UMEM Educational Pearls

Category: Neurology

Title: Seeing Double?

Keywords: diplopia, imaging, radiology, CT, ophthalmology (PubMed Search)

Posted: 11/28/2018 by Danya Khoujah, MBBS (Updated: 12/10/2018)
Click here to contact Danya Khoujah, MBBS

Diplopia can be a challenging complaint to address in the ED. Although not all patients will require imaging, use the simplified table below to help guide the imaging study needed:

 

Clinical Situation

Suspected Diagnosis

Imaging Study

Diplopia + cerebellar signs and symptoms

Brainstem pathology

MRI brain

6th CN palsy + papilledema

Increased intracranial pressure (e.g. idiopathic intracranial hypertension or cerebral venous thrombosis)

CT/CTV brain

3rd CN palsy (especially involving the pupil)

Compressive lesion (aneurysm of posterior communicating or internal carotid artery)

CT/CTA brain

Diplopia + thyroid disease + decreased visual acuity

Optic nerve compression

CT orbits

Intranuclear ophthalmoplegia

Multiple sclerosis

MRI brain

Diplopia + facial or head trauma

Fracture causing CN disruption

CT head (dry)

Diplopia + multiple CN involvement (3,4,6) + numbness over V1 and V2 of trigeminal nerve (CN5) +/- proptosis

Unilateral, decreased visual acuity

Orbital apex pathology

CT orbits with contrast

Uni- or bi-lateral, normal visual acuity

Cavernous sinus thrombosis

CT/CTV brain

C.N.: cranial nerve

 

References

Margolin E, Lam C. Approach to a Patient with Diplopia in the Emergency Department. J Emerg Med. 2018 Jun;54(6):799-806