What are the relevant aspects of the clinical history in the evaluation of diplopia?

Updated: May 21, 2019
  • Author: Jitander Dudee, MD, MA(Cantab), FACS, FRCOphth; Chief Editor: Andrew G Lee, MD  more...
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Answer

The traditional and detailed evaluation of the chief complaint includes onset (abrupt or slow), severity, duration, location, associated symptoms, and aggravating and relieving factors. A comprehensive and complete review of all these aspects, if necessary with a questionnaire, is more important than the appropriate physical examination or special tests.

Other significant aspects include a review of systems (eg, history of diabetes, vascular disease, or hypertension; headache and other neurologic complaints; muscle fatigue or weakness; medications and drugs being used [6] ), as well as a past medical and surgical history.

Inquire about recent trauma to the face and the head. Blunt injury to the cheek can result in a blow-out fracture of the orbit with hematoma or entrapment of the soft tissues and extraocular muscles, restricting upward and downward eye movement. Entrapment of the inferior rectus muscle can be confirmed by a forced duction test. Blunt head injury may also be associated with nonspecific sixth cranial nerve (abducens) weakness and severe diplopia when gazing to the affected side.

Evaluate old photographs, if available, to determine if a head posture (if present) is long-standing. Commonly, a congenitally weak superior oblique muscle can be compensated for by head tilt, but osteoarthritis of the neck or other mechanism can result in decompensation and sudden symptoms of a chronic subclinical condition.


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