Diplopia differential diagnosis

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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]
  • 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]
  • 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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