What is the proper workup for a patient presenting with diplopia (double vision) in the Emergency Room (ER)?

From the Guidelines

The proper workup for a patient presenting with diplopia in the Emergency Room should begin with a focused history and comprehensive neurological examination, as outlined in the most recent guidelines 1.

Key Components of the Workup

• Determine if the diplopia is monocular (persists when one eye is covered) or binocular (resolves when either eye is covered) to guide further evaluation.
• Assess extraocular movements, pupillary responses, and perform a cranial nerve examination focusing on nerves III, IV, and VI.
• Measure vital signs, including blood pressure, and perform a thorough head and neck examination.
• Consider laboratory tests such as complete blood count, metabolic panel, and inflammatory markers like ESR and CRP if indicated.
• Neuroimaging, with CT as the initial choice in the emergency setting, is often necessary to rule out stroke, hemorrhage, or mass lesions, while MRI provides better visualization of brainstem, orbit, and cranial nerves 1.

Special Considerations

• For patients with concerning features such as acute onset, associated neurological deficits, or signs of increased intracranial pressure, urgent neurology consultation is warranted.
• Additional testing may include lumbar puncture if inflammatory or infectious causes are suspected, particularly in the presence of fever or meningeal signs.
• A detailed sensorimotor exam should be performed, with attention to versions, ductions, saccades, pursuit, vergence, and near reflex, along with alignment in multiple gaze positions with attention to primary and secondary deviations 1.

Guiding Principles

• The workup should be guided by the distinction between monocular and binocular diplopia, as well as the presence of associated neurological symptoms or signs.
• The goal of the workup is to identify potentially life-threatening causes of diplopia requiring immediate intervention, such as stroke, aneurysm, or increased intracranial pressure, while also establishing a foundation for diagnosis of less urgent conditions.
• The most recent and highest quality study, such as the 2023 guidelines on esotropia and exotropia preferred practice pattern 1, should be prioritized in guiding the workup.

From the Research

Proper Workup for Diplopia in the ER

The proper workup for a patient presenting with diplopia in the Emergency Room (ER) involves a comprehensive approach to determine the underlying cause of the condition.

• A logical, localization-driven, and evidence-based approach is the most effective way to arrive at the correct diagnosis and provide the best outcome for the patient 2.
• The first step in the workup is to take a comprehensive history to delineate the exact type of visual disturbance experienced by the patient, including the type of diplopia (monocular or binocular), onset, and progression, as well as any associated or relieving factors 3, 4.
• Examination techniques, such as testing ocular motility, including smooth pursuit and saccadic function, and uncovering misalignments of the eyes using cover and Maddox rod testing, are primary components of the efferent neurologic examination 5.
• Further testing, such as lid testing and fatigable upgaze, may be necessary to detect myasthenia, and measuring proptosis and testing for resistance to retropulsion may be necessary to detect orbital disease 5.

Diagnostic Imaging

• Unenhanced plain computed tomography (CT) of the head or orbits is largely not useful in the work-up of diplopia 6.
• Magnetic resonance imaging is preferred for ocular motor nerve palsies 6.
• Contrast-enhanced CT imaging of the brain and orbits may be indicated in suspected orbital apex syndrome or a retro-orbital mass, thyroid eye disease, or ocular trauma 6.
• CT and CT venogram should be considered in cases of suspected cavernous sinus thrombosis 6.

Special Considerations

• All patients presenting with an acute isolated third nerve palsy should be imaged with CT and CT angiography of the brain to rule out a compressive aneurysm 6.
• In any patient over the age of 60 years presenting with recent (1 month) history of diplopia, inflammatory markers should be obtained to rule out giant cell arteritis 6.
• Patients with isolated fourth and sixth nerve palsies with the absence of other neurological signs on examination should be referred to Neurology or Ophthalmology for further work-up 6.