Neuro-ophthalmology Question of the Week: Emergency Department Evaluation of Diplopia

Question: Describe the appropriate steps to take in evaluating diplopia in the emergency department.


ED Concerns: aneurysm, giant cell arteritis, multiple sclerosis, myasthenia gravis, intraorbital or intracranial tumor, diabetic and other vasculopathic cranial nerve paresis

ED Evaluation:

1. Rule out monocular diplopia – not an emergency
A. Alternate Cover test – diplopia persists when one eye occluded = monocular diplopia
B. Pinhole test – have patient look at distant object through pinhole with eye with monocular diplopia and the other eye occluded.
        a. Diplopia disappears = refractive error, poorly fit contact lens, corneal abnormalities, lid abnormalities, iris abnormalities, lens abnormalities, retinal abnormalities
            –  Arrange ophthalmology clinic follow-up
         b. Diplopia persists = cerebral polyopia, psychogenic
            – Arrange neuro-ophthalmology clinic follow-up
2. Binocular diplopia present
A. Confirm by questioning patient that images are not distorted or of different sizes, i.e. diplopia not due to metamorphopsia, or aniseikonia. – Arrange ophthalmology clinic follow-up.
B. Determine if diplopia is comitant or incomitant by measuring tropia in different positions of gaze.
        a. Comitant misalignment
– Arrange strabismus clinic follow-up – not an emergency.
        b. Incomitant misalignment  –  possible cranial nerve paresis, supranuclear palsy,  oculomotor pathway lesion, restrictive disease, myasthenia gravis
            – Intermittent diplopia in patient over age 50 Stat ESR, CRP, Platelets to rule-out giant cell arteritis
            – Perform Ductions
                ➧ Normal Ductions rules-out restrictive process
                ➧ Abnormal Ductions
                     ⏩ Determine if defect is supranuclear or infranuclear
                       ⧫ Perform Doll’s Head Maneuver (oculocephalic reflex)
                            ➤ If the oculocephalic reflex is normal (overcomes abnormal duction) = supranuclear cause – Obtain emergent brain MRI with and without contrast.
                            ➤ If the oculocephalic reflex is abnormal = infranuclear cause
                                — Perform Forced Ductions
                                 — Positive Forced Ductions = restrictive disease – Thyroid ophthalmopathy, Inflammation, Trauma, Orbital Tumors – Arrange oculoplastics ED consultation.
                                — Negative Forced Ductions rule-out cranial nerve paresis.
                                 —Determine if pattern matches 3rd, 4th, 6th cranial nerve paresis or multiple cranial nerve paresis
                                 —Horizontal tropia – observe adduction and abduction to determine which EOMs are affected
                                 —Vertical tropia – perform Park’s 3 step test to determine which EOMs are affected.
– If pattern matches single or multiple cranial nerve paresis or Internuclear ophthalmoplegia obtain emergent orbit and brain MRI with and without contrast.
                                 — If pattern matches 3rd nerve paresis add emergent CT angio or MR angio.
– If MRI, CTA, or MRA is positive obtain ED  neurology/neurosurgery consultations.
– If neuroimaging negative – consider myasthenia gravis and vasculopathic cranial nerve palsy or paresis.
— Order Hemoglobin A1C and Myasthenia gravis adult antibody screening panel
— Arrange ED neurology consult

Diplopia Care Path
From: Clinical Pathways in Neuro-ophthalmology 2003

1. OphthoBook. Root T.
2. Clinical Decisions in Neuro-Ophthalmology, Burde RM, Savino PJ & Trobe JD. 3nd Edition. Mosby 2002
3. Clinical Pathways in Neuro-ophthalmology:An Evidence-Based Approach. Lee AC & Brazis PW. Thieme 2003


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