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Approach to patient with diplopia.

Edward Margolin1

  • 1University of Toronto, Faculty of Medicine, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada; University of Toronto, Department of Medicine (Division of Neurology), Toronto, Ontario, Canada.

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|August 11, 2020
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Summary

Neurologists should promptly evaluate diplopia. Urgent neuroimaging is crucial for binocular diplopia with brainstem signs or multiple cranial nerve palsies, guiding diagnosis and management.

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Area of Science:

  • Neurology
  • Ophthalmology

Background:

  • Diplopia, or double vision, is a common neurological complaint requiring careful evaluation.
  • Differentiating causes of diplopia is essential for timely and appropriate management.

Purpose of the Study:

  • To provide a concise guide for neurologists on managing patients presenting with diplopia.
  • To outline diagnostic pathways based on clinical presentation and neurological signs.

Main Methods:

  • Review of clinical guidelines and common etiologies of diplopia.
  • Categorization of diplopia based on onset, associated symptoms, and cranial nerve involvement.

Main Results:

  • Monocular diplopia or isolated comitant misalignment warrants ophthalmological referral.
  • Binocular diplopia with brainstem signs necessitates urgent brain MRI.
  • Third cranial nerve palsy requires urgent CT angiography to exclude aneurysms.
  • Sixth nerve palsy management varies (imaging vs. observation) in older patients with risk factors; others need MRI.
  • Fourth nerve palsy with specific gaze-dependent deviations requires MRI; others need ophthalmological referral.
  • Multiple cranial nerve palsies demand urgent neuroimaging, focusing on the cavernous sinus and superior orbital fissure.
  • Ocular myasthenia and orbital pathologies like thyroid eye disease are important differential diagnoses.

Conclusions:

  • A systematic approach to diplopia evaluation in neurology is critical.
  • Urgent neuroimaging is indicated for specific presentations of diplopia to rule out serious intracranial pathology.
  • Referral to ophthalmology is appropriate for certain types of diplopia.