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EPIDEMIOLOGY AND PATHOPHYSIOLOGY
CAUSES OF DIPLOPIA
SIGNS AND SYMPTOMS
DIAGNOSTIC APPROACH
MISCELLANEOUS
100
Diplopia or double vision, comes in 2 varieties
What are monocular and binocular
100
Name 2 critical (Tier 1) causes of diplopia
What is 1. Basilar Artery Thrombosis 2. Botulism 3. Basilar meningitis 4. Aneurysm
100
Results in an eye that is deviated down and out, with a dilated pupil and ptosis
What is Cranial Nerve 3 palsy
100
Name 1 of 4 aspects of questioning that guide the formulation of the differential diagnosis. (Important elements in history taking)
What is 1. The cadence of onset and symptoms 2. The directionality and orientation of the diplopia 3. The presence of pain 4. The presence of other associated symptoms Neuromuscular or neurologic symptoms
100
The prototypical neuromuscular cause of diplopia is _________
What is Myasthenia Gravis
200
For patients who visit the ED with diplopia, the majority of cases are _____________ (which of the 2 varieties of diplopia)
What is Binocular
200
Name 2 emergent (Tier 2) causes of diplopia
What is 1. Vertebral Dissection 2. Myasthenia Gravis 3. Wernicke's Encephalopathy 4. Orbital apex syndrome (Cavernous sinus process)
200
Diplopia that worsens on lateral gaze to one direction (caused by ____)
What is Cranial Nerve 6 palsy
200
Diplopia involving both eyes
What is "Graves Disease"
200
Diplopia that is variably triggered in multiple directions (without other distinct structural or neuropathic cause evident), which gets worse as patient fatigues and improves with rest, implies neuromuscular cause such as
What is myasthenia gravis
300
Diplopia (double vision) that persists in one affected eye, even with the other eye closed is known as __________
What is Monocular Diplopia
300
This condition is a diplopia causing entity, which is characterized by demyelinating lesions and internuclear ophthalmoplegia
What is Multiple Sclerosis
300
Sudden isolated CN 3,4, or 6 palsy, associated with orbital discomfort in a patient with chronic diabetes or hypertension – suggests _______________ as the cause
What is microvascular ischemia
300
Diplopia with Cranial Nerve 3 palsy and pupillary involvement is highly suggestive of ______________
What is An intracranial Aneurysm (Critical or emergent diagnosis) or skull base or brain tumor
300
Gradually evolving combination of double vision, slurred speech, and problems swallowing (additional symptoms may include – dry mouth, nausea, and diffuse muscle weakness)
What is Food-borne Botulism
400
The most common type of diplopia present in ED patients is associated with this cranial nerve palsy
What is Cranial nerve 6 palsy
400
This cause of diplopia, occurs when autoantibodies develop to a cranial ganglioside, and is characterized by - ophthalmoplegia, ataxia, and areflexia
What is Miller-Fisher syndrome
400
This condition is associated with diplopia which is usually worse in the morning
What is Graves myopathy
400
Presents in a young person with a history of migraines. Symptoms are similar to a brainstem stroke (diplopia, facial weakness), but patient also has an associated ipsilateral headache
What is "Ophthalmoplegic Migraine"
400
May present with nausea, vertigo or slurred speech (symptoms are usually sudden in onset, painless, and fluctuate)
What is Impending Basilar Artery Occlusion
500
Diplopia consists ___ % of ophthalmologic emergencies in the ED.
What is 1.4%
500
Inflammation or infection in the orbital apex or carvenous sinus which directly affects oculomotor Cranial nerves. This condition is characterized by a combination of CN 3, 4, and 6 palsies. With presenting symptoms including retro-orbital pain, conjunctival injection, and periorbital and facial numbness.
What is Orbital Apex Syndrome or (Carvenous Sinus process)
500
A rotational diplopia that worsens on looking down, and toward the nose. Makes descending stairs, reading and watching television in bed difficult. (is caused by _____)
What is Cranial Nerve 4 palsy
500
Diplopia and other Cranial nerve symptoms, together with headache, photophobia, stiff neck, or fever should raise suspicion for ____________
What is Basilar Meningio-encephalitis
500
An ice filled glove or bag is applied to the patient’s closed eye or eyes, held there for about 5 minutes and withdrawn. Any improvement in ptosis (typically about 5mm) , or diplopia, is noted (Name this test)
What is The Ice Test - A bedside test performed if myasthenia gravis is suspected.