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OD3 - Clinical Optometry Practice > NV - Double Vision I - Week 4 > Flashcards

NV - Double Vision I - Week 4 Flashcards

1
Q

List 8 history questions that should be asked if a patient complains of double vision.

A 
Does it disappear if you cover one eye?
Are both images the same?
Orientation?
Change with D/N viewing?
Change with gaze direction?
Onset?
Better or worse over time?
Constant or varying?
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2
Q

What should be done for double vision cases?

A

Basic neurological screening examination

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3
Q

What is the most common cause of double visiond?

A

Ischaemic oculomotor nerve palsies

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4
Q

Is it common or uncommon for ocular media to cause double vision? What kind of double vision would you expect?

A

Uncommon

-monocular double vision

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5
Q

List 6 examples of ocular media that can result in double vision.

A 
High astigmatism
Incorrect Rx
Corneal disease
Iridectomy
Decentred IOLs
Cataract
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6
Q

What are three vital clues that indicate monocular double vision may be present?

A

2 images are unequal
-one is clearer, the other is a ghost
2 images that are almost touching each other
Double vision persists despite covering one eye

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7
Q

What is one of the most common causes of double vision involving the orbit/EOMs and how does it cause double vision? List three additional causes of double vision involving the orbit/EOMs.

A 
Thyroid orbitopathy
-resitricts one of the EOMs
Orbital myositis
Mitochondrial myopathy
CPEO
-chronic progressive external ophthalmoplegia
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8
Q

List a condition that can mimic double vision.

A

Myasthenia gravis

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9
Q

What three nerves are often the most dangerous if involved with double vision and why?

A

CN3, 4, and 6 because they are often caused by an intracranial aneurysm or brain tumour compression

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10
Q

What percentage of CN3 palsies are life-threatening?

A

Up to 33%

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11
Q

If a patient has a life-threatening CN3 palsy, how long after onset of double vision may death occur?

A

They may die within hours or days of onset

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12
Q

What is often the first presenting complaint in patients with an undiagnosed brain aneurysm?

A

Double vision

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13
Q

Are partial CN3 palsies easy or hard to diagnose? Explain why.

A

Hard because they can present with various patterns of motility deficits

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14
Q

Is the rule of pupil a good way to gauge whether a brain aneurysm is present or not?

A

No

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15
Q

What three things can cause double vision originating in the brain?

A

Stroke
Tumour
Degenerative disease

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16
Q

List 6 possible causes of CN3 palsies. Note the most common.

A 
Compression
-aneurysm
Tumours
Raised intracranial pressure
Ischaemia (most common)
Inflammation
Trauma
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17
Q

List four ischaemic causes of CN3 palsies.

A

Diabetes
Hypertension
GCA
Atherosclerosis

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18
Q

List two inflammatory causes of CN3 palsies.

A

Multiple sclerosis

Infection

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19
Q

What is one of the earliest ocular changes that can occur with double vision?

A

Ptosis

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20
Q

What pupil change is often present with double vision?

A

Increased size

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21
Q

What two causes of double vision generally result in pain? What about persistent severe pain?

A

Compressive
Ischaemic
-aneurysm more likely than ischaemic with persistent severe pain

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22
Q

List three possible symptoms of the cause of double vision.

A

Ptosis
Increased pupil size
Pain

23
Q

List three signs od partial CN3 palsy.

A

Strabismus
Ptosis
Enlarged pupil

24
Q

What kind of strabismus may occur as a result of CN3 palsy (4)?

A

ExoT
HyperT
HypoT
-any possibility and combinations

25
Q

What pupil response do you expect to see with partial CN3 palsy and why?

A

Poor light and near response due to weak sphincter

26
Q

If you see aberrant regeneration in a partial CN3 palsy, what cause can you rule out?

A

Ischaemic cause

27
Q

Describe aberrant regeneration in partial CN3 palsy (3).

A

Upper lid retraction
Constricted pupil
Abnormal EM on adduction/elevation/depression of the eye

28
Q

Describe what may be occurring with aberrant regeneration in partial CN3 palsy (2).

A

Nerve fibres to the medial rectus grow back to the sphincter

Inferior rectus fibres misrouted to the letvator

29
Q

If you see aberrant regeneration in partial CN3 palsy and there is no history of nerve palsy, what is likely happening (3) and where?

A

Likely a slow-growing lesion, an aneurysm, or meningioma compressing CN3
-often in the cavernous sinus

30
Q

What three things would you expect to see with complete CN3 palsy?

A

Full ptosis
Eyes down and out
Normal or enlarged pupil

31
Q

If you see a normal pupil in what you suspect is complete CN3 palsy, what cause can be ruled out?

A

Ischaemic causes

32
Q

What scans are generally done for CN3 palsies (3)?

A

Urgent MRI brain scan plus MRA or CTA

33
Q

What is the treatment for aneurysms?

A

Clipping/coiling

34
Q

What is the treatment for CN3 palsies caused by atherosclerosis? Who is the referral to?

A

GP

  • stop smoking
  • reduce cholesterol levels
  • monitor sugar levels
  • BP control
35
Q

Are prisms generally used to treat double vision in CN3 palsies? What else?

A

May help with small deviations

-else patch eye for total occlusion

36
Q

What are four general causes of CN4 palies?

A

Trauma
Ischaemic
Compressive
Inflammatory

37
Q

List four useful tests to consider for CN palsies.

A

Vertical fusion reserves
Degree of extortion with double maddox rod
Observe fundus extorsion
-ONH/macula in the normal position
FAT for head tilt to the side of the lower eye

38
Q

List two symptoms of acquired unilateral CN4 palsy.

A

Vertical or oblique ± torsional diplopia

39
Q

List 7 signs of acquired unilateral CN4 palsy.

A

Head tilt away from the side of the palsy
HyperT or oblique deviation of one eye
Secondary overaction of ipsilateral inferior oblique
Underaction of ipsilateral superior oblique
Vertical fusional reserves <5PD
Double maddox rod - extorsion <10 degrees
Fundus - extorsion on the affected side

40
Q

List two symptoms of acquired bilateral CN4 palsy.

A

Torsional ± vertical or oblique diplopia

-opposite to unilateral acquired CN4 palsy

41
Q

List 8 signs of acquired bilateral CN4 palsy.

A 
Head tilt, often downwards
HyperT orno deviation
HyperT reverses with gaze
Overaction of both inferior obliques
Underaction of both superior obliques
Vertical fusional reserves <5PD
Double maddox rod - often extorsion >10 degrees
Fundus - extorsion on both sides
42
Q

List two symptoms of congenital unilateral CN4 palsy.

A

No torsion
-images are double but not lifted
Vertical or oblique DV
-often intermittent

43
Q

List 5 signs of acquired unilateral CN4 palsy.

A 
Head tilt away from palsy side
EM same as aqcuired
Vertical fusional reserves <5PD
Double maddox rod - no subjective torsion
Fundus - extorsion of affected side
44
Q

What may often occur with chronic head tilt due to congenital unilateral CN4 palsy?

A

Hemifacial hypoplasia

45
Q

List three differential diagnoses for congenital unilateral CN4 plasy.

A

Skew deviation
Partial CN3 palsy
Myasthenia gravis

46
Q

What is a must for non-traumatic bilateral CN4 palsy and to exclude what?

A

MRI brain scan to exclude pineal region tumour

47
Q

After how long can traumatic causes of CN4 palsies generally resolve?

A

6 months

48
Q

When may strabismus surgery be indicated for CN4 palsy`(2)?

A

Congenital or non-resolving CN4 palsies

49
Q

List 5 causes of CN6 palsies.

A 
Compression
Increased intracranial pressure
Trauma
Ischaemia
Inflammation
50
Q

What is a symptom of CN6 palsy? What about if its only mild (2)?

A

Horizontal double vision

-if mild, only present at distance or on side gaze to the side of the lesiond

51
Q

If you have a case of possible CN6 palsy, when should you suspect tumour causes (10)?

A

Gradual or intermittent onset of double vision
Progression of double vision over days/weeks
Pain
Numbness/parasthesia
New onset of facial weakness, deafness, tinnitus, or vertigo on the same side as the palsy
Decreased corneal/fcial sensation
Facial weakness, deafness, nystagmus
Limited EM in other gazes, ptosis, anisocoria
Bitemporal field defect
Abduction deficit of the other eye

52
Q

What is a sign of CN6 palsy?

A

Decreased abduction of one eye with slow abducting saccades

53
Q

List three differential diagnoses for CN6 palsy.

A 
Myasthenia gravis
Restrictive esotropia from a tight medial rectus
-TED
Congenital duanes retraction syndrome
-no double vision
54
Q

What should you do if there are multiple affected cranial nerves or unexplained double vision?

A

Urgent referral to a neuro-ophthalmologist

OD3 - Clinical Optometry Practice (114 decks)

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