Diplopia

Question 1

LR

Think of?
Look for?

Answer 1

Think of?
Small vessel disease
Elevated ICP
myasthenia gravis

Look for?
Risk factor (DM HTN)
Papilledema, loss of SVP
Worse with fatigue, repeated use

Question 2

MR, IR, IO, SR, LEAVATOR

Think of?
Look for?

Answer 2

Your pneumonic

Question 3

IR

THINK OF?

Look for?

Answer 3

Think of?
TRO
MYASTHENIA GRAVIS

LOOK FOR?
Exophthalmos 
Peri orbital edema
Inferior corneal staining
Worse with fatigue

Question 4

MR (isolated or bilateral)

Think of?

Look for?

Answer 4

Think of?
MS
TRO
MG
trauma/surgery (orbit)
Stroke (MLF)

Look for?
INO
Exophthalmos 
peri orbital edema
Inferior corneal staining 
Worse with fatigue

Question 5

IO

THINK OF?
Look for?

Answer 5

Think of?
Blowout orbital fracture

Look for?
Pertinent history

Question 6

LR &;/or
SO &;/or
MR, IR, IO, SR, &; LEAVATOR

Think of?
Look for?

Answer 6

Think of?
Cavernous sinus
Orbital apex
MG

LOOK FOR?
CN-V involvement 
Orbital bruit
Red eye
Pulsating exophthalmos

Question 7

SR & LEAVATOR
Or
MR, IR, IO

Think of?
Look for?

Answer 7

Think of?

• Orbital Alex disease affecting sup or inf division of CN 3
• MG

Look for?

• exophthalmos
• resistance to retribution
• papilledema, loss of SVP
• other CN involvement

Question 8

Levator (isolated) or variable

Think of?
Look for?

Answer 8

Think of?
MG

look for?
worse w fatigue
Better w rest

Question 9

Other combo they don’t match neuroanatomy?

Think of?
Look for?

Answer 9

Think of?

• Misdirection syndromes
• Duane

Look for?
History of trauma
Lingering 
ESO &/or EXO tropia
Globe retraction

Question 10

Medial longitudinal fasciculus?

DDX?

Answer 10

MS (if bilateral but also other types of INO),

STROKE (if not bilateral)

Question 11

Midline of Brain?

DDX?

Answer 11

Stroke (of small leveraging branches of Basilar artery)

Question 12

Midbrain near the red nucleus or the crus cerebri?

DDX?

Answer 12

Stroke (of small penetrating branches of basilar artery)

Question 13

Bw midbrain and cavernous sinus

(Ex: intracranial)?

Answer 13

• Aneurysm–> until proven other wise
• Temporal lobe herniation in cerebral mass lesion
• gradengio syndrome
• fracture of clivus
• cerebello-pontine
• angle mass

Question 14

Pons (nuclear CN6) (usually associated w gaze palsy)?

DDX?

Answer 14

Stroke

Mass

Question 15

Anterior posterior cavernous sinus

DDX?

Answer 15

Inflammation (unknown etiology)
Aneurysm (of internal Coratid)
Tolosa-hunt syndrome
Coratid-cavernous fistula 
Tumor

Question 16

Orbital Apex

DDX?

Answer 16

Tolosa-hunt syndrome
Tumor
Other mass lesion

Question 17

Orbit, muscle

DDX?

Answer 17

TRO 
MG
blowout fracture 
Tumor or other mass
Trauma
Progressive external opthalmoplegia (PEO)
Pseudo tumor of orbit 
Toxins

Question 18

Isolated CN-III w pupillary sparing

DDX

Answer 18

Microvasculature disease

(Esp diabetes), HTN

Question 19

Isolated CN III (including pupil)

Answer 19

HTN
DM
ANEURYSM

Question 20

Isolated CN IV

DDX

Answer 20

Blunt head trauma 
DM
HTN
TUMOR
Brown's tendon sheath syndrome

Question 21

Isolated CN VI

DDX

Answer 21

DM
HTN
Tumor
Elevated intracranial pressure

Question 22

Unknown

DDX?

Answer 22

Spasm of the near reflex

Question 23

SO

THINK OF?
Look for?

Answer 23

Think of?
Blunt head trauma 
Small vessel disease
Congenital 
Idiopathic 

Look for?
Pertinent history
Head tilt
Risk factor (DM, HTN)
Large vertical fusional reserves
Cyclo deviation