Differential Diagnosis for Flame Hemorrhages on Fundoscopy with Uncontrolled Diabetes, Eye Pain, Diplopia, and Eye Deviation

• Single Most Likely Diagnosis
  • Diabetic Papillopathy or Diabetic Retinopathy with Cranial Nerve Palsy: This condition is highly likely given the patient's uncontrolled diabetes, which can lead to various ocular complications including diabetic retinopathy and neuropathies affecting cranial nerves. The presence of flame hemorrhages is indicative of diabetic retinopathy, and the eye pain, diplopia, and deviation could be due to a cranial nerve palsy, possibly sixth nerve palsy given the "down and out" position of the eye.
• Other Likely Diagnoses
  • Central Retinal Vein Occlusion (CRVO): This condition can cause flame hemorrhages and is more common in patients with diabetes. It could also lead to eye pain, although diplopia and specific eye deviation might not be as directly related unless there's associated ischemia affecting cranial nerves.
  • Diabetic Neuropathy with Ocular Involvement: Diabetes can cause neuropathy affecting the nerves controlling eye movements, leading to diplopia and abnormal eye positioning. The flame hemorrhages would still point towards diabetic retinopathy, but the neuropathy could explain the motility issues.
• Do Not Miss Diagnoses
  • Giant Cell Arteritis: Although less common, this condition can cause sudden vision loss, eye pain, and diplopia, especially in older adults. It's crucial to consider this diagnosis due to its potential for severe and irreversible vision loss if not promptly treated.
  • Orbital Cellulitis or Abscess: Infection in the orbit can cause severe eye pain, proptosis, diplopia, and limitation of eye movements. The presence of fever, swelling, and significant pain would suggest this diagnosis, which is a medical emergency.
• Rare Diagnoses
  • Ocular Malignant Hypertension: This rare condition can cause severe hypertension leading to ocular symptoms including retinal hemorrhages, but it's less directly linked to the specific combination of symptoms and signs presented, especially the "down and out" eye position.
  • Sarcoidosis: This systemic disease can affect the eyes in various ways, including uveitis, retinal vasculitis, and cranial nerve palsies, potentially explaining some of the patient's symptoms. However, it's less common and would typically be considered after more common causes are ruled out.