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Diplopia Diagnostics: Exploring Underlying Causes and Clinical Features in Neurological Practice

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Abstract

Diplopia is a common complaint with two subtypes: monocular and binocular in the emergency department (ED) and outpatient clinic. Monocular diplopia is typically associated with ocular abnormalities and refractive errors, whereas binocular diplopia may indicate the presence of an underlying life-threatening cause. To emphasize the importance of identifying underlying neurologic disease in individuals experiencing diplopia. Over a 3-year period, patients admitted to the ED and neurology outpatient clinic with diplopia were retrospectively analyzed. ‘Secondary diplopia’ was defined when an organic cause was found. ‘Isolated diplopia’ was identified as the absence of additional signs and symptoms other than diplopia. All patients were examined for risk factors and investigated for an etiology. Out of the 222 (male: 138) patients, 213 (96%) had binocular diplopia. Secondary diplopia was observed in 113 (53%) patients and 82 (38.4%) had isolated diplopia. One hundred twenty-five (58.6%) patients had at least one sign or symptom associated with diplopia. The incidence of diabetes was significantly higher in secondary diplopia. Ninety-three (43.6%) patients had ocular cranial nerve palsy, most commonly in the 6th cranial nerve. Diplopia with at least one associated sign or symptom and ocular cranial nerve involvement was statistically significant for secondary diplopia. In cases of acute diplopia the presence of at least one additional associated sign or symptom was significantly higher. It is very important to investigate an underlying neurologic etiology that may be life-threatening because secondary diplopia was detected in half of the patients with diplopia in the present study.

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References

  1. Nazerian P, Vanni S, Tarocchi C, et al. Causes of diplopia in the emergency department. Eur J Emerg Med. 2014;21:118–24. https://doi.org/10.1097/MEJ.0b013e3283636120.

    Article  PubMed  Google Scholar 

  2. De Lott LB, Kerber KA, Lee PP, et al. Diplopia-related ambulatory and emergency department visits in the United States, 2003–2012. JAMA Ophthalmol. 2017;135:1339. https://doi.org/10.1001/jamaophthalmol.2017.4508.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Friedman D. Pearls: Diplopia. Semin Neurol. 2010;30:054–65. https://doi.org/10.1055/s-0029-1244995.

    Article  Google Scholar 

  4. Peragallo J, Newman N. Diplopia An Update. Semin Neurol. 2016;36:357–61. https://doi.org/10.1055/s-0036-1585428.

    Article  PubMed  Google Scholar 

  5. O’Colmain U, Gilmour C, MacEwen CJ. Acute-onset diplopia. Acta Ophthalmol. 2014;92:382–6. https://doi.org/10.1111/aos.12062.

    Article  PubMed  Google Scholar 

  6. Low L, Shah W, MacEwen CJ. Double vision. BMJ. 2015;351: h5385. https://doi.org/10.1136/bmj.h5385.

    Article  CAS  PubMed  Google Scholar 

  7. Margolin E, Lam CTY. Approach to a Patient with Diplopia in the Emergency Department. J Emerg Med. 2018;54:799–806. https://doi.org/10.1016/j.jemermed.2017.12.045.

    Article  PubMed  Google Scholar 

  8. Glaser JS. Neuro-ophthalmology. 2nd ed. Philadelphia: Lippincott; 1990.

    Google Scholar 

  9. Morris RJ. Double vision as a presenting symptom in an ophthalmic casualty department. Eye. 1991;5:124–9. https://doi.org/10.1038/eye.1991.23.

    Article  PubMed  Google Scholar 

  10. Comer RM, Dawson E, Plant G, et al. Causes and outcomes for patients presenting with diplopia to an eye casualty department. Eye. 2007;21:413–8. https://doi.org/10.1038/sj.eye.6702415.

    Article  CAS  PubMed  Google Scholar 

  11. Brown S, Atkins I, Doyle M, et al. Symptom producing diplopia. Am Orthopt J. 1983;33:105–10. https://doi.org/10.1080/0065955X.1983.11981607.

    Article  Google Scholar 

  12. Çelik A, Özdoğan S. Evaluation of diplopia as a vital and remarkable ocular finding among cancer patients. Irish J Med Sci. 2023;192:1621–7. https://doi.org/10.1007/s11845-022-03177-6.

    Article  PubMed  Google Scholar 

  13. Ozaras N, Goksugur N, Eroglu S, et al. Carbamazepine-induced hypogammaglobulinemia. Seizure. 2012;21:229–31. https://doi.org/10.1016/j.seizure.2011.12.013.

    Article  PubMed  Google Scholar 

  14. CelikBuyuktepe T, BingölKiziltunç P, Atilla H. Diplopia after migraine surgery. Ophthalmic Plast Reconstr Surg. 2021;37:e188–90. https://doi.org/10.1097/IOP.0000000000002000.

    Article  Google Scholar 

  15. Jain S. Diplopia: Diagnosis and management. Clin Med. 2022;22:104–6. https://doi.org/10.7861/clinmed.2022-0045.

    Article  Google Scholar 

  16. Rucker JC, Tomsak RL. Binocular Diplopia. Neurologist. 2005;11:98–110. https://doi.org/10.1097/01.nrl.0000156318.80903.b1.

    Article  PubMed  Google Scholar 

  17. Nolan J. Diplopia. Br J Ophthalmol. 1968;52:166–71. https://doi.org/10.1136/bjo.52.2.166.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Jacobson DM. Risk factors for ıschemic ocular motor nerve palsies. Arch Ophthalmol. 1994;112:961. https://doi.org/10.1001/archopht.1994.01090190109029.

    Article  ADS  CAS  PubMed  Google Scholar 

  19. Asbury AK, Aldredge H, Hershberg R, Fisher CM. Oculomotor palsy in diabetes mellitus: A clinico-pathological study. Brain. 1970;93:555–66. https://doi.org/10.1093/brain/93.3.555.

    Article  CAS  PubMed  Google Scholar 

  20. Trimble RB, Kelly V. Diplopia as a presenting symptom: a prospective study. Berne: Proc IV Int Orthopt Congr; 1979. pp. 91–4.

  21. Park K-A, Oh SY, Min J-H, et al. Cause of acquired onset of diplopia due to isolated third, fourth, and sixth cranial nerve palsies in patients aged 20 to 50 years in Korea: A high-resolution magnetic resonance imaging study. J Neurol Sci. 2019;407: 116546. https://doi.org/10.1016/j.jns.2019.116546.

    Article  PubMed  Google Scholar 

  22. Tamhankar MA, Ying G, Volpe NJ. Success of prisms in the management of diplopia due to fourth nerve palsy. J Neuroophthalmol. 2011;31:206–9. https://doi.org/10.1097/WNO.0b013e318211daa9.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Rush JA, Younge BR. Paralysis of Cranial Nerves III, IV, and VI Cause and Prognosis in 1000 Cases. Arch Ophthalmol. 1981;99:76–9. https://doi.org/10.1001/archopht.1981.03930010078006.

    Article  CAS  PubMed  Google Scholar 

  24. Koskas P, Héran F. Towards understanding ocular motility: III, IV and VI. Diagn Interv Imaging. 2013;94:1017–31. https://doi.org/10.1016/j.diii.2013.08.008.

    Article  CAS  PubMed  Google Scholar 

  25. Berlit P. Isolated and combined pareses of cranial nerves III, IV and VI a retrospective study of 412 patients. J Neurol Sci. 1991;103:10–5. https://doi.org/10.1016/0022-510X(91)90276-D.

    Article  CAS  PubMed  Google Scholar 

  26. Richards BW, Jones FR, Younge BR. Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol. 1992;113:489–96. https://doi.org/10.1016/S0002-9394(14)74718-X.

    Article  CAS  PubMed  Google Scholar 

  27. Teuscher AU, Meienberg O. Ischaemic oculomotor nerve palsy Clinical features and vascular risk factors in 23 patients. J Neurol. 1985;232(3):144–9. https://doi.org/10.1007/bf00313889.

    Article  CAS  PubMed  Google Scholar 

  28. Tiffin PA, MacEwen CJ, Craig EA, et al. Acquired palsy of the oculomotor, trochlear and abducens nerves. Eye (Lond). 1996;10(Pt 3):377–84. https://doi.org/10.1038/eye.1996.77.

    Article  PubMed  Google Scholar 

  29. Anagnostou E, Kouzi I, Kararizou E. Painful ophthalmoplegia: the role of imaging and steroid response in the acute and subacute setting. Neurol Sci. 2013;331(1–2):145–9. https://doi.org/10.1016/j.jns.2013.05.036.

    Article  Google Scholar 

  30. Volpe NJ, Lee AG. Do patients with neurologically isolated ocular motor cranial nerve palsies require prompt neuroimaging? J Neuroophthalmol. 2014;34:301–5. https://doi.org/10.1097/WNO.0000000000000149.

    Article  PubMed  Google Scholar 

  31. Fang C, Leavitt JA, Hodge DO, et al. Incidence and etiologies of acquired third nerve palsy using a population-based method. JAMA Ophthalmol. 2017;135:23. https://doi.org/10.1001/jamaophthalmol.2016.4456.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Gross JR, McClelland CM, Lee MS. An approach to anisocoria. Current Opinion in Ophthalmol. 2016;27:486–92. https://doi.org/10.1097/ICU.0000000000000316.

    Article  Google Scholar 

  33. Chou KL, Galetta SL, Liu GT, et al. Acute ocular motor mononeuropathies: prospective study of the roles of neuroimaging and clinical assessment. J Neurol Sci. 2004;15;219(1–2):35–9. https://doi.org/10.1016/j.jns.2003.12.003.

    Article  Google Scholar 

  34. Batocchi AP, Evoli A, Majolini L, et al. Ocular palsies in the absence of other neurological or ocular symptoms: analysis of 105 cases. J Neurol. 1997;244(10):639–45. https://doi.org/10.1007/s004150050160.

    Article  CAS  PubMed  Google Scholar 

  35. Bendszus M, Beck A, Koltzenburg M, et al. MRI in isolated sixth nerve palsies. Neuroradiol. 2001;43(9):742–5. https://doi.org/10.1007/s002340100572.

    Article  CAS  Google Scholar 

  36. Murchison AP, Gilbert ME, Savino PJ. Neuroimaging and acute ocular motor mononeuropathies: a prospective study. Arch Ophthalmol. 2011;129(3):301–5. https://doi.org/10.1001/archophthalmol.2011.25.

    Article  PubMed  Google Scholar 

  37. Kesim Şahin O (2023) Pituitary apoplexy presenting as unilateral oculomotor palsy in a patient with diabetes mellitus. Haydarpasa Numune Training Res Hospital Med J. https://doi.org/10.14744/hnhj.2022.74507

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Authors and Affiliations

  1. Department of Neurology, University of Health Sciences, Haydarpaşa Numune Training and Research Hospital, Selimiye, Tıbbiye Cd No:23, 34668, Üsküdar, Istanbul, Turkey

    Ozlem Kesim Sahin, Gursan Gunes Uygun & Devran Süer

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  1. Ozlem Kesim Sahin
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  3. Devran Süer
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Contributions

OKS: study conceptualisation, data collection,, data analysis, wrote manuscript; GGU:data collection, wrote manuscript, data analysis; DS: study conceptualisation, data collection,, data analysis.

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Correspondence to Ozlem Kesim Sahin.

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This research study was conducted in compliance with the Declaration of Helsinki and was approved by Haydarpaşa Numune Training and Research Hospital Ethics Committee (Date: 05/07/2021 No: 2021/200).

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Sahin, O.K., Uygun, G.G. & Süer, D. Diplopia Diagnostics: Exploring Underlying Causes and Clinical Features in Neurological Practice. SN Compr. Clin. Med. 6, 25 (2024). https://doi.org/10.1007/s42399-024-01653-x

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