1. Double Vision Emergency Department Diagnosis and Management J. Stephen Huff, MD Departments of Emergency Medicine and Neurology University of Virginia Charlottesville

2. J. Stephen Huff, MD Objectives Questions –What is the differential diagnosis of diplopia? –What causes ptosis and why is it important? –What examination techniques are useful? –What are the indications for emergent imaging? Neuroimaging –Tests –Tempo Management - referral, consultation

3. J. Stephen Huff, MD The Case A 65-year-old man presented to the ED complaining of acute onset double vision. He denied headache, fever, weakness, dizziness, trauma, or change in mental status. Past medical history was positive for diabetes and hypertension. Medications included insulin and enalapril. He denied tobacco use or alcohol use.

4. J. Stephen Huff, MD The Case - continued On physical exam: BP 160/90, P 80, RR 16, HR 98, pulse oximetry 99%. Head atraumatic, no scalp tenderness; eyes visual acuity 20/30 (corrected); pupils 4 mm and reactive; OS ptosis; OS pupil in a down and out position. Diplopia was minimal when looking to the left and pronounced when looking to the right. Fundi sharp discs. Remainder of neurologic examination was normal.

5. J. Stephen Huff, MD Patient looking at target straight ahead

6. J. Stephen Huff, MD Neurologists Diagnostic Approach Is there a problem of the nervous system? Where is the problem? What is the problem? Many esoteric and uncommon problems...

7. J. Stephen Huff, MD Solomon and Aring remarked in a 1934 paper, A knowledge of the more common causes of coma [read diplopia] as a presenting sign, and the relative frequency of these causes, would obviously be helpful in making the diagnosis.…The textbooks are of little assistance. They mention many causes of coma [diplopia] and discuss at length some that are rare, while others that are more common they do not include at all. They do not attempt to give any idea of the relative frequency of the various causes.

8. J. Stephen Huff, MD Evidence-based approach Diplopia in the Emergency Department ISOLATED chief complaint –Not part of more complex symptomatology Medline / Ovid Other data bases….

9. J. Stephen Huff, MD Evidence-based approach Little data….many opinions…. One hit! Morris RD: Double vision as a presenting symptom in an Ophthalmic Casualty Department. Eye 1991;5:124

10. J. Stephen Huff, MD From the Casualty Department of Moorfields Eye Hospital 275 consecutive patients over 9 months –Ambulatory patients –Referrals by general practitioners, opticians –Excluded referrals for second opinion by ophthalmologists 1.4% of all patients to this specialized ED

11. J. Stephen Huff, MD 275 consecutive patients 25% - monocular diplopia 75% - binocular diplopia

12. J. Stephen Huff, MD Monocular diplopia Extra-ocular –problems with optical lens or contacts Ocular (most common) –Lids - chalazion –Cornea - infections, trauma, keratoconus (25%) –Iris - pharmacologic mydriasis –Lens - opacities, cataracts, IOP (39%) –Retinal - detachment, CRVO, neovascularization Trauma No cause established -psychogenic? (12%)

13. J. Stephen Huff, MD Binocular diplopia - 206 patients Cranial nerve palsies- infranuclear-(39%) Muscular (14%) –Thyroid –Myasthenia Orbital sinusitis, cellulitis, tumor (4%) Trauma - blowout fracture, blunt trauma, post-surgical (13%) Supranuclear lesions (7%) No cause established (11%)

14. J. Stephen Huff, MD Cranial nerve palsies- infranuclear (39%) Cranial Nerve III –Diabetes / Vascular –Pituitary tumor Cranial Nerve IV –Congenital –Diabetes / Vascular –Trauma Cranial Nerve VI –Diabetes / Vascular –MS –CNS tumor –Pseudotumor

15. J. Stephen Huff, MD Supranuclear lesions (7%) Internuclear ophthalmoplegia (MS) Brainstem ischemia Migraine Wernickes encephalopathy

16. J. Stephen Huff, MD Ophthalmologic Casualty Department Summary Wide range of ocular and neurologic disorders Dont miss diagnoses uncommon –CNS tumor –Aneurysm

17. J. Stephen Huff, MD Questions Approach to the patient Are there associated signs and symptoms? Is the diplopia monocular or binocular? Is there any exophthalmos or proptosis? Is there any associated ptosis? Was the onset acute or gradual? Is there any variability or remission? Was there any pain?

18. J. Stephen Huff, MD Are there associated signs and symptoms? Severe headache? Weakness? Fatigue? Paralysis? Clumsiness / unsteady gait? Multiple cranial nerve palsies? –If so, there are other problems...

19. J. Stephen Huff, MD Is the diplopia monocular or binocular? Monocular - likely refractive or ocular problem Binocular - likely an isolated cranial nerve problem

20. J. Stephen Huff, MD Is there any exophthalmos or proptosis? Infiltrative lesions Myopathy –Thyroid Sinusitis Orbital abscess Orbital cellulitis

21. J. Stephen Huff, MD Is there any associated ptosis? Bilateral- may suggest myasthenia Unilateral-suggests cranial nerve III problem –Horners?

22. J. Stephen Huff, MD Was the onset acute or gradual? Acute –Vascular –Stroke –Ocular? Gradual –Infiltrative lesions –Myopathies

23. J. Stephen Huff, MD Is there any variability or remission? Variability –Multiple sclerosis –Myasthenia

24. J. Stephen Huff, MD Was there any pain? Folklore... Aneurysms may be painful –infections Vascular lesions may be painless –MS –Myopathy

25. J. Stephen Huff, MD Questions - Our Patient Are there associated signs and symptoms? No Is the diplopia monocular or binocular? Binocular Is there any exophthalmos or proptosis? No Is there any associated ptosis? Yes Was the onset acute or gradual? Acute Is there any variability or remission? No Was there any pain? No

26. J. Stephen Huff, MD Summary Our Patient Painless isolated binocular diplopia of acute onset with ptosis but without proptosis or exophthalmos in a patient with diabetes and hypertension...

27. J. Stephen Huff, MD Physical examination Monocular or binocular? –Cover eye... –Glasses / contacts off... –Pinhole-may correct monocular diplopia –Cataract or disc problem? Proptosis or exophthalmos? –Look –Feel

28. J. Stephen Huff, MD Physical examination Associated neurologic abnormalities? Define cranial nerve problem –Observe –Tracking / yoke movements –Pupillary reaction

29. J. Stephen Huff, MD Physical examination-review H - tracking movements eyes Cranial nerve III –Actions- moves globe up, down, in –Pupillary constriction –If weak, may have unopposed abduction (down and out) Cranial nerve IV –Superior oblique (SO4) –Actions- Intorsion, depression Cranial nerve VI –Lateral rectus –Actions - Abduction –If weak, may have unopposed adduction

30. J. Stephen Huff, MD Laws of diplopia - DeMyer Describe the images; identify the position of maximum diplopia... Identify the eye that produces the false image; the false image is projected peripheral to the true image and is often less sharp... When the patient looks in the direction of action of the paretic muscle, the distances between images increases...

31. J. Stephen Huff, MD Laws of diplopia - DeMyer Allows reasoning of which muscle is weak and identification of cranial nerve abnormality...

32. J. Stephen Huff, MD Patient looking at target straight ahead

33. J. Stephen Huff, MD Our patient Cranial nerve III problem Patients left eye deviated laterally from unopposed action of lateral rectus (IV) In our patient (not this picture!) pupil reactivity is spared...

35. J. Stephen Huff, MD Cranial nerve III caveats Aneurysmal compression common –Generally, painful –Generally, pupillary reactions affected Diabetic III neuropathy (vasculopathic) –Generally, pupil reactivity spared –Generally, painless

36. J. Stephen Huff, MD Diabetic III palsy Pupillary sparing almost always present Pupillomotor fibers travel on outside III –Selectively vulnerable to compression –Resistant to ischemia which often affects central portion of III

37. J. Stephen Huff, MD The Case A 65-year-old man presented to the ED complaining of acute onset double vision. He denied headache, fever, weakness, dizziness, trauma, or change in mental status. Past medical history was positive for diabetes and hypertension. Medications included insulin and enalapril. He denied tobacco use or alcohol use.

38. J. Stephen Huff, MD The Case - continued On physical exam: BP 160/90, P 80, RR 16, & 98, pulse oximetry 99%. Head atraumatic, no scalp tenderness; eyes visual acuity 20/30 (corrected); pupils 4 mm and reactive; OS ptosis; OS pupil in a down and out position. Diplopia was minimal when looking to the left and pronounced when looking to the right. Fundi sharp discs. Remainder of neurologic examination was normal.

39. J. Stephen Huff, MD Physical examination Associated neurologic abnormalities? No Define cranial nerve problem –Cranial nerve III, isolated, with pupillary sparing This is likely a patient with a diabetic third palsy; consultation and outpatient followup is an option….

40. J. Stephen Huff, MD Objectives-revisited Questions –What is the differential diagnosis of diplopia? –What causes ptosis and why is it important? –What examination techniques are useful? –What are the indications for emergent imaging? Neuroimaging –Tests –Tempo Management - referral, consultation

41. J. Stephen Huff, MD Neuroimaging-general remarks Our patient –Painless isolated III palsy with pupillary sparing –Consensus--may forego imaging with followup –If pupillary reactivity impaired (or becomes impaired), consider emergent neuroimaging, consultation Isolated VI palsy suggests increased ICP Multiple cranial nerve palsies or other abnormalities on examination - image and consult

42. J. Stephen Huff, MD Take a closer look at this patient-- Pupils are asymmetric!