1-2. Double Vision Flashcards
What history questions do you ask about double vision?
(9 questions)
- Does it disappear when one eye is covered?
- Are both images the same?
- Are they up and down, or side to side?
- How far apart are they?
- Does it change at distance or near?
- Does it change with gaze direction?
- When did the double vision start?
- Has it improved since onset?
- Is it constant or does it vary throughout the day?
Eye causes of DV
Due to ....
Causes: ..., ..., ..., ..., ..., ..., ...
Clues:
1. ...
2. ...
3. ...
Eye causes of DV.
Due to uncommon ocular media.
Causes: high astigmatism, incorrect Rx, corneal disease, iridectomy, decentred IOL, cataract, pterygium
Clues:
1. unequal images, one clear and one blurry
2. images almost touching each other
3. DV when one eye covered
Orbit/EOM causes of DV
- Restriction of one/multiple EOM by
... - Muscle diseases such as
...or...
Orbit/EOM causes of DV
- Restriction of one/multiple EOM by
thyroid orbitopathy - Muscle diseases such as
orbital myositisormitochondrial myopathy
Neuromuscular junction causes of DV
...
Neuromuscular junction causes of DV
Myasthenia gravis
Brain causes of DV
Caused by ..., ..., or ... and can lead to ..., ..., ..., or a ...
Brain causes of DV
Caused by stroke, tumour, or degenerative disease and can lead to nerve palsy, intranuclear ophthalmoplegia, skew deviation, or a supranuclear palsy
What are the causes of CN III palsy?
Compression:
* ... - at junction of internal carotid and PCAs
* ...
* ... with ...
Ischemia: ..., ..., ..., ...
Inflammation: ... or ...
Trauma: ... or ...
What are the causes of CN III palsy?
Compression:
* aneurysm - at junction of internal carotid and PCAs
* brain tumour
* raised intracranial pressure with uncal herniation
Ischemia: diabetes, hypertension, GCA, atherosclerosis
Inflammation: MS or infection
Trauma: severe open injuries or closed head injuries
What are the symptoms of CN III palsy?
(4 points)
- DV
- ptosis - early stage or with DV
- pupils - increase in size
- pain - compressive and ischemic causes, usually on the same side as lesion
What are the signs of partial CN III palsy?
(4 points)
- Strabismus - XT, HyperT, HypoT
- Ptosis
- Enlarged pupil
- Aberrant regeneration - axon grows along the wrong way/onto wrong muscle
What are the signs of complete CN III palsy?
(3 points)
- Full ptosis
- Down and out position of eye - only SO and LR working
- normal (pupil sparing) pupil or enlarged pupil
What is the management for CN III palsy?
-
...or... - Aneurysm causes:
...and/or... - Atherosclerotic causes: GP to stop
..., reduce..., monitor...and... - Small strabismus:
...although not ideal as... - Strabismus:
...
What is the management for CN III palsy?
-
MRI+MRAorCTA - Aneurysm causes:
clippingand/orcoiling - Atherosclerotic causes: GP to stop
smoking, reducecholesterol, monitorsugar levelsandBP - Small strabismus:
prism rxalthough not ideal aspx might not be able to adapt to high prism, and prism might change - Strabismus:
strabismus/ptosis surgery for cosmesis, >12months
What are the causes of CN IV palsy?
They can be ... or ... in origin, and affect the patient ... or ....
...-
...conditions -
...and/or...origins
What are the causes of CN IV palsy?
They can be congenital or acquired in origin, and affect the patient unilaterally or bilaterally.
Trauma-
Ischemicconditions -
Compressiveand/orinflammatoryorigins
Which tests are useful for checking CN IV palsy?
(4 points)
- Vertical fusional reserves
- Double Maddox Rox
- Fundus extorsion (via OCT or fundus examination)
- Family Album Test
How do you conduct a Double Maddox Rod?
Place a red and white MR in front of either eye. Cover each eye (one at a time) to see if the view is rotated. If yes, ask patient to rotate on MR until both are parallel.
What are the symptoms and signs of acquired unilateral CN IV palsy?
Symptoms:
* ... or ... diplopia
* With or without ...
Signs:
* ... away from ...
* ... or ... of affected eye
* Secondary overaction of ..., resulting in ...
* Underaction of ..., resulting in ...
* Vertical fusion reserves: <...PD
* Double Maddox Rod: extorsion <...degrees
* Fundus observation: ...
What are the symptoms and signs of acquired unilateral CN IV palsy?
Symptoms:
* vertical or oblique diplopia
* With or without torsional diplopia
Signs:
* head tilt away from side of the palsy
* HyperT or oblique deviation of affected eye
* Secondary overaction of ipsilateral IO, resulting in eye goes up when adducted
* Underaction of ipsilateral SO, resulting in eye might shoot up when eye looks down and out
* Vertical fusion reserves: <5PD
* Double Maddox Rod: extorsion <10degrees
* Fundus observation: extorsion on affected side
What are the symptoms and signs of acquired bilateral CN IV palsy?
Symptoms:
* ...
* With or without ... or ... diplopia
Sings:
* ... head tilt
* ... or ...
* ... reverses with gaze
* Overaction of ... resulting in ...
* Underaction of ..., resulting in ...
* Vertical fusion reserves: <...PD
* Double Maddox Rod: extorsion >...degrees
* Fundus observation: ...
What are the symptoms and signs of acquired bilateral CN IV palsy?
Symptoms:
* Torsional diplopia
* With or without vertical or oblique diplopia
Sings:
* downwards head tilt
* HyperT or no deviation
* HyperT reverses with gaze
* Overaction of both IO resulting in upshoot of both eyes when adducting, V pattern
* Underaction of both SO, resulting in eye might shoot up when eye looks down and to opposite side
* Vertical fusion reserves: <5PD
* Double Maddox Rod: extorsion >10degrees
* Fundus observation: extorsion on both sides
What are the symptoms and signs of congenital unilateral CN IV palsy?
Symptoms:
* ...
* ... or ... diplopia, which is ...
Signs:
* ... away from ...
* ... may lead to ...
* EM same as ...
* Vertical fusional reserves: >...PD
* Double Maddox Rod: ...
* Fundus observation: ...
What are the symptoms and signs of congenital unilateral CN IV palsy?
Symptoms:
* no torsion
* vertical or oblique diplopia, which is often intermittent
Signs:
* head tilt away from side of the palsy
* chronic head tilt may lead to hemifacial hypoplasia
* EM same as acquired
* Vertical fusional reserves: >5PD
* Double Maddox Rod: often no subjective torsion
* Fundus observation: extorsion on affected side
What are the differential diagnoses for CN IV palsy?
(3 points)
- Skew deviation can mimic a CN4 palsy in every detail (BS stroke, MS, tumour), except intorsion of affect eye
- Partial CN III palsy (IR palsy can lead to HyperT)
- MG
What is the management for CN IV palsy?
- Non-traumatic unilateral -> may need
...to rule out...and... - Non-traumatic bilateral -> must do
...to rule out... - Traumatic causes -> manage as
..., can... - Ischemic causes ->
...,... - Strabismus surgery ->
...
What is the management for CN IV palsy?
- Non-traumatic unilateral -> may need
brain MRIto rule outtumourandaneurysm - Non-traumatic bilateral -> must do to
brain MRIto rule outpineal region tumour - Traumatic causes -> manage as
appropriate, canresolve in 6months - Ischemic causes ->
GP referral?,could resolve on their own - Strabismus surgery ->
cosmetic fix for congenital or non-resolving CN IV palsies
What are the causes of CN VI palsy?
-
...is common, unilateral or bilateral -
..., unilateral or bilateral -
..., unilateral or bilateral -
...is common, unilateral -
...is rare, unilateral
What are the causes of CN VI palsy?
-
Compressionis common, unilateral or bilateral -
Increase intracranial pressure, unilateral or bilateral -
Trauma, unilateral or bilateral -
Ischemiais common, unilateral -
Inflammationis rare, unilateral
What are the symptoms of CN VI palsy?
-
...diplopia; mild symptoms present at...or...
Tumour suspected if: -
...or...onset of DV -
...of DV (i.e....); ischemic causes stabilise and resolve -
...; ischemic and compressive causes are usually... - numbness on
... - new onset of
...,...,..., or...
What are the symptoms of CN VI palsy?
-
Horizontaldiplopia; mild symptoms present atdistanceoron the side gaze of the lesion side
Tumour suspected if: -
gradualorintermittentonset of DV -
progressionof DV (i.e.images separate more); ischemic causes stabilise and resolve -
pain; ischemic and compressive causes are usuallypainless - numbness on
ipsilateral orbital region - new onset of
ipsilateral facial weakness,deafness,tinnitus, orvertigo
What are the signs of CN VI palsy?
-
...of one eye and...
Tumour suspected if:
* decreased ...
* ..., ..., ...
* limited ...
* ...
* ...
What are the signs of CN VI palsy?
-
decreased abductionof one eye andslowing abducting saccades
Tumour suspected if:
* decreased corneal sensation
* facial weakness, deafness, nystagmus
* limited EOM movements
* bitemporal field defect
* abduction defect in other eye, bilateral CN6
For causal consideration, what is the hierarchy?
(5 points)
- Diabetes
- Hypertension
- Atherosclerosis
- Aneurysm
- Tumour
What are the differential diagnoses for CN VI palsy?
(3 points)
- myasthenia gravis
- restrictive EsoT due to tight MR
- congenital Duane’s retraction syndrome
What is the management for CN VI palsy?
...- Ischemic causes ->
..., can recover - If no significant improvement,
...which is useful to...or... - If no improvement after 6 months, either
...or... - If there are multiple CN affected or unexplained DV,
...
What is the management for CN VI palsy?
brain MRI- Ischemic causes ->
GP referral?, can recover - If no significant improvement,
Botox to ipsilateral MRwhich is useful tosuss if there is LR functionordecrease MR fibrosis - If no improvement after 6 months, either
surgery for straightening eyesorwait longer for compressive/traumatic causes - If there are multiple CN affected or unexplained DV,
refer to neuro-ophthal
