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diplopia Flashcards

1
Q

What are the 5 differential diagnosis of diplopia?

A
  1. emergent
  2. refractive
  3. functional
  4. neuropathological
  5. mechanical
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2
Q

Patient presents with diplopia. How do we rule out an emergency?

A

! all of the oculomotor, including the pupil, and / or the abducens nerve involved
! the pa+ent is distressed, not well
! the pa+ent displays other neurological signs
! eg, change in mental status ! severe headache

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3
Q

Patient presents with

  • sudden onset
  • focal neurological signs/symptoms
  • CN 7 (drooping on one side of face)
  • mental status
  • patient has risk factors for stroke
A

stroke

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4
Q

Within how many minutes of the onset of a stroke, may be possible to reduce morbidity significantly?

A

180

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5
Q

What are the two types of stroke? and which is easier to save?

A

Type 1: occlusive **easier to save

Type 2: hemorrhagic

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6
Q

patient presents with emergency diplopia, what do we check for next?

A

is it monocular or binocular?

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7
Q

number one cause for monocular diplopia

A

astigmatism

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8
Q

which of the diplopias are acquired?

A

binocular

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9
Q

if its monocular diplopia, what do we do?

A

refract, then check the media (opacities or dislocated lens)

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10
Q

what if its binocular diplopia?

A

check for comitant deviation

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11
Q

what is comitant?

A

size of the deviation is within 5 or fewer prism diopters in ALL positions of gaze

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12
Q

what is incomitant?

A

size of the deviation is greater than 5 prism diopters in some positions of gaze

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13
Q

3 characteristics of comitancy testing

A
  1. be a good observer
  2. muscle field testing
  3. projection testing
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14
Q

what are 2 types of muscle field testing?

A

red lens and cover test

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15
Q

what are 3 types of projection tests?

A
  1. allied ring fusion test (ARFT)
  2. Hess Lancaster Screen
  3. Foster torches
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16
Q

What do you do if the deviation is comitant?

A
  1. perform functional analysis
  2. manage
  3. remember spread of comitancy
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17
Q

whats important about spread of comitancy

A

deviation started incomitant then became comitant over time

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18
Q

5 signs that spread of comitancy: problem has been there for a while

A
  1. abnormal head position
  2. large fusional reserves
    often associated with:
  3. diplopia related to fatigue
  4. cyclophoria
  5. A or V syndrome
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19
Q

what do we check for next, if deviation is not comitant?

A

does it match CN control?

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20
Q

how do we check if it matches CN control?

A
  1. identify the paretic EOM

2. is the ocular misalignment horizontal, or does it have a vertical component?

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21
Q

what do we check for if deviation is purely horizontal?

A

eso vs exo

> on L or R gaze

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22
Q

an exo deviation greater on left gaze: what muscle?

A

RMR

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23
Q

exo deviation greater on right gaze: what muscle?

A

LMR

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24
Q

eso deviation greater on left gaze: what muscle?

A

LLR

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25
Q

eso deviation greater on right gaze: what muscle?

A

RLR

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26
Q

What are the 3 questions to ask for vertical component deviations?

A
  1. which is the hyper eye
  2. is the deviation greater on left or right gaze
  3. is the deviation greater on head tilt to the left or to the right
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27
Q

how do you interpret the pattern of paretic EOMS? (2)

A
  1. pattern of EOM paresis conforms to the innervation of a single cranial nerve.
  2. the pattern of impaired muscles does NOT match single nerve damage
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28
Q

what do you do when the pattern conforms to the innervation of 1 nerve (3)?

A

locate the pathology
locate the neuropathology
analysis

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29
Q

✿ oculomotor nerve - nerve, fascicle, nucleus
✿ superior oblique muscle: 4th cranial nerve
✿ abducens nerve
✿ more than one cranial nerve
✿ spread of comitancy

A

locate the pathology and analysis

30
Q

! Testothercranialnerves
! Remember that the normal eye exam includes tests of CNs 2 through 8
! Testthepyramidalmotorsystem

A

locate the neuropathology

31
Q

4 DDX for SO EOM affected

A
  • blunt head trauma
  • small vessel disease
  • congenital
  • idiopathic
32
Q
  • pertinent history, head tilt
  • risk factor (e.g., DM, HTN)
  • large vertical fusional reserves
  • cylco-deviation
A

what to look for when SO EOM affected

33
Q

3 DDX when LR EOM affected

A
  • small vessel disease
  • elevated ICP
  • myasthenia gravis
34
Q

3 things to look for when LR EOM is affected

A
  1. risk factors (DM and HTN)
  2. papilledema, (-) SVP
  3. worse with fatigue, repeated use
35
Q

5 DDX when MR, IR, IO, SR, and levator is affected

A
  1. small vessel disease
  2. space occupying cranial mass
  3. brainstem stroke
  4. cavernous sinus
  5. orbital apex
36
Q

4 things to look for when MR, IR, IO, SR, and levator is affected

A
  1. risk factor
  2. papilledema, loss of SVP
  3. focal brainstem signs
  4. other CN involvement
37
Q

3 DDx when LR &/or SO &/or MR, IR, IO, SR, & levator are affected

A
  1. cavernous sinus
  2. orbital apex
  3. MG
38
Q

4 things to look for when LR &/or SO &/or MR, IR, IO, SR, & levator are affected

A
  1. CN V involvement
  2. orbital bruit
  3. red eye
  4. pulsating exophthalmos
39
Q

2 DDx when SR & levator or

MR, IR, IO are affected

A
  1. orbital apex disease affecting superior or inferior division of cn 3
  2. MG
40
Q

4 things to look for whe SR & levator or

MR, IR, IO are affected

A
  1. exophthalmos
  2. resistance to retropulsion
  3. papilledema (loss of SVP
  4. other CN involvement
41
Q

If the third nerve is involved, including the pupil, it is an ___________ unless you are confident it is not.

42
Q

5 Ddx if the pattern does not fit cranial nerve damage

A
  1. MG
  2. INO
  3. Duane’s retraction syndrome
  4. aberrant regeneration syndromes
  5. mechanical impediments to EOM action
43
Q

if the levator or variable is affected what do you think of (Dx)?

44
Q

what are two things to look for if levator or variable is affected?

A
  1. worse with fatigue

2. better with rest

45
Q

4 things to do when its MG?

A
  1. History
  2. tensilon test
  3. ocular and systemic forms
  4. review swallowing and breathing
46
Q

! Mode of action: anti-anticholinesterase
! Finding goes away for 2-10 minutes
! Remember actions of the cholinergic (parasympathetic) system
! Be prepared for fainting, vomiting

A

tensilon test in suspected MG

47
Q

4 DDx when MR (isolated or bilateral) is affected

A
  1. MS
  2. TRO
  3. trauma/surgery (orbit)
  4. stroke (MLF)
48
Q

5 things to look for when MR (isolated or bilateral) is affected

A
  1. INO
  2. exophthalmos
  3. periorbital edema
  4. inferior corneal staining
  5. worse with fatigue
49
Q

what are the 3 main defining characteristics of INO?

A
  1. ADduc+on of 1 or both eyes is impaired (cf isolated MR palsy)
  2. Convergence is spared
    ie: MR(s) “impaired” on versions but spared on convergence
  3. Nystagmus of the ABducting eye only (unilateral nystagmus)
50
Q

what are the 3 forms of INO?

A
  1. unilateral
  2. bilateral
  3. 1.5
51
Q

what is 1.5 INO?

A

INO to one side + gaze palsy to other side

52
Q

what do u think of if its unilateral and 1.5?

53
Q

what do u think of if its bilateral in right age group?

54
Q

what are 2 things to look for in MS?

A
  1. internuclear ophthalmoplegia, esp bilateral
    in right age group
  2. Optic neuropathy, esp. +APD. 20% of MS presents with optic neuropathy
55
Q

somatic symptoms, such as weakness or paresthesia in arms & feet, stumbling, clumsiness, decreased bladder control, Uthoff’s sign

56
Q

whats the basic picture of Duane’s Retraction Syndrome?

A

eye retracts into globe on attempted eye movement

57
Q

whats the most common form of Duane’s retraction Syndrome?

A

looks like esotropia at first glance

58
Q

T/F: Duane’s retraction syndrome is congenital and benign

59
Q

how many types of Duane Retraction Syndrome are there?

A
  1. type 1: intermittent congenital esotropia

2 type 2: exotropia

60
Q

combinations of muscle actions “don’t make neurological sense”
e.g. lid elevation on down gaze
from sub-acute or previous pathology

A

aberrant regeneration syndromes

61
Q

what do you think (Dx) of when theres a mechanical impediments to EOM action?

62
Q

what Dx do you think of when IO (isolated) is affected?

A

blow out orbital fracture

63
Q

what to look for when IO (isolated) is affected?

A

pertinent history

64
Q

What are the 2 Ddx when IR (isolated) is damaged?

65
Q

What are the 4 things to look for when IR is damaged?

A
  1. exophthalmos
  2. periorbital edema
  3. inferior corneal staining
  4. worse with fatigue
66
Q

5 Ddx when MR (isolated or bilateral) are affected?

A
  1. MS
  2. TRO
  3. MG
  4. Trauma/surgery (orbit)
  5. stroke (MLF)
67
Q

what are the 5 things to look for when MR is affected?

A
  1. INO
  2. exophthalmos
  3. perioorbital edema
  4. inferior corneal staining
  5. worse with fatigue
68
Q

what are the 4 things to rule out when there are mechanical impediments to EOM action?

A
  1. orbit mass
  2. cellulitis
  3. trauma
  4. surgery
69
Q

Thyroid related orbitopathy accounts for 90% of what?

A

exophthalmos

70
Q

thyroid related orbitopahy accounts for probably more than 90% of diplopia due to what?

A

orbital pathology

71
Q

! binocular diplopia
! ocular irrita+on
! “my eyes look funny”

A

TRO symptoms

72
Q 
emergent
!  refractive (monocular)
!  functional (comitant misalignment)
!  neuropathological (incomitant misalignment)
!  onenerve
!  notonenerve
!  mechanical impediments to EOM action

ocular disease 3 (10 decks)

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