Diplopia differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

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	Inflitration or mass effect in the orbital apex or cavernous sinus Compression of the oculomotor nerve	Palsies of oculomotor, trochlear and/or abducens nerves Periorbital or facial numbness Retro-orbital pain Proptosis Signs of venous congestion
	Orbital cellulitis
	Thyroid-associated ophthalmopathy (Grave's disease)	Autoimmune	Proptosis Restriction of elevation and abduction of the eyes Tachycardia Intolerance to heat Weight loss Insomnia Fatigue Diarrhea
Extraocular muscle disorder	Thyroid-associated ophthalmopathy due to ocular surgery, congenital myopathies, mitochondrial myopathies, muscular dystrophy
	extraocular muscle injury or hematoma
Neuromuscular junction dysfunction	Myasthenia gravis	Auto-antibodies against nicotinic acetylcholine receptors	Fluctuating muscular weakness Ptosis Diplopia and weakness worsens with activity and improves with rest
	Botulism	Inhibition of acetylcholine release due to toxin at cholinergic synapse and pre-synaptic myoneural junction	Dysathria Dysphagia Autonomic dysreflexia Pupillary dysfunction
Palsies of the third, fourth or sixth cranial nerves	Microvascular ischemia – diabetic neuropathy, hemorrhage, tumor, vascular malformation, aneurysm, meningitis, multiple sclerosis
Central nervous system injury (pathways and cranial nerve nuclei)	Basilar artery thrombosis