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Journal of the Neurological Sciences Oct 2020This article presents an overview of the most important points a neurologist must remember when dealing with a patient complaining of diplopia. Patients with monocular... (Review)
Review
This article presents an overview of the most important points a neurologist must remember when dealing with a patient complaining of diplopia. Patients with monocular diplopia and those with full ocular motility and comitant misalignment should be referred to an ophthalmologist and do not require further testing. Patients with recent onset of binocular diplopia who have associated "brainstem" symptoms should have an urgent brain MRI. All patients with 3rd cranial nerve palsy require urgent brain CTA to rule out compressive aneurysmal lesion. Management of patients over 50 years of age with microvascular risk factors with new onset of 6th nerve palsy is controversial: some image these patients at presentation while others choose a short period of observation as most of these patients would have a microvascular etiology for the 6th nerve palsy which should improve spontaneous in 2-3 months. All others with 6th nerve palsy require brain MRI with contrast. Patients with 4th palsy with hyperdeviation that worsens in downgaze should have an MRI with contrast and all others referred to an ophthalmologist. If there is more than one cranial nerve palsy, urgent neuroimaging should be performed with attention to cavernous sinus and superior orbital fissure. Ocular myasthenia should be suspected in patients with eye misalignment that does not fit a pattern for any cranial nerve palsy. Orbital pathology (most commonly thyroid eye disease) can result in restriction of ocular motility and has specific clinical signs associated with it.
Topics: Abducens Nerve Diseases; Diplopia; Humans; Infant; Magnetic Resonance Imaging; Oculomotor Nerve Diseases; Strabismus
PubMed: 32777577
DOI: 10.1016/j.jns.2020.117055 -
Survey of Ophthalmology 2023A 14-year-old boy with a history of shunted congenital hydrocephalus began having headaches with nausea and vomiting after transcontinental flights. He gradually...
A 14-year-old boy with a history of shunted congenital hydrocephalus began having headaches with nausea and vomiting after transcontinental flights. He gradually developed horizontal diplopia indicative of mild bilateral sixth nerve palsy, without papilledema or ventriculomegaly. Intracranial pressure monitoring showed no signs of elevation. After he subsequently developed papilledema, surgical exploration showed shunt malfunction, and shunt replacement produced rapid resolution of symptoms. This case demonstrates the importance of relying on clinical history and neuro-ophthalmologic examination in patients with hydrocephalus and suspected shunt failure, even when objective confirmatory evidence of intracranial pressure elevation is lacking.
Topics: Male; Humans; Adolescent; Papilledema; Ventriculoperitoneal Shunt; Hydrocephalus; Intracranial Hypertension; Diplopia
PubMed: 35181281
DOI: 10.1016/j.survophthal.2022.02.003 -
Survey of Ophthalmology 2021A 13-year-old boy reported acute horizontal binocular diplopia and headache. Ten days before these symptoms he suffered from a gastrointestinal infection....
A 13-year-old boy reported acute horizontal binocular diplopia and headache. Ten days before these symptoms he suffered from a gastrointestinal infection. Ophthalmological examination revealed bilateral ophthalmoparesis and diffuse hyporeflexia. Magnetic resonance imaging of the brain was normal. Lumbar puncture revealed albumin-cytological dissociation. There were no anti-GQ1b antibodies, but serum anti-GM1 antibodies were detected. He received intravenous immunoglobulins and had fully recovered two weeks later. Miller Fisher syndrome and its atypical variants are uncommon in childhood; nevertheless, they should be considered in the differential diagnosis of bilateral acute ophthalmoparesis.
Topics: Adolescent; Autoantibodies; Diplopia; Headache; Humans; Magnetic Resonance Imaging; Male; Miller Fisher Syndrome; Ophthalmoplegia
PubMed: 33010288
DOI: 10.1016/j.survophthal.2020.09.007 -
Journal of Pediatric Ophthalmology and... Sep 2020
Topics: Diplopia; Disease Management; Eyeglasses; Humans; Vision, Binocular
PubMed: 32956474
DOI: 10.3928/01913913-20200501-01 -
Neurology India 2022Diplopia, or double vision, is a symptom resulting from the perception of two images of a single object. We report a case of a possible silodosin-induced diplopia never...
Diplopia, or double vision, is a symptom resulting from the perception of two images of a single object. We report a case of a possible silodosin-induced diplopia never reported before in the literature. We suggest that binocular diplopia should be considered in people assuming silodosin even if further studies should be conducted to explore possible pathogenetic mechanisms.
Topics: Diplopia; Humans; Indoles; Vision, Binocular
PubMed: 35864693
DOI: 10.4103/0028-3886.349650 -
Seminars in Ophthalmology Jul 2024Dragged-fovea diplopia syndrome (DFDS) is a type of binocular double vision caused by a displacement of the fovea in one or both eyes due to retinal disorders including... (Review)
Review
Dragged-fovea diplopia syndrome (DFDS) is a type of binocular double vision caused by a displacement of the fovea in one or both eyes due to retinal disorders including epiretinal membranes or other maculopathies. DFDS induces diplopia through a mismatch between peripheral motor fusion and central (foveal) fusion. It can be diagnosed by utilizing the Lights on - Lights off test. While there is no cure, there are treatments for DFDS including monocular occlusion or blurring (tape, lenses, IOL), Bangerter filter, and Fresnel prisms. While this syndrome has been identified in the literature by multiple names including central-peripheral Rivalry (CPR)-type diplopia, macular diplopia, and foveal displacement syndrome, this article works to summarize the current known characteristics, diagnostic tests, and treatment for this syndrome.
Topics: Humans; Diplopia; Syndrome; Fovea Centralis; Vision, Binocular; Visual Acuity; Tomography, Optical Coherence; Retinal Diseases
PubMed: 38591258
DOI: 10.1080/08820538.2024.2323121 -
Clinical Rheumatology Oct 2020
Topics: Diagnosis, Differential; Diplopia; Humans; Myositis; Orbital Myositis; Pain
PubMed: 32577849
DOI: 10.1007/s10067-020-05147-8 -
Journal of Cachexia, Sarcopenia and... Dec 2022Ophthalmoparesis and ptosis can be caused by a wide range of rare or more prevalent diseases, several of which can be successfully treated. In this review, we provide... (Review)
Review
Ophthalmoparesis and ptosis can be caused by a wide range of rare or more prevalent diseases, several of which can be successfully treated. In this review, we provide clues to aid in the diagnosis of these diseases, based on the clinical symptoms, the involvement pattern and imaging features of extra-ocular muscles (EOM). Dysfunction of EOM including the levator palpebrae can be due to muscle weakness, anatomical restrictions or pathology affecting the innervation. A comprehensive literature review was performed to find clinical and imaging clues for the diagnosis and follow-up of ptosis and ophthalmoparesis. We used five patterns as a framework for differential diagnostic reasoning and for pattern recognition in symptomatology, EOM involvement and imaging results of individual patients. The five patterns were characterized by the presence of combination of ptosis, ophthalmoparesis, diplopia, pain, proptosis, nystagmus, extra-orbital symptoms, symmetry or fluctuations in symptoms. Each pattern was linked to anatomical locations and either hereditary or acquired diseases. Hereditary muscle diseases often lead to ophthalmoparesis without diplopia as a predominant feature, while in acquired eye muscle diseases ophthalmoparesis is often asymmetrical and can be accompanied by proptosis and pain. Fluctuation is a hallmark of an acquired synaptic disease like myasthenia gravis. Nystagmus is indicative of a central nervous system lesion. Second, specific EOM involvement patterns can also provide valuable diagnostic clues. In hereditary muscle diseases like chronic progressive external ophthalmoplegia (CPEO) and oculo-pharyngeal muscular dystrophy (OPMD) the superior rectus is often involved. In neuropathic disease, the pattern of involvement of the EOM can be linked to specific cranial nerves. In myasthenia gravis this pattern is variable within patients over time. Lastly, orbital imaging can aid in the diagnosis. Fat replacement of the EOM is commonly observed in hereditary myopathic diseases, such as CPEO. In contrast, inflammation and volume increases are often observed in acquired muscle diseases such as Graves' orbitopathy. In diseases with ophthalmoparesis and ptosis specific patterns of clinical symptoms, the EOM involvement pattern and orbital imaging provide valuable information for diagnosis and could prove valuable in the follow-up of disease progression and the understanding of disease pathophysiology.
Topics: Humans; Graves Ophthalmopathy; Blepharoptosis; Ophthalmoplegia; Diplopia; Myasthenia Gravis; Pain
PubMed: 36172973
DOI: 10.1002/jcsm.13089 -
Journal of Neurology Feb 2023The etiologic distribution and clinical features of diplopia may differ according to the specialties involved in the management. This study aimed to establish the... (Review)
Review
BACKGROUND AND OBJECTIVES
The etiologic distribution and clinical features of diplopia may differ according to the specialties involved in the management. This study aimed to establish the clinical features and underlying etiologies of diplopia by recruiting patients from all departments.
METHODS
We reviewed the medical records of 4127 patients with diplopia as the chief complaint, who had been recruited from all departments at Seoul National University Bundang Hospital, Seongnam, Republic of Korea, from 2003 to 2020.
RESULTS
Diplopia was binocular in 3557 (94.2%) and monocular in 219 (5.8%) patients. The common causes of binocular diplopia included microvascular (n = 516, 14.5%), strokes (n = 412, 11.6%), neoplastic (n = 304, 8.5%), myasthenia gravis (n = 253, 7.1%), traumatic (n = 240, 6.7%), and decompensated phoria (n = 232, 6.5%), and comprised more than a half of the causes. Patients with binocular diplopia were usually managed by neurologists (2549/3557, 71.7%), followed by ophthalmologists (2247/3557, 63.2%), emergency physicians (1528/3557, 43.0%), neurosurgeons (361/3557, 10.1%), and others (271/3557, 7.6%). The etiologies of binocular diplopia differed markedly according to the patients' age and the specialties involved in the management (p < 0.001).
CONCLUSIONS
Given the differences in the etiologic distribution of diplopia according to the patients' age and the specialties involved in the management, the results of previous reports on the characteristics and etiology of diplopia, primarily performed in a single specialty department, should be interpreted with a possible selection bias.
Topics: Humans; Diplopia; Vision, Binocular; Strabismus; Referral and Consultation; Hospitals
PubMed: 36355187
DOI: 10.1007/s00415-022-11471-7 -
Current Opinion in Neurology Feb 2023To review several etiologies of nonneurologic diplopia that the neurologist should be familiar with. The pathophysiology, clinical presentation, neuroimaging findings,... (Review)
Review
PURPOSE OF REVIEW
To review several etiologies of nonneurologic diplopia that the neurologist should be familiar with. The pathophysiology, clinical presentation, neuroimaging findings, and treatment options are briefly summarized for each condition.
RECENT FINDINGS
Certain etiologies for diplopia can be associated with life-threatening neurologic conditions and should be investigated thoroughly for proper localization and immediate management of the underlying disease. However, nonneurological causes of binocular diplopia are very common and disabling, but are often nonemergent and may not require in-depth investigation or neuroimaging. Some of the etiologies of nonneurologic diplopia mimic cranial nerve palsies, making them confusing to evaluate when the physician is not familiar with these etiologies. Unfamiliarity with these diagnoses can lead to unnecessary neuroimaging, inefficient utilization of medical resources, and undue alarm to the patient. Recent advances in clinical diagnostic tools and neuroimaging have clarified our understanding of the diverse underlying mechanisms of nonneurologic binocular diplopia.
SUMMARY
Diplopia can be a difficult symptom for the neurologist to evaluate. A systematic approach to the evaluation of diplopia can help establish the urgency and necessity of an extensive workup.This review will help to familiarize the neurologist with nonneurological causes of binocular diplopia, minimize expensive and unnecessary evaluations, and reassure patients and physicians alike.
Topics: Humans; Diplopia; Neurologists; Neuroimaging
PubMed: 36630211
DOI: 10.1097/WCO.0000000000001129