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Rosens > 17. Diplopia > Flashcards

17. Diplopia Flashcards

1
Q

Defn diplopia

A

seeing two or more images

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2
Q

Monocular vs binocular diplopia: which improves with one eye closed?

A

binocular

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3
Q

Key hx questions about diplopia

A
  1. monocular or binocular
  2. timing and onset of sx
  3. directionality, orientation (horiz, vertical or torsional)
    4) +/- pain
    5) presence of other assoc sx
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4
Q

List 6 causes of monocular diplopia

A

dry eyes
corneal irregularity
cataract
lens dislocation
retinal wrinkles
conversion d/o

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5
Q

DDX binocular diplopia: major categories?

A

1) structural orbitaopathy
2) m inflammation of orbit
3) CN palsy 3,4,6 - single vs multiple
4)Neuroaxial process involving brainstem and related cranial nerves
5) NM disorder

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6
Q

DDX binocular diplopia: list 3 causes of structural orbitopathy

A

trauma
infection/abscess
craniofacial masses

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7
Q

DDX binocular diplopia: orbital myositis: list 5 causes

A

thyroid eye disease
GPA
GCA
SLE
dermatomyositis
sarcoidosis
RA
idiopathic orbital inflamm syndrome/”orbital pseudotumor”

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8
Q

DDX binocular diplopia: name 5 potential causes of an isolated CN 3, 4 or 6 palsy

A

MS
HT vasculopathy
diabetic vasculopathy
IIH
compression
trauma

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9
Q

Name 3 causes of multiple oculomotor nerve palsies

A

cavernous sinus infection, mass, vasculitis or thrombosis
orbital apex syndrome

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10
Q

DDX binocular diplopia: neuroaxial process involving brainstem and related CN
- one focal cause?

A

MS

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11
Q

DDX binocular diplopia: neuroaxial process involving brainstem and related CN
- name 4 localized brainstem cause?

A

tumor
stroke
hemorrhage
basilar a thrombosis
va dissection
opthalmoplegic migraine

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12
Q

DDX binocular diplopia: neuroaxial process involving brainstem and related CN
- name 3 diffuse causes - ie brainstem and or CN 3, 4, 6?

A

infectious - basilar meningoencephalitis
autoimmune: miller-fisher or GBS
metabolic: wernicke encephalopathy

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13
Q

DDX binocular diplopia: name 2 NM disorder causes

A

MG
botulism

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14
Q

CN palsy - which assoc with horizontal dilopia

A

medial/lateral rectus m

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15
Q

CN palsy - which assoc with torsional diplopia

A

superior or inferior oblique m dysfunction or lateral medullay syndrome

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16
Q

CN palsy - which assoc with vertical diplopia

A

brainstem pathology or CN 6 palsy

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17
Q

CN III muscles of the eye

A

superior rectus, inferior rectus, medial rectus, inferior rectus

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18
Q

CN IV m of eye

A

superior oblique

19
Q

CN VI m of eye

A

lateral rectus

20
Q

What does a lateral rectus/CN VI palsy look like?

A

affected eye turns inward, pt limited abduction of affected eye with horizontal diplopia worse looking towards affected side

21
Q

What does a superior oblique/CN IV palsy look like?

A

eye is displaced slightly upward and has vertical/torsional diplopia

*may compensate with a head tilt so look for this!

22
Q

CN III palsy - what does this look like?

A

eye down and out

if complete, ptosis, dilated pupil

23
Q

What are signs of a structural orbitopathy or myositis?

A

proptosis
periorbital swelling
edema
conjunctival or scleral hyperemia
palpebral swelling of a single eye

24
Q

Stigmata of thyroid eye disease

A

proptosis
eyelid retraction
diffuse conjunctival edema
vascular injection

typically inferior and medial recti m - so first causing a restriction of elevation and abd of eye leading to diplopia

25
Q

Why does a total CN 3 palsy cause dilated pupil and ptosis?

A

levator palpebrae superioris m innerv - lifts upper eyeid and provides parasymp inerv

26
Q

Difference in CN 3 palsy for a microvascular ischemia in HTN and db vs compressive lesion like an aneurysm

A

pupil spared

mydraisis due to compression of pupillmo parasymp fibers on exterior of nerve

27
Q

Why is CN IV more susceptible to trauma?

A

sits against tentorium

28
Q

Why do you get CN 3, 4, 6 ipsi palsy in cavernous sinus pathology?

A

sinus at base of skull with this CN (also 5), plus internal carotid a traversing sinus on each side

29
Q

Orbital apex syndrome vs cavernous sinus pathology: how to differntiate?

A

apex syndrome - decreased visual acuity since the optic nerve passes through the orbital apex

30
Q

What other signs than diplopia may botulism present with?

A

slurred speech
difficulty swallowing
descending flaccid paralysis with mult palsies
dry outh/ileus/postural hypotension, resp m weakness, pupil abnormalities

31
Q

Why do pt with Wernicke get. CN VI palsy?

A

metabolically induced lesions in pontine tegmentum, abducens nucleus and oculomotor nucleus

32
Q

Miller fischer syndrome triad

A

opthalmoplegia
ataxia
areflexia

33
Q

M weakness - more likely miller fischer or gbs?

A

gbs with opthalmoplegia

34
Q

MG tests - ice bag tset - how to do, why does it work?

A

ice bag test - e-filled glove or bag to the patient’s closed eye for 5 minutes; a positive test is an improvement in the ptosis (typically ≈5 mm) or diplopia

mitigate the effect of myasthenia-related acetylcholine receptor blockade by decreasing cholinesterase activity and promoting the efficacy of acetylcholine at the endplate.

35
Q

Historical test for MG

A

edrophonium

36
Q

Name 4 critical causes of diplopia

A

basilar a thrombosis
botulism
basilar meningitis
aneurysm

37
Q

Wernicke triad

A

nystagmus
ams
ataxia

38
Q

A 65-year-old man with a longstanding history of diabetes and hypertension presents with sudden onset of persistent diplopia that began a few hours before arrival. He describes left retro-orbital dis- comfort, and his examination is notable for a left eye that is deviated laterally and downward, with a palsy of movement medially and upward. He also has a left-sided ptosis but no conjunctival injec- tion, chemosis, or proptosis. His pupils are equal in size at 4 mm, round, and equally reactive to light in both a direct and consensual reflex, and his examination is otherwise unremarkable. What is the most likely cause of the diplopia?
a. Braintumor
b. Cerebral aneurysm
c. Microvascularischemia
d. Orbital apex syndrome

A

c

39
Q

A 76-year-old man with hypertension, hypercholesterolemia, and
diet-controlled diabetes presents with a sudden onset of diplopia that developed 30 minutes before arrival. Paramedics state that the patient’s wife reported that he suddenly began staggering around the room, unable to bear weight on his left side. On examination, the patient has normal vital signs except for mild hypertension and has a right CN III palsy, with left arm and leg weakness. He has no airway complaints and denies any pain. What is the most appropri- ate initial response?
a. Checking blood gas levels and assessing the patient’s negative inspiratory force
b. Emergent treatment with botulinum antitoxin
c. Initiating broad-spectrum antibiotics to cover upper respiratory
pathogens
d. Initiating clinical measures to address an acute ischemic stroke

A

d

40
Q

A 56-year-old woman presents with recurrent episodes of diplopia that have been ongoing for a week. She describes double vision that gradually comes and goes, typically worse at the end of the day, with no particular direction or orientation to the diplopia. The patient’s coworker, who is present in the emergency depart- ment (ED) with her, states that the patient’s eyes “looked droopy” during an animated staff meeting they attended that afternoon but look normal now. The patient also describes waxing and waning general muscular weakness that has also been present this past week but denies any other symptoms and states that when she rests, she feels better. With which entity are her symptoms most consistent?
a. Botulism
b. Hypothyroidism
c. Miller-Fishersyndrome d. Myasthenia gravis

A

d

41
Q

Which constellation of symptoms is most concerning for food- borne botulism?
a. Double vision, headache, and right leg weakness
b. Double vision, left eye discomfort, and periorbital swelling
c. Double vision, nystagmus, and confusion
d. Double vision, slurred speech, difficulty swallowing, and dry
mouth

A

d

42
Q

A 45-year-old woman presents with progressively worsening dou-
ble vision and the inability to adduct the eye on one side in the contralateral direction during lateral gaze that resolves during convergence on physical examination. What disease should be sus- pected with these findings?
a. Multiplesclerosis
b. Botulism
c. Myastheniagravis
d. Idiopathic intracranial hypertension

A

a

43
Q

MS - CN palsy resolves on what test?

A

convergence

Rosens (59 decks)

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