Pearls: Diplopia

ABSTRACT

Double vision may arise from ocular, neurologic, or extraocular muscle disorders. The approach to patients with diplopia requires a systematic approach to the history and the physical examination. There are many challenges in the evaluation of diplopia, ranging from the patient’s mental status to the fine points of the examination. This article provides a process for interviewing and examining these patients, explaining the rationale and differential diagnosis of various clinical presentations. Common causes of monocular and binocular diplopia are addressed by the pattern of diplopia described by the patient. The examination and the interpretation of examination findings are presented by incorporating the “upside-down-and-backwards” concept. This review offers some Pearls—perhaps even diamonds—on evaluating patients who complain of diplopia, as well as those who have eye movement abnormalities but can’t articulate their symptoms.

KEYWORDS

Diplopia - internuclear ophthalmoplegia - Maddox rod - skew deviation

REFERENCES

• 1 Bronstein A M. Under-rated neuro-otological symptoms: Hoffman and Brookler 1978 revisited.  Br Med Bull. 2002;  63 213-221
• 2 Cleary M, Williams G J, Metcalfe R A. The pattern of extra-ocular muscle involvement in ocular myasthenia.  Strabismus. 2008;  16(1) 11-18
• 3 Kusner L L, Puwanant A, Kaminski H J. Ocular myasthenia: diagnosis, treatment, and pathogenesis.  Neurologist. 2006;  12(5) 231-239
• 4 Lee H B, Rodgers I R, Woog J J. Evaluation and management of Graves’ orbitopathy.  Otolaryngol Clin North Am. 2006;  39(5) 923-942, vi
• 5 Keane J R. The pretectal syndrome: 206 patients.  Neurology. 1990;  40(4) 684-690
• 6 Slavin M L. Hyperdeviation associated with isolated unilateral abducens palsy.  Ophthalmology. 1989;  96(4) 512-516
• 7 Brodsky M C, Donahue S P, Vaphiades M, Brandt T. Skew deviation revisited.  Surv Ophthalmol. 2006;  51(2) 105-128
• 8 Brazis P W. Isolated palsies of cranial nerves III, IV, and VI.  Semin Neurol. 2009;  29(1) 14-28
• 9 Reich S G. Teaching video: is it III alone, or III and IV?.  Neurology. 2007;  68(21) E34
• 10 Galetta S L, Liu G T, Raps E C, Solomon D, Volpe N J. Cyclodeviation in skew deviation.  Am J Ophthalmol. 1994;  118(4) 509-514
• 11 Donahue S P, Lavin P J, Hamed L M. Tonic ocular tilt reaction simulating a superior oblique palsy: diagnostic confusion with the 3-step test.  Arch Ophthalmol. 1999;  117(3) 347-352
• 12 Anderson T, Luxon L, Quinn N, Daniel S, Marsden C D, Bronstein A. Oculomotor function in multiple system atrophy: clinical and laboratory features in 30 patients.  Mov Disord. 2008;  23(7) 977-984
• 13 Buracchio T, Rucker J C. Pearls and oy-sters of localization in ophthalmoparesis.  Neurology. 2007;  69(24) E35-E40
• 14 Silverman I E, Liu G T, Volpe N J, Galetta S L. The crossed paralyses. The original brain-stem syndromes of Millard-Gubler, Foville, Weber, and Raymond-Cestan.  Arch Neurol. 1995;  52(6) 635-638
• 15 Richards B W, Jones Jr F R, Younge B R. Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves.  Am J Ophthalmol. 1992;  113(5) 489-496
• 16 Kodsi S R, Younge B R. Acquired oculomotor, trochlear, and abducent cranial nerve palsies in pediatric patients.  Am J Ophthalmol. 1992;  114(5) 568-574
• 17 Holmes J M, Mutyala S, Maus T L, Grill R, Hodge D O, Gray D T. Pediatric third, fourth, and sixth nerve palsies: a population-based study.  Am J Ophthalmol. 1999;  127(4) 388-392