Seeing Double: Finding the Cause of Diplopia

Brianne N. Hobbs, OD


January 31, 2014

In This Article


In previous studies, 1%-15% of patients were determined to have non-microvascular related palsies, a number that is substantially lower than the findings of this study. This case series included only patients who were referred to neuro-ophthalmology, so it is possible that these patients were more likely to have neurologic disease than the routine patients typically managed by optometrists. It has been suggested that the presence or absence of pain can predict whether a palsy is microvascular or non-microvascular in etiology, but pain was not a predictive factor in this trial.

What are the clinical implications of this trial? Neuroimaging can save lives by detecting life-threatening, yet treatable conditions. The incidence of giant cell arteritis-related mononeuropathy was higher than reported in previous trials, so clinicians should keep giant cell arteritis high on the list of differentials in older patients with mononeuropathies. Cranial nerve VI palsies in elderly patients may not be as innocuous as once believed; abducens palsies had the highest incidence of serious causes in this study.

Ordering neuroimaging for every patient with a cranial nerve palsy is probably defensible, but a thorough investigation of the patient's symptoms and medical history is a useful tool to increase yield and reduce medical costs by discerning which patients are most likely to benefit from neuroimaging.



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