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Ocular Disease 3 - Final > Diplopia > Flashcards

Diplopia Flashcards

1
Q

what are the 5 categories of differential diagnoses for diplopia?

A

emergent, refractive, functional, neuropathological, and mechanical

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2
Q

what is the first thing you do if a patient presents with diplopia?

A

rule out an emergency - if its an emergency you need to refer

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3
Q

what are some signs that the diplopia is an emergency?

A

more than one CN is involved (3 and 4), patient is distressed/unwell, displays other neurological signs and/or they have a stroke

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4
Q

what is the next question after ruling out an emergency?

A

is the diplopia binocular

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5
Q

what do you do if the diplopia is not binocular (it is monocular)?

A

refract and check the media for any opacities

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6
Q

the diplopia is binocular - what is the next question you ask?

A

is it comitant

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7
Q

what do you do if the binocular diplopia is comitant (within 5PD in all gazes)?

A

perform a functional analysis, VT and monitor

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8
Q

what is the spread of comitancy?

A

if the deviation is comitant - this means that the problem has been there for awhile (maybe started incomitant in the past)

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9
Q

what do you look at after you determine the patient has binocular incomitant diplopia?

A

identify the paretic muscle and see if it matches CN control

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10
Q

what are the causes of diplopia if it is incomitant and does not match CN control?

A

think = MG, orbit or INO

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11
Q

what are the causes of diplopia if it is incomitant and does match CN control?

A

think = CN3, CN4, CN6

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12
Q

how do you test for comitancy?

A

good observer, muscle field tests or projection tests

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13
Q

what is the foster torch test?

A

a projection test for comitancy - the red light is seen by the right eye and the green is seen by the left eye, the patient is supposed to put the two colored lines on top of each other on a grid

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14
Q

if the diplopia is incomitant and purely horizontal with an exo deviation - which EOM is affected if the deviation is greater on left gaze?

A

right medial rectus

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15
Q

if the diplopia is incomitant and purely horizontal with an exo deviation - which EOM is affected if the deviation is greater on right gaze?

A

left medial rectus

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16
Q

if the diplopia is incomitant and purely horizontal with an eso deviation - which EOM is affected if the deviation is greater on left gaze?

A

left lateral rectus

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17
Q

if the diplopia is incomitant and purely horizontal with an eso deviation - which EOM is affected if the deviation is greater on right gaze?

A

right lateral rectus

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18
Q

what do you use if the patient has a vertical component with the incomitant diplopia?

A

Parks- 3 step flow chart (given on the exam)

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19
Q

what are the 3 questions you ask with Parks 3-step flow chart?

A

which is the hyper eye, is the deviation greater on left or right gaze and is the deviation greater on head tilt to the left or right

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20
Q

if the SO (isolated) is affected what do you think of? (CN4)

A

blunt head trauma, small vessel disease, congenital, and idiopathic

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21
Q

if the SO (isolated) is affected what do you look for? (CN4)

A

pertinent history, head tilt, risk factor (DM, HTN), large vertical fusional ranges and cyclo-deviation

22
Q

if the LR (isolated) is affected what do you think of? (CN6)

A

small vessel disease, elevated ICP, and myasthenia gravis

23
Q

if the LR (isolated) is affected what do you look for? (CN6)

A

risk factor (DM, HTN), papilledema/loss of SVP, worse with fatigue or repeated use

24
Q

if the MR, IR, IO, SR, and levator are affected what do you think of? (CN3)

A

small vessel disease, space occupying cranial mass, brainstem stroke, cavernous sinus, orbital apex disease

25
Q

if the MR, IR, IO, SR, and levator are affected what do you look for? (CN3)

A

risk factor (DM, HTN), papilledema/loss of SVP, focal brainstem signs, and other CN involvement

26
Q

if the LR and/or SO and/or MR, IR, IO, SR, and levator are affected what do you think of?

A

cavernous sinus, orbital apex disease, and myasthenia gravis

27
Q

if the LR and/or SO and/or MR, IR, IO, SR, and levator are affected what do you look for?

A

CN5 involvement, orbital bruit, red eye, and pulsating exophthalmos

28
Q

if SR and levator or MR, IR, and IO are affected what do you think of?

A

orbital apex disease affecting superior or inferior division of CN3, myasthenia gravis

29
Q

if SR and levator or MR, IR, and IO are affected what do you look for?

A

exophthalmos, resistance to retropulsion, papilledema/loss of SVP, other CN involvement

30
Q

what condition do you use the tensilon test for?

A

myasthenia gravis

31
Q

what is the tensilon test?

A

use anti-anticholinesterase - inject into patient and see if drug reverses the ptosis for 2-10 minutes (be prepared for fainting or vomiting)

32
Q

what do you want to ask the patient/review if you are thinking myasthenia gravis?

A

history (effect of fatigue) and if they are having trouble with swallowing or breathing

33
Q

what are the 3 defining characteristics of INO?

A
  1. adduction of 1 or both eyes is impaired
  2. convergence is spared
  3. nystagmus of the abducting eye only (unilateral nystamus)
34
Q

what are the 3 forms of INO?

A

unilteral, bilateral and 1.5

35
Q

what is 1.5 INO?

A

INO to one side and a gaze palsy to the other side

36
Q

what do you think of if the patient has unilateral INO or 1.5 INO?

A

stroke

37
Q

what do you think of if the patient has bilateral INO?

A

MS

38
Q

what are some things you look for in an optometric practice for MS?

A

INO (especially bilateral), optic neuropathy and APD (also somatic symptoms such as paresthesia, weakness, clumsiness)

39
Q

what is Duane’s retraction syndrome?

A

the MR and LR contract at the same time and the eye retracts into the globe - looks like esotropia at first
it is congenital and benign
comes in 3 different forms

40
Q

what is aberrant regeneration syndrome?

A

a nerve re-grows to the wrong target and muscles contract in patterns that they are not supposed to normally
ex: lid elevation on down gaze or crocodile tears

41
Q

if the levator (isolated) is affected what do you think of?

A

myasthenia gravis

42
Q

if the levator (isolated) is affected what do you look for?

A

worse with fatigue and is better with rest

43
Q

if the MR (isolated or bilateral) is affected what do you think of?

A

MS, TRO, myasthenia gravis, trauma/surgery, stroke (MLF)

44
Q

if the MR (isolated or bilateral) is affected what do you look for?

A

INO, exophthalmos, periorbital edema, inferior corneal staining, worse with fatigue

45
Q

if the IO (isolated) is affected what do you think of?

A

blow out orbital fracture

46
Q

if the IO (isolated) is affected what do you look for?

A

pertinent history

47
Q

if the IR (isolated) is affected what do you think of?

A

TRO, myasthenia gravis

48
Q

if the IR (isolated) is affected what do you look for?

A

exophthalmos, periorbital edema, inferior corneal staining, worse with fatigue

49
Q

if other combinations of EOMs are affected that do not match neuroanatomy or a single CN damage what do you think of?

A

misdirection syndromes or Duane’s

50
Q

if other combinations of EOMs are affected that do not match neuroanatomy or a single CN damage what do you look for?

A

history of trauma, longstanding, eso or exotropia, and globe retraction

Ocular Disease 3 - Final (6 decks)

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