Analysis of diplopia referrals in a tertiary neuro-ophthalmology center

To determine the potential for morbidity and mortality in patients referred to a tertiary neuro-ophthalmology service for evaluation of diplopia.

A retrospective chart review of all patients seen by to a tertiary neuro-ophthalmologists in a tertiary neuro-ophthalmology practice between December 2, 2021, and May 21, 2022, was performed. All patients who were referred for diplopia were included. The primary outcome was to describe the potential for vision loss, progression of symptoms, or systemic morbidity or mortality without a neuro-ophthalmic consult.

One hundred ninety-six patients were referred for diplopia. The mean age at presentation was 61.3 ± 17.0 years, and 48.5% were women. The most common final diagnosis reached following neuro-ophthalmology consultation were cranial nerve palsies (38.3%, 75/196), convergence insufficiency and decompensated phoria (22.4%, 44/196), non-neuro-ophthalmic causes (19.9%, 39/196), thyroid eye disease (4.5%, 9/196), myasthenia gravis (3.5%, 7/196), and multiple sclerosis (6/196, 3.1%). On the basis of final diagnosis, 15.3% of patients referred to the neuro-ophthalmology service for diplopia had the potential for morbidity or mortality. Specifically, 1% (2/196) were at risk for visual loss due severe papilledema in the context of untreated idiopathic intracranial hypertension, and 3.0% (6/196) had the potential for systemic morbidity or mortality due to their final diagnosis (brain aneurysms in 2/196, pituitary apoplexy in 1/196, anaplastic glioma in 1/196, and other malignancy in 2/196). In addition, 11.2% (22/196) had the potential for progression of symptoms and systemic morbidity due to thyroid eye disease (9/196), myasthenia gravis (7/196), and multiple sclerosis (6/196). Of the patients who had a prereferral neuroimaging study, 30.1% required additional neuroimaging after neuro-ophthalmic consultation.

Overall, 15.3% (30/196) of patients with diplopia had potential for morbidity and mortality without neuro-ophthalmic consultation. This study emphasizes the importance of urgent neuro-ophthalmologic referral for patients with diplopia to allow for appropriate evaluation and investigations to reduce potential morbidity and mortality.