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Probability diagnosis

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Binocular:

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  • Ocular nerve palsy (3,4,6) various causes

  • CVA/TIA

  • Ophthalmoplegic migraine

  • Physiological (disparateness)

  • Drug effect e.g. alcohol, benzodiapines

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Monocular:

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  • Eye disorder e.g. cataract, refractive error, cornea

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Serious disorders not to be missed

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Vascular:

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  • CVA/TIA

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Infection:

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  • Intraocular abscess

  • Sinusitis

  • Botulism

  • HIV/AIDS

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Tumour/cancer:

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  • Involving 3, 4 or 6 cranial nerves

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Other:

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  • Facial bone trauma/head injury

  • Guillain-Barré syndrome

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Pitfalls (often missed)

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Any orbital infiltration

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Rarities:

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  • Multiple sclerosis

  • Myasthenia gravis

  • Orbital myositis

  • Cavernous sinus thrombosis

  • Wernicke’s encephalopathy

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Masquerades checklist

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Diabetes: mononeuritis

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Drugs e.g. sedatives, opioids, alcohol

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Thyroid/other endocrine: hyperthyroid

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Is the patient trying to tell me something?

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A consideration if nil findings. Some cases are idiopathic.

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Key history

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A careful history is required to determine nature of diplopia: if one or both eyes, intermittent, constant or associated pain. Check for other neurological symptoms incl. other cranial nerve dysfunction, and other associated general symptoms such as weight loss and fever. Check past medical history incl. diabetes, hypertension and cerebrovascular disease, as well as drug history, esp. alcohol or illicit, prescription and OTC drugs.

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Key examination

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  • General features: appearance of patient, vital signs

  • Inspection of the eyes and neck (goitre)

  • Ocular motility

  • Visual acuity

  • Establish if binocular or monocular

  • Perform the cover test

  • Cranial nerves in general

  • Other basic neurological examination

  • Ophthalmoscopy

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Key investigations

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Nil for most cases

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First line:

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  • urinalysis

  • blood sugar

  • FBE

  • ESR/CRP

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Consider:

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  • TFTs

  • imaging if indicated (refer)

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Diagnostic tips

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Refer urgently if diplopia is binocular, of recent onset and persistent. Other ‘red flags’ incl. any pupil involvement, pain, proptosis, any other neurological symptoms or signs.

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