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Question: Monocular Or Binocular? Standard Office Visit

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Question: Monocular Or Binocular? Standard Office Visit Deciphering DIPLOPIA The symptom is diplopia. But what’s the diagnosis? When your patient sees two images, you may need to consider 20 possible causes, and ruling out 19 of those can be a headache. he various etiologies of diplopia because they’re not trained in techniques to measure ocular comprise one of the most sweeping alignment.” But the consequences of a delayed or incorrect differential diagnoses in all of oph- diagnosis are not comfortable, either. “Most double vision thalmology. The patient who com- is not dangerous. But some is super dangerous,” said An- plains of double vision can have drew G. Lee, MD. “You have to do a complete and thorough Tsomething as benign as dry eye or as life- exam to look for the distinctive dangerous sign. That sign threatening as an intracranial tumor. The could suggest a life-threatening diagnosis. It’s a red flag,” he cause may be as rare as Wernicke encephal- said. Dr. Lee is professor of ophthalmology, neurology and opathy or as common as convergence insuf- neurosurgery at Weill Cornell Medical College in New York ficiency. “It’s a huge differential diagnosis,” as well as chairman of ophthalmology at The Methodist said Nurhan Torun, MD, director of the Hospital in Houston, adjunct professor of ophthalmology at neuro-ophthalmology service at Beth Israel the University of Iowa in Iowa City and clinical professor of Deaconess Medical Center and an instruc- ophthalmology at the University of Texas in Galveston. tor of ophthalmology at Harvard Medical School in Boston. The exam of a diplopic patient demands a meticulous “Diplopia tends to be intimidating for many practitioners.” history and the posing of questions pertinent to the dispo- Intimidation may even turn to dread. “When most oph- sition of double images in various positions of gaze: Is the thalmologists see a patient with a chief complaint of diplo- diplopia monocular or binocular? Are the images horizon- pia, they hate it,” said Michael S. Lee, MD, associate profes- tal or vertical? Answers to these may determine whether sor of ophthalmology, neurology and neurosurgery at the the pathology is neurological or mechanical—involving a University of Minnesota in Minneapolis. “They often don’t nerve, an extraocular muscle or a neuromuscular junction. know what to do with the patient.” What they do know, of course, is that the proper workup will take longer than a Question: Monocular or Binocular? standard office visit. The first step in cornering diplopia is to determine whether A multidisciplinary monster. Eric Eggenberger, DO, pro- it is monocular or binocular, said Karl C. Golnik, MD, pro- fessor of neurology at Michigan State University in East fessor of ophthalmology, neurology and neurosurgery at the Lansing, noted that diplopia challenges neurologists as University of Cincinnati. well. “Ophthalmologists are not as comfortable with it as • If it’s monocular, the patient sees double with only one they are with vision loss because many of the diagnoses are eye open, and the extra image typically appears as a ghost, neurologic. And neurologists are not comfortable with it Dr. Golnik said. Causes of this include media or refractive alfred kamajian. t. BY MIRIAM KARMEL, CONTRIBUTING WRITER eyenet 31 problems, dry eye, warped cornea, cataract, unstable tear literally hundreds of potential diagnoses,” Dr. Eggenberger film, IOL decentrations, media opacities, the wrong glasses said, and many of them are life-threatening. and even uveitis. “Begin by localizing,” he said. “Once you’ve determined • With binocular diplopia, however, the patient sees double location you need to incorporate the patient’s age, demo- only if both eyes are open. Cover either eye and the patient’s graphics, history and other findings on exam to help with problem disappears—though the physician’s trouble may understanding the pathophysiology. This keeps you from have just begun. jumping to conclusions.” Surprisingly, many doctors assume the diplopia is binoc- Dr. Torun added that an assessment of ocular motility ular, without considering monocular, though the differen- will help narrow things down. “That requires a very careful tial diagnosis is different for each, Dr. Golnik said. In fact, exam of the misalignment in different positions of gaze and he explains to referring colleagues that he does not need to looking for restriction of motility in any position of gaze,” see patients with monocular double vision because they typ- she said. “Unless we make a correct diagnosis of the under- ically don’t require a neurological evaluation. “Once you’ve lying eye movement problem, our differential is not going to determined it’s monocular, your level of anxiety goes down be appropriate.” and your diagnostic techniques switch.” Dr. Golnik agreed. After the physician establishes binoc- Dr. Michael Lee agreed. “It’s really reassuring if someone ular diplopia, the next step is to figure out whether there’s has monocular double vision,” he said, explaining that the a pattern to the misalignment. For example, he said, if it’s cause must be within the eye itself. comitant—the double vision is the same no matter where the patient turns his head—the problem is less worrisome. Binocular Dangers On the other hand, if it’s incomitant—the double vision Binocular diplopia can be a cause for alarm. It may be a goes away when the patient turns his head to the left but symptom of aneurysm, stroke, neoplasm, myasthenia gravis remains bad when turned right—then it’s time to worry. or trauma. Even certain infections, such as sinus disease There are exceptions and nuances, but, said Dr. Golnik, with a fungal infection, can present with double vision, “You can guide diagnostic evaluation better if you can find especially in an immune-compromised patient. “There are the pattern.” Dangerous Sign: Problem with more than one of the Five to Fear following: lid, pupil or eye movement. “There are clearly some life-threatening causes of double 2 Dangerous Diagnosis: Horner syndrome (ptosis with vision. Those are the ones an ophthalmologist can’t afford small pupil), third-nerve palsy (ptosis with big pupil) or to miss,” Dr. Andrew Lee said. Following are five especially inflamma tory disease, such as Guillain-Barré or Miller worrying possibilities. Fisher variant. Dangerous Prognosis: If any one of the lid, pupil or motility Dangerous Sign: Pupil involvement suggesting third- appears abnormal, you have to check the other two, said Dr. nerve palsy. Andrew Lee. “You’re not allowed to have more than one of 1 Dangerous Diagnosis: Aneurysm. these neuro-ophthalmic problems at a time.” More than one Dangerous Prognosis: “The one that’s going to kill you is the abnormality requires a referral or a more aggressive evalu- third-nerve palsy,” said Dr. Michael Lee, explaining it’s the ation for the life-threatening etiologies, he said. The big- most common presentation of an aneurysm of the posterior gest dangers are aneurysmal third-nerve palsy and Horner communicating artery. Dr. Golnik added that a third-nerve syndrome from carotid dissection. Even mild third-nerve palsy with a large and poorly reactive pupil is a big red flag, palsy could be due to aneurysm, which can kill the patient. and he doesn’t let the technician dilate the patient until he Guillain-Barré also can cause death, or systemic paralysis. does the exam. Sometimes, however, the red flag turns out to be a false alarm. While third-nerve palsy is a warning Dangerous Sign: More than one cranial nerve palsy. sign for aneurysm, it could also be associated with high Dangerous Diagnosis: Multiple cranial neuropathy. blood pressure or diabetes. For example, Dr. Eggenberger 3 Dangerous Prognosis: Intracranial or meningeal- said, an 85-year-old with high blood pressure, diabetes and based tumors, meningitis or polyneuropathy. Involvement normal pupils is probably not harboring a compressive le- of more than one nerve is a huge red flag, Dr. Andrew Lee sion, but in a 25-year-old with pain and pupil involvement, said. Sixth-nerve involvement by itself in a diabetic patient the safer assumption would be that it’s compressive. As probably indicates an ischemic mononeuropathy. Likewise, for those in-between cases, he said, “There’s no cookbook an isolated, complete and pupil-spared third nerve may in- answer. It takes some time. It’s not a quick evaluation. And dicate a benign and isolated ischemic palsy. But involvement it’s very individualized. The challenge is in knowing which of both the third and the sixth is dangerous and could be a patient is going to get better in three months and which har- cavernous sinus lesion. bors a life-threatening diagnosis.” Dr. Golnik remembers one patient referred to him with 32 november/december 2009 TROUBLE. A 62-year-old woman with right-side ptosis, nonreactive, dilated pupil and severely limited extraocular movement was found to have a poste- rior communicating artery aneurysm. a diagnosis of unilateral sixth-nerve palsy who actually had diagnosis. “But I also saw she had quite variable eye move- metastatic lung cancer in the skull base. Dr. Golnik’s exam ments. She had difficulty holding her eyes in an eccentric found involvement with the fifth and seventh nerves, some- position, with the eyes drifting toward the center, which is thing the referring physician might have found by checking a feature of myasthenia.” The workup for myasthenia was facial sensation and facial muscle strength. positive, and the patient was later admitted to the hospital in myasthenic crisis. The case illustrated the importance, Dangerous Sign: Weakness or fatigue, often variable. Dr. Torun said, of early diagnosis of an ocular motility Dangerous Diagnosis: Myasthenia gravis. problem, which may be the initial presentation of a serious 4 Dangerous Prognosis: Respiratory failure or aspira- systemic disorder.
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