Differential Diagnosis for 80-year-old Male with Diplopia and V2 Pain

Single Most Likely Diagnosis

• Temporal Arteritis (Giant Cell Arteritis): This condition is a common cause of diplopia and facial pain in the elderly, particularly those over 70 years old. The V2 pain suggests involvement of the maxillary division of the trigeminal nerve, which can be affected in temporal arteritis.

Other Likely Diagnoses

• Trigeminal Neuralgia: This condition typically presents with sudden, severe, shock-like pain in one or more branches of the trigeminal nerve, which could include the V2 division. Diplopia could occur if the pain affects the nerves controlling eye movement.
• Diabetic Cranial Neuropathy: Diabetes can cause neuropathy affecting various cranial nerves, including those responsible for eye movement, leading to diplopia. Pain in the V2 distribution could be related to diabetic neuropathy affecting the trigeminal nerve.
• Microvascular Cranial Neuropathy: Similar to diabetic cranial neuropathy, microvascular ischemic disease can cause neuropathy of cranial nerves, leading to diplopia and facial pain.

Do Not Miss Diagnoses

• Aneurysm or Arteriovenous Malformation (AVM): Although less common, an aneurysm or AVM in the brain could cause diplopia by affecting cranial nerves controlling eye movement and could also cause facial pain if it compresses or affects the trigeminal nerve.
• Cavernous Sinus Thrombosis: This is a rare but potentially life-threatening condition that can cause diplopia due to involvement of cranial nerves III, IV, and/or VI, which pass through the cavernous sinus. Facial pain could be a symptom if the trigeminal nerve is affected.
• Stroke or Transient Ischemic Attack (TIA): A stroke or TIA could cause diplopia and facial pain if areas of the brain responsible for these functions are affected.

Rare Diagnoses

• Tolosa-Hunt Syndrome: A rare disorder characterized by headache, facial pain, and diplopia due to nonspecific inflammation of the cavernous sinus or superior orbital fissure.
• Multiple Cranial Neuropathies due to Malignancy: Metastatic disease or direct invasion by tumors can cause multiple cranial neuropathies, leading to symptoms like diplopia and facial pain.
• Sarcoidosis: A systemic granulomatous disease that can affect any part of the nervous system, including cranial nerves, leading to a variety of symptoms including diplopia and facial pain.