Diplopia
The first step in the approach to diplopia in the ED is to determine if the diplopia is monocular or binocular - Andy Rogers MD
image by: Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center
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Don't Forget the Double Vision
Diplopia, or double vision, can be a tricky and complicated disorder. There are various forms of double vision and many etiologies, ranging from non-serious to life-threatening. I always felt a little confused and unsure of how to approach someone with Diplopia. So here goes my step-wise approach to optimize the care of a patient with non-traumatic diplopia.
Step 1: Is this Monocular or Binocular? This is the most important initial question, as it distinguishes whether the problem stems from the brain or the eye.
Monocular diplopia is almost always eye related and not life-threatening. Binocular diplopia is brain-related and should therefore raise some alarms. Monocular…
Resources
Approach to the Patient with Diplopia in the Emergency Department
Diplopia can be the result of benign causes, such as refractive error, or life-threatening etiologies, such as compressive aneurysms or tumors; therefore, it is important for the assessing physician to be proficient at assessing diplopia and recognize when the patient may require an urgent referral or neuroimaging.
Diplopia Evaluation and Management
Diplopia does not always require imaging; however certain associated findings warrant specific evaluation: 3rdcranial nerve involvement: CTA. Increased ICP: CT head. Associated neuro deficits/complex motility disorders: CT head, preferably MRI. Suspected infection: CT head/orbits with contrast. Suspected Cavernous Sinus Thrombosis: CTV, followed by MRV if CTV negative.
Key Points for Evaluating Diplopia
Does the diplopia resolve by covering one eye? (Differentiates binocular diplopia (disappears when one eye covered; most common) from monocular diplopia (persists with one eye covered; usually related to a focal, ocular problem).
CRACKCast E021 – Diplopia
... how to risk stratify diplopia and when to be most concerned for this uncommon chief complaint.
Seeing double: toil and trouble?
The first step in the approach to diplopia in the ED is to determine if the diplopia is monocular or binocular. Some patients may not know or not have checked prior to presentation. Ask the patient “does the double vision resolve when you close one eye?”
B Pod Case: Double Vision
Monocular diplopia is secondary to local eye disease, and workup can typically be deferred to outpatient ophthalmology follow- up. Binocular diplopia on the other hand occurs secondary to disconjugate alignment of the eyes, and has a broad differential diagnosis. Cranial nerve palsies are the most common cause of binocular diplopia, typically involving cranial nerves 3, 4 or 6.
How to Evaluate Diplopia and Spot Life-Threatening Etiologies
Diplopia, colloquially referred to as “double vision,” is a challenging chief complaint in the emergency department. The etiologies are vast.
SAEM Clinical Image Series: Double Vision
Pneumocephalus after epidural injections is a rare complication of a common procedure. Only a few cases are reported per year. Unintentional dura puncture causes air to be introduced into the subarachnoid/subdural space and migrates intracranially, and may cause a headache. It is possible that there is cranial nerve III compression as it exits the brainstem.
Don't Forget the Double Vision
Diplopia, or double vision, can be a tricky and complicated disorder. There are various forms of double vision and many etiologies, ranging from non-serious to life-threatening. I always felt a little confused and unsure of how to approach someone with Diplopia.
Maimonides Emergency Medicine
First, figure out is it monocular or binocular diplopia?
Resus
Monocular Diplopia- This does NOT resolve when one eye is closed or covered. The very fact that it does not resolve when one eye is closed indicates that it is NOT due to ocular misalignment ie ocular muscle issues. The cause is almost all cases due to a refractive error or dry eyes. Patients should be referred to ophthalmology.
BC Emergency Medicine Network
Monocular diplopia is almost never a neurologic problem and results from distortions to the light path in the affected eye. The most common causes include keratoconjunctivitis sicca (dry eyes), cataracts, corneal irregularity and rarely retinal irregularities.
StatPearls
Diplopia refers to seeing two images and is due either to ocular misalignment, in which case it disappears when either eye is occluded or to an optical problem, in which case it is termed monocular diplopia and does not disappear with monocular viewing. Patients with ocular misalignment can harbor serious pathology and should be evaluated in a systematic and thorough manner in order to uncover all potentially serious cases.
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