What is the diagnosis for an elderly patient with a recent history of influenza (flu) and coughing fits, presenting with symptoms of diplopia (double vision) and partial blindness?

Diagnosis: Orbital Trauma with Possible Orbital Fracture

This elderly patient presenting with diplopia and partial blindness following severe coughing fits during influenza most likely has sustained orbital trauma, potentially including an orbital blowout fracture with associated ocular complications.

Clinical Reasoning

The combination of recent influenza with severe coughing fits followed by acute diplopia and vision loss strongly suggests trauma-induced orbital injury. Violent coughing can generate sufficient force to cause orbital fractures, particularly in elderly patients with potentially weakened bone structure 1.

Key Diagnostic Considerations

Primary concern: Orbital fracture with potential complications

• Diplopia occurs in 58% to 68% of blowout fractures 1
• The etiology may be multifactorial, including direct damage to extraocular muscles, orbital hemorrhage, edema, soft tissue swelling, and fracture of orbital bones with or without muscle entrapment 1
• Cranial neuropathies and disruption of fusion can result in diplopia 1

Vision-threatening complications requiring immediate evaluation:

• Partial blindness suggests possible optic nerve involvement, retinal damage, or compressive optic neuropathy 1
• 5.5% of patients with facial fractures present with complete loss of vision in one eye, and 24% of blowout fractures present with severe eye injury 2

Immediate Diagnostic Workup

Essential initial examination components:

• Visual acuity testing to detect vision-threatening pathology 3, 2
• Pupillary examination to identify afferent defects or neurologic involvement 1, 3
• Intraocular pressure measurement 1, 2
• Confrontational visual field testing 1
• Exophthalmometry 1, 2
• Detailed sensorimotor examination with attention to versions, ductions, and alignment in multiple gaze positions 1
• Forced duction testing to distinguish restriction from paresis 1, 2
• Dilated fundus examination (if safe) with attention to any torsion, optic nerve swelling, or retinal pathology 1, 3

Critical warning signs requiring urgent intervention:

• Bradycardia, heart block, dizziness, nausea, vomiting, or loss of consciousness may indicate entrapped muscle causing oculocardiac reflex, which can be life-threatening and requires immediate medical and surgical treatment 1, 2

Imaging Protocol

CT orbit without contrast with fine cuts and multiplanar reconstructions is the study of choice 2:

• Sensitivity of 94.9% for intraorbital pathology 2
• CT rather than MRI is required if there is any concern about possible ferrous-metallic foreign body 1
• Provides sufficient information about presence of orbital fracture and entrapment 1

MRI considerations:

• Provides more precise imaging of extraocular muscles and surrounding tissues, including the pulley system 1
• Reduces radiation exposure 1
• Should be obtained if CT is inconclusive and metallic foreign body has been excluded 1

Alternative Diagnoses to Consider (Less Likely)

While orbital trauma is most probable, other considerations include:

Influenza-related optic neuritis (less likely given the coughing mechanism):

• Rare cases of visual loss associated with influenza A have been reported, presenting with optic nerve swelling and vitreous cells 4
• However, this typically presents with bilateral vitritis and elevated influenza titers, not acute diplopia 4

Increased intracranial pressure from severe coughing (must be excluded):

• Acute convergent squint can indicate increased intracranial pressure or posterior fossa lesions 3
• Brain MRI with contrast should be performed if additional CNS signs or symptoms are present 3

Management Priorities

All life-threatening and vision-threatening conditions must be treated before addressing strabismus 1, 2:

1. Immediate ophthalmology consultation for any patient with acute vision loss and diplopia following trauma 3, 2

2. Urgent surgical intervention if muscle entrapment with oculocardiac reflex is present 1, 2

3. Observation period: Diplopia may be transient following ocular trauma, but if it has not resolved within 6 months, it is unlikely to resolve spontaneously 1

4. Surgical timing: Strabismus surgery is typically delayed until the condition is stable for at least 6 months, though earlier intervention may be appropriate in select cases 1

Prognostic Factors

Poor visual prognosis indicators 2:

• Lesions not due to mechanical causes
• Ciliary body detachment
• Lacerations ≥ 5 mm
• Intraocular foreign bodies
• Vitreous hemorrhage
• Endophthalmitis

Common pitfall: Do not assume influenza alone is causing the visual symptoms—the temporal relationship with severe coughing fits points to mechanical trauma as the primary mechanism 1.