Objectives

1. Double VisionEmergency Department Diagnosis and ManagementJ. Stephen Huff, MDDepartments of Emergency Medicine and Neurology University of Virginia Charlottesville

2. 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 Objectives

3. 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. The Case

4. 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. The Case - continued

5. Patient looking at target straight ahead

6. Is there a problem of the nervous system? Where is the problem? What is the problem? Many esoteric and uncommon problems... Neurologist’s Diagnostic Approach

7. “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.” Solomon and Aring remarked in a 1934 paper,

8. Diplopia in the Emergency Department ISOLATED chief complaint Not part of more complex symptomatology Medline / Ovid Other data bases…. Evidence-based approach

9. Little data….many opinions…. One hit! Morris RD: Double vision as a presenting symptom in an Ophthalmic Casualty Department. Eye 1991;5:124 Evidence-based approach

10. 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 From the Casualty Department of Moorfield’s Eye Hospital

11. 25% - monocular diplopia 75% - binocular diplopia 275 consecutive patients

12. 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%) Monocular diplopia

13. 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%) Binocular diplopia - 206 patients

14. Cranial Nerve III Diabetes / Vascular Pituitary tumor Cranial Nerve IV Congenital Diabetes / Vascular Trauma Cranial Nerve VI Diabetes / Vascular MS CNS tumor Pseudotumor Cranial nerve palsies- infranuclear (39%)

15. Internuclear ophthalmoplegia (MS) Brainstem ischemia Migraine Wernicke’s encephalopathy Supranuclear lesions (7%)

16. Wide range of ocular and neurologic disorders “Don’t miss” diagnoses uncommon CNS tumor Aneurysm Ophthalmologic Casualty Department Summary

17. 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? QuestionsApproach to the patient

18. Severe headache? Weakness? Fatigue? Paralysis? Clumsiness / unsteady gait? Multiple cranial nerve palsies? If so, there are other problems... Are there associated signs and symptoms?

19. Monocular - likely refractive or ocular problem Binocular - likely an isolated cranial nerve problem Is the diplopia monocular or binocular?

20. Infiltrative lesions Myopathy Thyroid Sinusitis Orbital abscess Orbital cellulitis Is there any exophthalmos or proptosis?

21. Bilateral- may suggest myasthenia Unilateral-suggests cranial nerve III problem Horner’s? Is there any associated ptosis?

22. Acute Vascular Stroke Ocular? Gradual Infiltrative lesions Myopathies Was the onset acute or gradual?

23. Variability Multiple sclerosis Myasthenia Is there any variability or remission?

24. Folklore... Aneurysms may be painful infections Vascular lesions may be painless MS Myopathy Was there any pain?

25. 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 Questions - Our Patient

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

27. Monocular or binocular? Cover eye... Glasses / contacts off... Pinhole-may correct monocular diplopia Cataract or disc problem? Proptosis or exophthalmos? Look Feel Physical examination

28. Associated neurologic abnormalities? Define cranial nerve problem Observe Tracking / yoke movements Pupillary reaction Physical examination

29. 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 Physical examination-review

30. 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... “Laws of diplopia” - DeMyer

31. Allows reasoning of which muscle is weak and identification of cranial nerve abnormality... “Laws of diplopia” - DeMyer

32. Patient looking at target straight ahead

33. 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... Our patient

35. Aneurysmal compression common Generally, painful Generally, pupillary reactions affected Diabetic III neuropathy (“vasculopathic”) Generally, pupil reactivity spared Generally, painless Cranial nerve III caveats

36. 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 Diabetic III palsy

37. 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. The Case

38. 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. The Case - continued

39. 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…. Physical examination

40. 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 Objectives-revisited

41. 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 Neuroimaging-general remarks

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