Double VisionEmergency Department Diagnosis and Management

J. Stephen Huff, MD

Departments of Emergency Medicine and Neurology University of Virginia

Charlottesville

J. Stephen Huff, MD

Objectives• Questions – What is the differential diagnosis of diplopia? – What causes ptosis and why is it important?– What examination techniques are useful?– What are the indications for emergent imaging?

• Neuroimaging– Tests– Tempo

• Management - referral, consultation

J. Stephen Huff, MD

The Case

A 65-year-old man presented to the ED complaining of acute onset double vision. He denied headache, fever, weakness, dizziness, trauma, or change in mental status. Past medical history was positive for diabetes and hypertension. Medications included insulin and enalapril. He denied tobacco use or alcohol use.

J. Stephen Huff, MD

The Case - continued

On physical exam: BP 160/90, P 80, RR 16, HR 98, pulse oximetry 99%. Head atraumatic, no scalp tenderness; eyes visual acuity 20/30 (corrected); pupils 4 mm and reactive; OS ptosis; OS pupil in a down and out position. Diplopia was minimal when looking to the left and pronounced when looking to the right. Fundi sharp discs. Remainder of neurologic examination was normal.

J. Stephen Huff, MD

Patient looking at target straight ahead

J. Stephen Huff, MD

Neurologist’s Diagnostic Approach

• Is there a problem of the nervous system?• Where is the problem?• What is the problem?

• Many esoteric and uncommon problems...

J. Stephen Huff, MD

Solomon and Aring remarked in a 1934 paper,

“A knowledge of the more common causes of coma [read diplopia] as a presenting sign, and the relative frequency of these causes, would obviously be helpful in making the diagnosis.…The textbooks are of little assistance. They mention many causes of coma [diplopia] and discuss at length some that are rare, while others that are more common they do not include at all. They do not attempt to give any idea of the relative frequency of the various causes.”

J. Stephen Huff, MD

Evidence-based approach

• Diplopia in the Emergency Department

• ISOLATED chief complaint–Not part of more complex

symptomatology

• Medline / Ovid

• Other data bases….

J. Stephen Huff, MD

Evidence-based approach

• Little data….many opinions….

• One hit!

• Morris RD: Double vision as a presenting symptom in an Ophthalmic Casualty Department. Eye 1991;5:124

J. Stephen Huff, MD

From the Casualty Department of Moorfield’s Eye Hospital

• 275 consecutive patients over 9 months– Ambulatory patients – Referrals by general practitioners, opticians– Excluded referrals for second opinion by

ophthalmologists

• 1.4% of all patients to this specialized ED

J. Stephen Huff, MD

275 consecutive patients

• 25% - monocular diplopia

• 75% - binocular diplopia

J. Stephen Huff, MD

Monocular diplopia

• Extra-ocular– problems with optical lens or contacts

• Ocular (most common)– Lids - chalazion– Cornea - infections, trauma, keratoconus (25%)– Iris - pharmacologic mydriasis– Lens - opacities, cataracts, IOP (39%)– Retinal - detachment, CRVO, neovascularization

• Trauma• No cause established -psychogenic? (12%)

J. Stephen Huff, MD

Binocular diplopia - 206 patients

• Cranial nerve palsies- infranuclear-(39%)• Muscular (14%)– Thyroid–Myasthenia

• Orbital sinusitis, cellulitis, tumor (4%)• Trauma - blowout fracture, blunt trauma,

post-surgical (13%)• Supranuclear lesions (7%)• No cause established (11%)

J. Stephen Huff, MD

Cranial nerve palsies- infranuclear (39%)

• Cranial Nerve III– Diabetes / Vascular– Pituitary tumor

• Cranial Nerve IV– Congenital– Diabetes / Vascular– Trauma

• Cranial Nerve VI– Diabetes / Vascular– MS– CNS tumor– Pseudotumor

J. Stephen Huff, MD

Supranuclear lesions (7%)

• Internuclear ophthalmoplegia (MS)

• Brainstem ischemia

• Migraine

• Wernicke’s encephalopathy

J. Stephen Huff, MD

Ophthalmologic Casualty Department Summary

• Wide range of ocular and neurologic disorders

• “Don’t miss” diagnoses uncommon–CNS tumor

–Aneurysm

J. Stephen Huff, MD

QuestionsApproach to the patient

• Are there associated signs and symptoms?

• Is the diplopia monocular or binocular?

• Is there any exophthalmos or proptosis?

• Is there any associated ptosis?

• Was the onset acute or gradual?

• Is there any variability or remission?

• Was there any pain?

J. Stephen Huff, MD

Are there associated signs and symptoms?

• Severe headache?

• Weakness?

• Fatigue?

• Paralysis?

• Clumsiness / unsteady gait?

• Multiple cranial nerve palsies?– If so, there are other problems...

J. Stephen Huff, MD

Is the diplopia monocular or binocular?

• Monocular - likely refractive or ocular problem

• Binocular - likely an isolated cranial nerve problem

J. Stephen Huff, MD

Is there any exophthalmos or proptosis?

• Infiltrative lesions

• Myopathy–Thyroid

• Sinusitis

• Orbital abscess

• Orbital cellulitis

J. Stephen Huff, MD

Is there any associated ptosis?

• Bilateral- may suggest myasthenia

• Unilateral-suggests cranial nerve III problem–Horner’s?

J. Stephen Huff, MD

Was the onset acute or gradual?

• Acute–Vascular–Stroke–Ocular?

• Gradual– Infiltrative lesions–Myopathies

J. Stephen Huff, MD

Is there any variability or remission?

• Variability–Multiple sclerosis

–Myasthenia

J. Stephen Huff, MD

Was there any pain?

• Folklore...

• Aneurysms may be painful– infections

• Vascular lesions may be painless–MS

–Myopathy

J. Stephen Huff, MD

Questions - Our Patient

• Are there associated signs and symptoms? No• Is the diplopia monocular or binocular?

Binocular• Is there any exophthalmos or proptosis? No• Is there any associated ptosis? Yes• Was the onset acute or gradual? Acute• Is there any variability or remission? No• Was there any pain? No

J. Stephen Huff, MD

SummaryOur Patient

Painless isolated binocular diplopia of acute onset with ptosis but without proptosis or exophthalmos in a patient with diabetes and hypertension...

J. Stephen Huff, MD

Physical examination

• Monocular or binocular?– Cover eye...– Glasses / contacts off...– Pinhole-may correct monocular diplopia– Cataract or disc problem?

• Proptosis or exophthalmos?– Look– Feel

J. Stephen Huff, MD

Physical examination

• Associated neurologic abnormalities?

• Define cranial nerve problem–Observe–Tracking / yoke movements–Pupillary reaction

J. Stephen Huff, MD

Physical examination-review• H - tracking movements eyes • Cranial nerve III

– Actions- moves globe up, down, in– Pupillary constriction– If weak, may have unopposed abduction (down and out)

• Cranial nerve IV– Superior oblique (SO4)– Actions- Intorsion, depression

• Cranial nerve VI– Lateral rectus– Actions - Abduction– If weak, may have unopposed adduction

J. Stephen Huff, MD

“Laws of diplopia” - DeMyer

• Describe the images; identify the position of maximum diplopia...• Identify the eye that produces the false

image; the false image is projected peripheral to the true image and is often less sharp...• When the patient looks in the direction of

action of the paretic muscle, the distances between images increases...

J. Stephen Huff, MD

“Laws of diplopia” - DeMyer

• Allows reasoning of which muscle is weak and identification of cranial nerve abnormality...

J. Stephen Huff, MD

Patient looking at target straight ahead

J. Stephen Huff, MD

Our patient

• Cranial nerve III problem• Patient’s left eye deviated laterally

from unopposed action of lateral rectus (IV)

• In our patient (not this picture!) pupil reactivity is spared...

J. Stephen Huff, MD

Cranial nerve III caveats

• Aneurysmal compression common– Generally, painful– Generally, pupillary reactions affected

• Diabetic III neuropathy (“vasculopathic”)– Generally, pupil reactivity spared– Generally, painless

J. Stephen Huff, MD

Diabetic III palsy

• Pupillary sparing “almost always” present

• Pupillomotor fibers travel on outside III– Selectively vulnerable to compression– Resistant to ischemia which often affects

central portion of III

J. Stephen Huff, MD

The Case

A 65-year-old man presented to the ED complaining of acute onset double vision. He denied headache, fever, weakness, dizziness, trauma, or change in mental status. Past medical history was positive for diabetes and hypertension. Medications included insulin and enalapril. He denied tobacco use or alcohol use.

J. Stephen Huff, MD

The Case - continued

On physical exam: BP 160/90, P 80, RR 16, & 98, pulse oximetry 99%. Head atraumatic, no scalp tenderness; eyes visual acuity 20/30 (corrected); pupils 4 mm and reactive; OS ptosis; OS pupil in a down and out position. Diplopia was minimal when looking to the left and pronounced when looking to the right. Fundi sharp discs. Remainder of neurologic examination was normal.

J. Stephen Huff, MD

Physical examination

• Associated neurologic abnormalities? No• Define cranial nerve problem– Cranial nerve III, isolated, with pupillary

sparing

• This is likely a patient with a “diabetic third” palsy; consultation and outpatient followup is an option….

J. Stephen Huff, MD

Objectives-revisited• Questions – What is the differential diagnosis of diplopia? – What causes ptosis and why is it important?– What examination techniques are useful?– What are the indications for emergent imaging?

• Neuroimaging– Tests– Tempo

• Management - referral, consultation

J. Stephen Huff, MD

Neuroimaging-general remarks

• Our patient– Painless isolated III palsy with pupillary sparing– Consensus--may forego imaging with followup– If pupillary reactivity impaired (or becomes

impaired), consider emergent neuroimaging, consultation

• Isolated VI palsy suggests increased ICP• Multiple cranial nerve palsies or other

abnormalities on examination - image and consult

J. Stephen Huff, MD

Take a closer look at this patient--Pupils are asymmetric!