Diplopia differential diagnosis: Difference between revisions

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! align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Exam Findings'''
! align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Exam Findings'''
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| colspan="1" rowspan="4" style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Orbit (anatomy)|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  
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* [[Optic disc]] paleness
* [[Optic disc]] paleness
|-
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| rowspan="3" style="background: #DCDCDC; padding: 5px; text-align: center;" |Extraocular muscle disorder
| rowspan="3" style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Extraocular muscles|Extraocular muscle]] disorder'''
|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>
|[[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>
|
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* Facial trauma
* [[Facial trauma]]
* Sinus surgery  
* [[Sinus surgery]]
* Extreme strabismus
* Extreme [[strabismus]]
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* Hematoma
* [[Hematoma]]
* Entrapment of muscle in the fractured orbital wall
* Entrapment of [[muscle]] in the fractured [[Orbit (anatomy)|orbital wall]]
* Damage to the oculomotor nerve entry zone
* Damage to the [[oculomotor nerve]] entry zone
* Muscle transection
* [[Muscle]] [[transection]]
* Partial or complete muscle destruction with entrapment in scar tissue.
* Partial or complete [[muscle]] destruction with entrapment in [[scar tissue]].
|
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* Restriction of eye movements  
* Restriction of [[eye]] movements  
* Hematoma formation
* [[Hematoma]] formation
* Down and out eyes in case of damage to oculomotor nerve  
* Down and out eyes in case of damage to [[oculomotor nerve]]
* Absent oculocardiac reflex of affected muscle
* Absent [[oculocardiac reflex]] of affected muscle
* Bone damage  
* [[Bone]] damage  
|-
|-
|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>
|[[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>
|
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* Dominant optic atrophy (OPA1 gene mutation)
* [[Dominant optic atrophy]] (OPA1 [[gene mutation]])
* Leber hereditary optic neuropathy (point mutation in mitochondrial DNA)
* [[Leber hereditary optic neuropathy]] ([[point mutation]] in [[mitochondrial DNA]])
* Chronic progressive external ophthalmoplegia also known as Kearns-Sayre syndrome (TYMP, ANT1, PEO1, POLG, POLG2, and even OPA1 gene mutations)
* [[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]])
|
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* Retinal ganglion cells and nerve fiber layer of the retina affected in dominant optic atrophy (may lead to blindness)
* [[Retinal]] [[ganglion cells]] and [[nerve fiber layer]] of the [[retina]] affected in [[dominant optic atrophy]] (may lead to [[blindness]])
* Acute and painless central vision loss of both eyes in Leber hereditary optic neuropathy (days to months)
* [[Acute (medicine)|Acute]] and painless central [[vision loss]] of both eyes in [[Leber hereditary optic neuropathy]] (days to months)
* Extraocular muscle mobility impairment in chronic progressive external ophthalmoplegia
* [[Extraocular muscles|Extraocular muscle]] mobility impairment in [[Kearns-Sayer syndrome|chronic progressive external ophthalmoplegia]]


**  
**  
|
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* Chronic progressive external ophthalmoplegia:
* [[Kearns-Sayer syndrome|Chronic progressive external ophthalmoplegia]]:
** Restriction of eye movements
** Restriction of eye movements
** Visual acuity is spared
** [[Visual acuity]] is spared
** Ptosis
** [[Ptosis]]


* Leber hereditary optic neuropathy:
* [[Leber's hereditary optic neuropathy|Leber hereditary optic neuropathy]]:
** Disc pseudoedema
** [[Optic disc|Disc]] pseudoedema
** Thickening of the retinal nerve fiber layers
** Thickening of the [[retinal]] [[Nerve fiber layer|nerve fiber layers]]


* Dominant optic atrophy:
* [[Dominant optic atrophy]]:
** Blindness
** [[Blindness]]
** Thinning of the neuroretinal rim
** Thinning of the [[Nerve fiber layer|neuroretinal rim]]
** Cup to disc ratio > 0.5
** [[Cup-to-disc ratio|Cup to disc ratio]] > 0.5
** Peripapillary atrophy  
** Peripapillary [[atrophy]]
** Sectoral pallor of the optic nerve
** Sectoral [[pallor]] of the [[optic nerve]]
|-
|-
|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>
|[[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>
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* Oculopharyngeal muscular dystrophy (Mutations of the polyadenylate binding protein nuclear 1, PABPN1 gene)
* [[Oculopharyngeal muscular dystrophy]] ([[mutations]] of the polyadenylate binding protein nuclear 1, [[PABPN1|PABPN1 gene]])
* Oculopharyngodistal myopathy  
* Oculopharyngodistal myopathy  
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* Dysphagia
* [[Dysphagia]]
* Weakness of proximal muscles (distal muscles in case of oculopharyngodistal myopathy)  
* [[Proximal muscle weakness|Weakness of proximal muscles]] (distal muscles in case of oculopharyngodistal myopathy)  
* Atrophy of the tongue
* [[Atrophy]] of the [[tongue]]
* Weakness of facial muscles
* [[Muscle weakness|Weakness]] of [[facial muscles]]
* Dysphonia
* [[Dysphonia]]
|
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* Ptosis
* [[Ptosis]]
* Ophthalmoplegia
* [[Ophthalmoplegia]]
|-
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| colspan="1" rowspan="2" style="background: #DCDCDC; padding: 5px; text-align: center;" |Neuromuscular junction dysfunction
| 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>
| 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>
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* Auto-antibodies against nicotinic acetylcholine receptors  
* [[Autoimmunity|Auto-antibodies]] against [[Nicotinic acetylcholine receptor|nicotinic acetylcholine receptors]]
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* Fluctuating muscular weakness
* Fluctuating [[muscular weakness]]
* Ptosis
* [[Ptosis]]
* Diplopia and weakness worsens with activity and improves with rest  
* [[Diplopia]] and [[Muscle weakness|weakness]] worsens with activity and improves with rest  
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* 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<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>
|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>

Revision as of 21:08, 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]
  • Inhibition of acetylcholine release due to toxin at cholinergic synapse and pre-synaptic myoneural junction
  • Dysathria
  • Dysphagia
  • Autonomic dysreflexia
  • Pupillary dysfunction
  • Ptosis
  • Blurred vision
  • Ophthalmoplegia
Palsies of the third, fourth or sixth cranial nerves Oculomotor nerve palsy
  • Microvascular ischemia:
    • Diabetic neuropathy
  • Hemorrhage
  • Tumor
  • Vascular malformation
  • Aneurysm
  • Meningitis
  • Multiple sclerosis
  • Muscles affected:
    • Medial, inferiorn superior rectii
    • Inferior oblique muscle
    • Levator palpebrae muscle
    • Ciliary and constrictor pupillae muscles
  • Multi-directional horizantal and vertical diplopia
  • No diplopia on lateral gaze to the affected side
  • Eyelid droop (ptosis)
  • Down and out pupil
  • Pupillary dilation
Trochlear nerve palsy
  • Muscles affected:
    • Superior oblique muscle
  • Rotational diplopia that is worse on looking downwards and towards the nose
  • Extorsion on downward gaze
Abducens nerve palsy
  • Muscles affected:
    • Lateral rectus muscle
  • 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]
  • Occlusive thrombosis of the basilar artery
  • Brainstem ischemia
  • Dysarthria
  • Vertigo
  • Cranial nerve palsies
  • Presence of risk factors for ischemic stroke
  • Nystagmus
  • Visual field defects
  • Restriction of eye movements (maybe internuclear ophthalmoplegia)
Vertebral dissection[15][16]
  • Vertebrobasilar insufficiency
  • Acute onset
  • Neck pain
  • Vertigo
  • Presence of risk factors for vertebral dissection
  • Occipital and nuchal pain
  • Monocular blindness
  • Hemianopsia
  • Bilateral visual field defects
  • Amaurosis fugax
  • Ptosis
  • Miosis
Aneurysm
  • Enlarging aneurysm causes direct compression of the cranial nerves
  • Oculomotor nerve palsy
  • Pupillary involvement
  • Aneurysm visible on fundoscopy
Wernicke's encephalopathy[17][18]
  • Thiamine deficiency leads to metabolic failure and tissue injury
  • Nystagmus
  • Ataxia
  • Altered mental status
  • Ophthalmoplegia
  • Malnutrition
  • History of alcoholism
  • Optic disc edema
  • Preretinal hemorrhage

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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