1425hrs Clinical approach to diplopia - Kimberley Cockerham, MD
/Different types:
CN palsy
CNIII with dilated pupil
Isolated CN palsy that progresses
Isolated CN palsy that doesn't resolve
Any new CN palsy in cancer presume cancer related
Take home messages:
- slow saccades = brain
- positive forced ductions = orbit
Exam
Step 1 assoc'd signs
- VA, pupils, typical exam
- can right off drifting out eye but not a drifting in eye
- CNIII can be confusing, check size pupil light and dark and check for RAPD
- evidence of other disease? inflammation, infection, neoplasis
- brain process, papilledema
- check head position, eyelids, periorbital changes, orbital findings, etc
- look for thyroid findings
Step 2 brain vs orbit
- slowed saccades in brain with normal forced ductions
- exact opposite of above if orbit
- use tonopen for kinder gentler forced duction
Step 3 identify pattern of motility
- does it fit a CN pattern?
- no CN pattern could be orbital or myasthenia
- maddox rod can help for smaller deviations
- CN IV, know if head tilted left it is probably right palsy but some TED patients and myasthenics can appear same way
Step 4: systemic disease
- MG, Graves, Giant Cell Arteririts, Increased ICP, MS
- don't forget typical GCA symptoms and the less common stomach pain from mesenteric ischemia
- the MG package: ptosis, XT, difficulty sustained upgaze, weak orbicularis, try the Ice test using a cold pack on the ptotic eye. If the eye pops up after ice, positive test for MG
Discuss patient 48 you female with left head turn and diplopia
- refractive errors, corneal opacities, lens, iris, macula, neurological, non- pathological
- if monocular, see if improves with pinhole
- if binocluar, no point in doing pinhole test
- thyroid patients more likely diplopic in the morning and MG as they fatigue
- paraneoplastic
- migraine
- Flake!
Back to our patient, diplopia constant except in extreme right gaze
- so esotropia and limited abduction
- has orbital pain, tearing, eyes bulgy, a bit of puffiness to eye
- remote hx of thyroid disease
- no surgical or other traumatic event
- also patient weight gain, fatigue, hair loss
- assoc'd findings: normal vision and pupils, injected conj, inc IOP on upgaze, increase resistance retropulsion
- slow eye movements in this patient, ie slow saccades therefore brain
- so now down to CNVI and related to her diabetes
- normal forced ductions in a patient with CNVI and TED findings
This patient has TED and acute onset of constant diplopia with constant velocity abnormality making this brain ie CNVI