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OD2 ND > 1-2. Double Vision > Flashcards

1-2. Double Vision Flashcards

1
Q

What history questions do you ask about double vision?

(9 questions)

A
  • 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?
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2
Q

Eye causes of DV

Due to ....

Causes: ..., ..., ..., ..., ..., ..., ...

Clues:
1. ...
2. ...
3. ...

A

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

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3
Q

Orbit/EOM causes of DV

  • Restriction of one/multiple EOM by ...
  • Muscle diseases such as ... or ...
A

Orbit/EOM causes of DV

  • Restriction of one/multiple EOM by thyroid orbitopathy
  • Muscle diseases such as orbital myositis or mitochondrial myopathy
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4
Q

Neuromuscular junction causes of DV

...

A

Neuromuscular junction causes of DV

Myasthenia gravis

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5
Q

Brain causes of DV

Caused by ..., ..., or ... and can lead to ..., ..., ..., or a ...

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

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6
Q

What are the causes of CN III palsy?

Compression:
* ... - at junction of internal carotid and PCAs
* ...
* ... with ...

Ischemia: ..., ..., ..., ...

Inflammation: ... or ...

Trauma: ... or ...

A

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

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7
Q

What are the symptoms of CN III palsy?

(4 points)

A
  • DV
  • ptosis - early stage or with DV
  • pupils - increase in size
  • pain - compressive and ischemic causes, usually on the same side as lesion
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8
Q

What are the signs of partial CN III palsy?

(4 points)

A
  • Strabismus - XT, HyperT, HypoT
  • Ptosis
  • Enlarged pupil
  • Aberrant regeneration - axon grows along the wrong way/onto wrong muscle
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9
Q

What are the signs of complete CN III palsy?

(3 points)

A
  • Full ptosis
  • Down and out position of eye - only SO and LR working
  • normal (pupil sparing) pupil or enlarged pupil
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10
Q

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: ...
A

What is the management for CN III palsy?

  • MRI+MRA or CTA
  • Aneurysm causes: clipping and/or coiling
  • Atherosclerotic causes: GP to stop smoking, reduce cholesterol, monitor sugar levels and BP
  • Small strabismus: prism rx although not ideal as px might not be able to adapt to high prism, and prism might change
  • Strabismus: strabismus/ptosis surgery for cosmesis, >12months
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11
Q

What are the causes of CN IV palsy?

They can be ... or ... in origin, and affect the patient ... or ....

  • ...
  • ... conditions
  • ... and/or ... origins
A

What are the causes of CN IV palsy?

They can be congenital or acquired in origin, and affect the patient unilaterally or bilaterally.

  • Trauma
  • Ischemic conditions
  • Compressive and/or inflammatory origins
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12
Q

Which tests are useful for checking CN IV palsy?

(4 points)

A
  • Vertical fusional reserves
  • Double Maddox Rox
  • Fundus extorsion (via OCT or fundus examination)
  • Family Album Test
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13
Q

How do you conduct a Double Maddox Rod?

A

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.

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14
Q

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: ...

A

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

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15
Q

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: ...

A

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

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16
Q

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: ...

A

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

17
Q

What are the differential diagnoses for CN IV palsy?

(3 points)

A
  • 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
18
Q

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 -> ...
A

What is the management for CN IV palsy?

  • Non-traumatic unilateral -> may need brain MRI to rule out tumour and aneurysm
  • Non-traumatic bilateral -> must do to brain MRI to rule out pineal region tumour
  • Traumatic causes -> manage as appropriate, can resolve in 6months
  • Ischemic causes -> GP referral?, could resolve on their own
  • Strabismus surgery -> cosmetic fix for congenital or non-resolving CN IV palsies
19
Q

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
A

What are the causes of CN VI palsy?

  • Compression is common, unilateral or bilateral
  • Increase intracranial pressure, unilateral or bilateral
  • Trauma, unilateral or bilateral
  • Ischemia is common, unilateral
  • Inflammation is rare, unilateral
20
Q

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 ...
A

What are the symptoms of CN VI palsy?

  • Horizontal diplopia; mild symptoms present at distance or on the side gaze of the lesion side
    Tumour suspected if:
  • gradual or intermittent onset of DV
  • progression of DV (i.e. images separate more); ischemic causes stabilise and resolve
  • pain; ischemic and compressive causes are usually painless
  • numbness on ipsilateral orbital region
  • new onset of ipsilateral facial weakness, deafness, tinnitus, or vertigo
21
Q

What are the signs of CN VI palsy?

  • ... of one eye and ...

Tumour suspected if:
* decreased ...
* ..., ..., ...
* limited ...
* ...
* ...

A

What are the signs of CN VI palsy?

  • decreased abduction of one eye and slowing 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

22
Q

For causal consideration, what is the hierarchy?

(5 points)

A
  1. Diabetes
  2. Hypertension
  3. Atherosclerosis
  4. Aneurysm
  5. Tumour
23
Q

What are the differential diagnoses for CN VI palsy?

(3 points)

A
  • myasthenia gravis
  • restrictive EsoT due to tight MR
  • congenital Duane’s retraction syndrome
24
Q

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, ...
A

What is the management for CN VI palsy?

  • brain MRI
  • Ischemic causes -> GP referral?, can recover
  • If no significant improvement, Botox to ipsilateral MR which is useful to suss if there is LR function or decrease MR fibrosis
  • If no improvement after 6 months, either surgery for straightening eyes or wait longer for compressive/traumatic causes
  • If there are multiple CN affected or unexplained DV, refer to neuro-ophthal

OD2 ND (16 decks)

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