sign (Absent creases on forehead on upward gaze)
* Joffroy sign (Absent creases on forehead on upward gaze)
* Stellwag sign (Infrequent and incomplete blinking)
* [[Stellwag's sign|Stellwag sign]] (Infrequent and incomplete blinking)
* Boston sign (jerky irregular movements on downward gaze)
* [[Boston's sign|Boston sign]] (jerky irregular movements on downward gaze)
* Vigouroux sign (eyelid fullness)
* Vigouroux sign (eyelid fullness)
* Dalrymple’s sign
* [[Dalrymple sign|Dalrymple’s sign]]
* Optic disc edema
* [[Optic disc]] [[edema]]
* Choroidal folds
* [[Choroidal|Choroidal folds]]
* Optic disc paleness
* [[Optic disc]] paleness
|-
|-
| colspan="1" rowspan="5" |Extraocular muscle disorder
| rowspan="3" style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Extraocular muscles|Extraocular muscle]] disorder'''
| colspan="1" rowspan="1" |Thyroid-associated ophthalmopathy due to ocular surgery 
|[[Extraocular muscles|Extraocular muscle]] injury or hematoma<ref name="pmid16171176">{{cite journal |vauthors=Thacker NM, Velez FG, Demer JL, Wang MB, Rosenbaum AL |title=Extraocular muscle damage associated with endoscopic sinus surgery: an ophthalmology perspective |journal=Am J Rhinol |volume=19 |issue=4 |pages=400–5 |date=2005 |pmid=16171176 |doi= |url=}}</ref><ref name="pmid26426604">{{cite journal |vauthors=Chen J, Kang Y, Deng D, Shen T, Yan J |title=Isolated Total Rupture of Extraocular Muscles |journal=Medicine (Baltimore) |volume=94 |issue=39 |pages=e1351 |date=September 2015 |pmid=26426604 |doi=10.1097/MD.0000000000001351 |url=}}</ref>
|
|
* [[Facial trauma]]
* [[Sinus surgery]]
* Extreme [[strabismus]]
|
|
* [[Hematoma]]
* Entrapment of [[muscle]] in the fractured [[Orbit (anatomy)|orbital wall]]
* Damage to the [[oculomotor nerve]] entry zone
* [[Muscle]] [[transection]]
* Partial or complete [[muscle]] destruction with entrapment in [[scar tissue]].
|
|
* Restriction of [[eye]] movements
* [[Hematoma]] formation
* Down and out eyes in case of damage to [[oculomotor nerve]]
* Absent [[oculocardiac reflex]] of affected muscle
* [[Bone]] damage
|-
|-
|Extraocular muscle injury or hematoma
|[[Mitochondrial myopathy|Mitochondrial myopathies]]<ref name="pmid21730846">{{cite journal |vauthors=Schrier SA, Falk MJ |title=Mitochondrial disorders and the eye |journal=Curr Opin Ophthalmol |volume=22 |issue=5 |pages=325–31 |date=September 2011 |pmid=21730846 |doi=10.1097/ICU.0b013e328349419d |url=}}</ref>
|
|
* [[Dominant optic atrophy]] (OPA1 [[gene mutation]])
* [[Leber hereditary optic neuropathy]] ([[point mutation]] in [[mitochondrial DNA]])
* [[Kearns-Sayer syndrome|Chronic progressive external ophthalmoplegia]] also known as [[Kearns-Sayre syndrome]] (TYMP, ANT1, [[PEO1]], [[POLG]], [[POLG2]], and even OPA1 [[Gene mutation|gene mutations]])
|
|
* [[Retinal]] [[ganglion cells]] and [[nerve fiber layer]] of the [[retina]] affected in [[dominant optic atrophy]] (may lead to [[blindness]])
* [[Acute (medicine)|Acute]] and painless central [[vision loss]] of both eyes in [[Leber hereditary optic neuropathy]] (days to months)
* [[Extraocular muscles|Extraocular muscle]] mobility impairment in [[Kearns-Sayer syndrome|chronic progressive external ophthalmoplegia]]
**
|
|
* [[Kearns-Sayer syndrome|Chronic progressive external ophthalmoplegia]]:
** Restriction of eye movements
** [[Visual acuity]] is spared
** [[Ptosis]]
* [[Leber's hereditary optic neuropathy|Leber hereditary optic neuropathy]]:
** [[Optic disc|Disc]] pseudoedema
** Thickening of the [[retinal]] [[Nerve fiber layer|nerve fiber layers]]
* [[Dominant optic atrophy]]:
** [[Blindness]]
** Thinning of the [[Nerve fiber layer|neuroretinal rim]]
** [[Cup-to-disc ratio|Cup to disc ratio]] > 0.5
** Peripapillary [[atrophy]]
** Sectoral [[pallor]] of the [[optic nerve]]
|-
|-
|Congenital myopathie
|[[Muscular dystrophy]]<ref name="urlOculopharyngeal Muscular Dystrophy - NORD (National Organization for Rare Disorders)">{{cite web |url=https://rarediseases.org/rare-diseases/oculopharyngeal-muscular-dystrophy/ |title=Oculopharyngeal Muscular Dystrophy - NORD (National Organization for Rare Disorders) |format= |work= |accessdate=}}</ref>
|
|
* [[Oculopharyngeal muscular dystrophy]] ([[mutations]] of the polyadenylate binding protein nuclear 1, [[PABPN1|PABPN1 gene]])
* Oculopharyngodistal myopathy
|
|
* [[Dysphagia]]
* [[Proximal muscle weakness|Weakness of proximal muscles]] (distal muscles in case of oculopharyngodistal myopathy)
* [[Atrophy]] of the [[tongue]]
* [[Muscle weakness|Weakness]] of [[facial muscles]]
* [[Dysphonia]]
|
|
* [[Ptosis]]
* [[Ophthalmoplegia]]
|-
|-
|Mitochondrial myopathies,
| colspan="1" rowspan="2" style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Neuromuscular junction]] dysfunction'''
| colspan="1" rowspan="1" |[[Myasthenia gravis]]<ref name="urlUpdate on the Diagnosis of Ocular Myasthenia Gravis - American Academy of Ophthalmology">{{cite web |url=https://www.aao.org/current-insight/update-on-diagnosis-of-ocular-myasthenia-gravis |title=Update on the Diagnosis of Ocular Myasthenia Gravis - American Academy of Ophthalmology |format= |work= |accessdate=}}</ref><ref name="pmid25449931">{{cite journal |vauthors=Nair AG, Patil-Chhablani P, Venkatramani DV, Gandhi RA |title=Ocular myasthenia gravis: a review |journal=Indian J Ophthalmol |volume=62 |issue=10 |pages=985–91 |date=October 2014 |pmid=25449931 |pmc=4278125 |doi=10.4103/0301-4738.145987 |url=}}</ref>
|
|
* [[Autoimmunity|Auto-antibodies]] against [[Nicotinic acetylcholine receptor|nicotinic acetylcholine receptors]]
|
|
|
* Fluctuating [[muscular weakness]]
|-
* [[Ptosis]]
|Muscular dystrophy
* [[Diplopia]] and [[Muscle weakness|weakness]] worsens with activity and improves with rest  
|
|
|
|-
| colspan="1" rowspan="2" |Neuromuscular junction dysfunction
| colspan="1" rowspan="1" |Myasthenia gravis<ref name="urlUpdate on the Diagnosis of Ocular Myasthenia Gravis - American Academy of Ophthalmology">{{cite web |url=https://www.aao.org/current-insight/update-on-diagnosis-of-ocular-myasthenia-gravis |title=Update on the Diagnosis of Ocular Myasthenia Gravis - American Academy of Ophthalmology |format= |work= |accessdate=}}</ref><ref name="pmid25449931">{{cite journal |vauthors=Nair AG, Patil-Chhablani P, Venkatramani DV, Gandhi RA |title=Ocular myasthenia gravis: a review |journal=Indian J Ophthalmol |volume=62 |issue=10 |pages=985–91 |date=October 2014 |pmid=25449931 |pmc=4278125 |doi=10.4103/0301-4738.145987 |url=}}</ref>
|
* Auto-antibodies against nicotinic acetylcholine receptors
|
* Fluctuating muscular weakness
* Ptosis
* Diplopia and weakness worsens with activity and improves with rest  
|
|
* Ptosis
* Ptosis
* Incommitant strabismus or/and external ophthalmoplegia
* Incommitant [[strabismus]] or/and external [[ophthalmoplegia]]
* Cogan’s lid-twitch sign  
* Cogan’s lid-twitch sign  
* Weakness of the orbicularis oculi muscle
* Weakness of the [[orbicularis oculi muscle]]
|-
|-
|Botulism
|[[Botulism]]<ref name="pmid22993467">{{cite journal |vauthors=Khakshoor H, Moghaddam AA, Vejdani AH, Armstrong BK, Moshirfar M |title=Diplopia as the primary presentation of foodborne botulism |journal=Oman J Ophthalmol |volume=5 |issue=2 |pages=109–11 |date=May 2012 |pmid=22993467 |pmc=3441016 |doi=10.4103/0974-620X.99375 |url=}}</ref>
|
|
* Inhibition of acetylcholine release due to toxin at cholinergic synapse and pre-synaptic myoneural junction  
* Inhibition of [[acetylcholine]] release due to [[toxin]] at [[Cholinergic|cholinergic synapse]] and pre-synaptic [[myoneural junction]]
|
|
* Dysathria
* Dysathria
* Dysphagia
* [[Dysphagia]]
* Autonomic dysreflexia
* [[Autonomic dysreflexia]]
* Pupillary dysfunction
* [[Pupillary]] dysfunction
|
|
* [[Ptosis]]
* [[Blurred vision]]
* [[Ophthalmoplegia]]
|-
|-
| colspan="1" rowspan="3" |Palsies of the third, fourth or sixth cranial nerves
| colspan="1" rowspan="3" style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Palsy|Palsies]] of the [[Oculomotor nerve palsy|third]], [[Trochlear nerve malfunction|fourth]] or [[Sixth nerve palsy|sixth]] [[cranial nerves]]'''
| colspan="1" rowspan="1" |Oculomotor nerve palsy
| colspan="1" rowspan="1" |[[Oculomotor nerve palsy]]
| rowspan="3" |
| rowspan="3" |
* Microvascular ischemia:
* [[Microvascular disease|Microvascular ischemia]]:
** Diabetic neuropathy
** [[Diabetic neuropathy]]
* Hemorrhage
* [[Hemorrhage]]
* Tumor
* [[Tumor]]
* Vascular malformation
* [[Vascular malformation]]
* Aneurysm
* [[Aneurysm]]
* Meningitis
* [[Meningitis]]
* Multiple sclerosis
* [[Multiple sclerosis]]
|
|
* Muscles affected:
* [[Muscles]] affected:
** Medial, inferiorn superior rectii
** [[Medial rectus muscle|Medial]], [[Inferior rectus muscle|inferior]] [[Superior rectus muscle|superior rectii]]
** Inferior oblique muscle  
** [[Inferior oblique muscle]]
** Levator palpebrae muscle  
** [[Levator palpebrae superioris muscle|Levator palpebrae muscle]]
** Ciliary and constrictor pupillae muscles
** [[Ciliary muscle|Ciliary]] and constrictor pupillae muscles
|
|
* Multi-directional horizantal and vertical diplopia  
* Multi-directional horizantal and vertical diplopia  
* No diplopia on lateral gaze to the affected side  
* No diplopia on lateral gaze to the affected side  
* Eyelid droop (ptosis)
* [[Eyelid]] [[Drooping eyelid|droop]] ([[ptosis]])
* Down and out pupil  
* Down and out pupil  
* Pupillary dilation  
* [[Pupillary dilation]]
|-
|-
|Trochlear nerve palsy
|[[Trochlear nerve malfunction|Trochlear nerve palsy]]
|
|
* Muscles affected:
* [[Muscles]] affected:
** Superior oblique muscle  
** [[Superior oblique muscle]]
|
|
* Rotational diplopia that is worse on looking downwards and towards the nose  
* Rotational diplopia that is worse on looking downwards and towards the [[nose]]
* Extorsion on downward gaze  
* [[Extorsion]] on downward gaze  
|-
|-
|Abducens nerve palsy  
|[[Abducens nerve palsy]]
|
|
* Muscles affected:
* [[Muscles]] affected:
** Lateral rectus muscle  
** [[Lateral rectus muscle]]
|
|
* Horizontal diplopia on gaze towards the affected side  
* Horizontal diplopia on gaze towards the affected side  
* Lateral gaze palsy  
* Lateral gaze [[palsy]]
|-
|-
| colspan="1" rowspan="4" |Central nervous system injury (pathways and cranial nerve nuclei)
| colspan="1" rowspan="4" style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Central nervous system]] injury (pathways and [[Cranial nerves|cranial nerve]] nuclei)'''
| colspan="1" rowspan="1" |Basilar artery thrombosis<ref name="pmid26288672">{{cite journal |vauthors=Demel SL, Broderick JP |title=Basilar Occlusion Syndromes: An Update |journal=Neurohospitalist |volume=5 |issue=3 |pages=142–50 |date=July 2015 |pmid=26288672 |doi=10.1177/1941874415583847 |url=}}</ref><ref name="pmid14638878">{{cite journal |vauthors=von Campe G, Regli F, Bogousslavsky J |title=Heralding manifestations of basilar artery occlusion with lethal or severe stroke |journal=J. Neurol. Neurosurg. Psychiatry |volume=74 |issue=12 |pages=1621–6 |date=December 2003 |pmid=14638878 |doi= |url=}}</ref>
| colspan="1" rowspan="1" |[[Basilar artery]] [[thrombosis]]<ref name="pmid26288672">{{cite journal |vauthors=Demel SL, Broderick JP |title=Basilar Occlusion Syndromes: An Update |journal=Neurohospitalist |volume=5 |issue=3 |pages=142–50 |date=July 2015 |pmid=26288672 |doi=10.1177/1941874415583847 |url=}}</ref><ref name="pmid14638878">{{cite journal |vauthors=von Campe G, Regli F, Bogousslavsky J |title=Heralding manifestations of basilar artery occlusion with lethal or severe stroke |journal=J. Neurol. Neurosurg. Psychiatry |volume=74 |issue=12 |pages=1621–6 |date=December 2003 |pmid=14638878 |doi= |url=}}</ref>
|
|
* Occlusive thrombosis of the basilar artery  
* Occlusive [[thrombosis]] of the [[basilar artery]]
* Brainstem ischemia  
* [[Brainstem]] ischemia  
|
|
* Dysarthria
* [[Dysarthria]]
* Vertigo  
* [[Vertigo]]
* Cranial nerve palsies
* [[Cranial nerves|Cranial nerve]] [[Palsy|palsies]]
* Presence of risk factors for ischemic stroke
* Presence of [[risk factors]] for [[ischemic stroke]]
|
|
* Nystagmus  
* [[Nystagmus]]
* Visual field defects  
* [[Visual field defect|Visual field defects]]
* Restriction of eye movements (maybe internuclear ophthalmoplegia)  
* Restriction of eye movements (maybe [[internuclear ophthalmoplegia]])  
|-
|-
|Vertebral dissection<ref name="pmid19096659">{{cite journal |vauthors=Park KW, Park JS, Hwang SC, Im SB, Shin WH, Kim BT |title=Vertebral artery dissection: natural history, clinical features and therapeutic considerations |journal=J Korean Neurosurg Soc |volume=44 |issue=3 |pages=109–15 |date=September 2008 |pmid=19096659 |doi=10.3340/jkns.2008.44.3.109 |url=}}</ref><ref name="pmid22931728">{{cite journal |vauthors=Gottesman RF, Sharma P, Robinson KA, Arnan M, Tsui M, Ladha K, Newman-Toker DE |title=Clinical characteristics of symptomatic vertebral artery dissection: a systematic review |journal=Neurologist |volume=18 |issue=5 |pages=245–54 |date=September 2012 |pmid=22931728 |doi=10.1097/NRL.0b013e31826754e1 |url=}}</ref>  
|[[Vertebral artery dissection|Vertebral dissection]]<ref name="pmid19096659">{{cite journal |vauthors=Park KW, Park JS, Hwang SC, Im SB, Shin WH, Kim BT |title=Vertebral artery dissection: natural history, clinical features and therapeutic considerations |journal=J Korean Neurosurg Soc |volume=44 |issue=3 |pages=109–15 |date=September 2008 |pmid=19096659 |doi=10.3340/jkns.2008.44.3.109 |url=}}</ref><ref name="pmid22931728">{{cite journal |vauthors=Gottesman RF, Sharma P, Robinson KA, Arnan M, Tsui M, Ladha K, Newman-Toker DE |title=Clinical characteristics of symptomatic vertebral artery dissection: a systematic review |journal=Neurologist |volume=18 |issue=5 |pages=245–54 |date=September 2012 |pmid=22931728 |doi=10.1097/NRL.0b013e31826754e1 |url=}}</ref>  
|
|
* Vertebrobasilar insufficiency  
* [[Vertebrobasilar insufficiency]]
|
|
* Acute onset
* [[Acute|Acute onset]]
* Neck pain
* [[Neck pain]]
* Vertigo
* [[Vertigo]]
* Presence of risk factors for vertebral dissection
* Presence of [[risk factors]] for [[Vertebral artery dissection|vertebral dissection]]
|
|
* Occipital and nuchal pain
* Occipital and [[Neck pain|nuchal pain]]
* Monocular blindness
* [[Monocular visual loss|Monocular blindness]]
* Hemianopsia
* [[Hemianopsia]]
* Bilateral visual field defects  
* [[Bilateral]] [[Visual field defect|visual field defects]]
* Amaurosis fugax
* [[Amaurosis fugax]]
* Ptosis
* [[Ptosis]]
* Miosis
* [[Miosis]]
|-
|-
|Aneurysm
|[[Aneurysm]]
|
|
* Enlarging aneurysm causes direct compression of the cranial nerves  
* Enlarging [[aneurysm]] causes direct compression of the [[cranial nerves]]
|
|
* Oculomotor nerve palsy  
* [[Oculomotor nerve palsy]]
* Pupillary involvement  
* [[Pupillary]] involvement  
|
|
* Aneurysm visible on fundoscopy  
* [[Aneurysm]] visible on [[fundoscopy]]
|-
|-
|Wernicke's encephalopathy  
|[[Wernicke's encephalopathy]]<ref name="pmid28924437">{{cite journal |vauthors=Serlin T, Moisseiev E |title=Fundus Findings in Wernicke Encephalopathy |journal=Case Rep Ophthalmol |volume=8 |issue=2 |pages=406–409 |date=2017 |pmid=28924437 |doi=10.1159/000478924 |url=}}</ref><ref name="urlNystagmus from Wernicke’s Encephalopathy | NEJM">{{cite web |url=https://www.nejm.org/doi/full/10.1056/NEJMicm1615499 |title=Nystagmus from Wernicke’s Encephalopathy &#124; NEJM |format= |work= |accessdate=}}</ref>
|
|
* Thiamine deficiency leads to metabolic failure and tissue injury  
* [[Thiamine deficiency]] leads to metabolic failure and [[tissue]] injury  
|
|
* Nystagmus
* [[Nystagmus]]
* Ataxia
* [[Ataxia]]
* Altered mental status
* [[Altered mental status]]
* Ophthalmoplegia
* [[Ophthalmoplegia]]
* Malnutrition
* [[Malnutrition]]
* History of [[alcoholism]]
|
|
* [[Optic disc]] [[edema]]
* Preretinal [[hemorrhage]]
|}
|}


Latest revision as of 21:34, 19 February 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Overview

Diplopia may be caused by disorders of the orbit, extraocular muscles, neuromuscular junction dysfuntion, paralysis of the oculomotor, trochlear and abducens nerves, and injuries affecting the central nervous system (CNS). Given the various causes of diplopia, it is important to differentiate between the different causes that lead to diplopia.

Differentiating Diplopia From Other Diseases

Diplopia may be caused by disorders of the orbit, extraocular muscles, neuromuscular junction dysfuntion, paralysis of the oculomotor, trochlear and abducens nerves, and injuries affecting the central nervous system (CNS). Given the various causes of diplopia, it is important to differentiate between the different causes that lead to diplopia. The following table differentiates between various causes of diplopia:

Dilopia Causing Disorder Subcategory Mechanism Distinguising Features Exam Findings
Orbital disorder Trauma
Orbital apex mass[1]
Orbital cellulitis[2][3]
Thyroid-associated ophthalmopathy (Grave's disease)[4][5]
Extraocular muscle disorder Extraocular muscle injury or hematoma[6][7]
Mitochondrial myopathies[8]
Muscular dystrophy[9]
Neuromuscular junction dysfunction Myasthenia gravis[10][11]
Botulism[12]
Palsies of the third, fourth or sixth cranial nerves Oculomotor nerve palsy
Trochlear nerve palsy
  • Rotational diplopia that is worse on looking downwards and towards the nose
  • Extorsion on downward gaze
Abducens nerve palsy
  • Horizontal diplopia on gaze towards the affected side
  • Lateral gaze palsy
Central nervous system injury (pathways and cranial nerve nuclei) Basilar artery thrombosis[13][14]
Vertebral dissection[15][16]
Aneurysm
Wernicke's encephalopathy[17][18]

References

  1. ↑ "thejns.org".
  2. ↑ Chaudhry IA, Al-Rashed W, Arat YO (January 2012). "The hot orbit: orbital cellulitis". Middle East Afr J Ophthalmol. 19 (1): 34–42. doi:10.4103/0974-9233.92114. PMID 22346113.
  3. ↑ Lee S, Yen MT (January 2011). "Management of preseptal and orbital cellulitis". Saudi J Ophthalmol. 25 (1): 21–9. doi:10.1016/j.sjopt.2010.10.004. PMID 23960899.
  4. ↑ Şahlı E, Gündüz K (April 2017). "Thyroid-associated Ophthalmopathy". Turk J Ophthalmol. 47 (2): 94–105. doi:10.4274/tjo.80688. PMID 28405484.
  5. ↑ Barrio-Barrio J, Sabater AL, Bonet-Farriol E, Velázquez-Villoria Á, Galofré JC (2015). "Graves' Ophthalmopathy: VISA versus EUGOGO Classification, Assessment, and Management". J Ophthalmol. 2015: 249125. doi:10.1155/2015/249125. PMID 26351570.
  6. ↑ Thacker NM, Velez FG, Demer JL, Wang MB, Rosenbaum AL (2005). "Extraocular muscle damage associated with endoscopic sinus surgery: an ophthalmology perspective". Am J Rhinol. 19 (4): 400–5. PMID 16171176.
  7. ↑ Chen J, Kang Y, Deng D, Shen T, Yan J (September 2015). "Isolated Total Rupture of Extraocular Muscles". Medicine (Baltimore). 94 (39): e1351. doi:10.1097/MD.0000000000001351. PMID 26426604.
  8. ↑ Schrier SA, Falk MJ (September 2011). "Mitochondrial disorders and the eye". Curr Opin Ophthalmol. 22 (5): 325–31. doi:10.1097/ICU.0b013e328349419d. PMID 21730846.
  9. ↑ "Oculopharyngeal Muscular Dystrophy - NORD (National Organization for Rare Disorders)".
  10. ↑ "Update on the Diagnosis of Ocular Myasthenia Gravis - American Academy of Ophthalmology".
  11. ↑ Nair AG, Patil-Chhablani P, Venkatramani DV, Gandhi RA (October 2014). "Ocular myasthenia gravis: a review". Indian J Ophthalmol. 62 (10): 985–91. doi:10.4103/0301-4738.145987. PMC 4278125. PMID 25449931.
  12. ↑ Khakshoor H, Moghaddam AA, Vejdani AH, Armstrong BK, Moshirfar M (May 2012). "Diplopia as the primary presentation of foodborne botulism". Oman J Ophthalmol. 5 (2): 109–11. doi:10.4103/0974-620X.99375. PMC 3441016. PMID 22993467.
  13. ↑ Demel SL, Broderick JP (July 2015). "Basilar Occlusion Syndromes: An Update". Neurohospitalist. 5 (3): 142–50. doi:10.1177/1941874415583847. PMID 26288672.
  14. ↑ von Campe G, Regli F, Bogousslavsky J (December 2003). "Heralding manifestations of basilar artery occlusion with lethal or severe stroke". J. Neurol. Neurosurg. Psychiatry. 74 (12): 1621–6. PMID 14638878.
  15. ↑ Park KW, Park JS, Hwang SC, Im SB, Shin WH, Kim BT (September 2008). "Vertebral artery dissection: natural history, clinical features and therapeutic considerations". J Korean Neurosurg Soc. 44 (3): 109–15. doi:10.3340/jkns.2008.44.3.109. PMID 19096659.
  16. ↑ Gottesman RF, Sharma P, Robinson KA, Arnan M, Tsui M, Ladha K, Newman-Toker DE (September 2012). "Clinical characteristics of symptomatic vertebral artery dissection: a systematic review". Neurologist. 18 (5): 245–54. doi:10.1097/NRL.0b013e31826754e1. PMID 22931728.
  17. ↑ Serlin T, Moisseiev E (2017). "Fundus Findings in Wernicke Encephalopathy". Case Rep Ophthalmol. 8 (2): 406–409. doi:10.1159/000478924. PMID 28924437.
  18. ↑ "Nystagmus from Wernicke's Encephalopathy | NEJM".

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