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Open Access 01-12-2020 | Diplopia | Original Communication

Acute binocular diplopia: peripheral or central?

Authors: Olympia Kremmyda, Claudia Frenzel, Katharina Hüfner, Nicolina Goldschagg, Christian Brem, Jennifer Linn, Michael Strupp

Published in: Journal of Neurology | Special Issue 1/2020

Abstract

Objectives

Acute diplopia is a diagnostic challenge for clinicians, in particular in the emergency department. The most common cause of acute diplopia are ocular motor nerve palsies (OMP). In this prospective study, we focused on identifying the most crucial signs and symptoms for differentiating between peripheral and central OMP.

Methods

We prospectively evaluated 56 non-consecutive patients who presented at our emergency department with acute binocular diplopia (≤ 10 days). The patient history was taken using a standardized questionnaire and patients underwent a neurological, neuro-ophthalmological and neuro-otological examination, including measurement of the subjective visual vertical (SVV), Harms tangent screen test, and cranial MRI.

Results

Forty-six out of 56 patients were diagnosed with an ocular motor cranial nerve palsy (OMP), 21 of peripheral and 23 of central origin; in two patients, the etiology remained unknown. The following features were different in peripheral and central OMP: (1) the presence of vertigo/dizziness was more frequent in central (43.5%) than in peripheral (9.5%) OMP. (2) Central ocular motor signs, such as saccadic smooth pursuit, additional internuclear ophthalmoplegia, skew deviation, and saccade palsies, were also found more frequently in the central than in the peripheral group (86.7% vs. 33.3%). (3) Further, a pathological SVV deviation by monocular testing of the non-affected eye was also more common in central (77.3%) than in peripheral OMP (38.9%). The presence of all three factors has a positive predictive value of 100% (CI 50–100%) for the presence of a central lesion.

Conclusions

In acute diplopia due to central OMP, the most important accompanying symptom is vertigo/dizziness, and the most important clinical signs are central ocular motor disorders (which require examination of the non-paretic eye) and an SVV deviation in the non-paretic eye.

Nazerian P, Vanni S, Tarocchi C, Portaccio E, Vannucci N, Para O, Giannazzo G, Gigli C, Grifoni S (2014) Causes of diplopia in the emergency department: diagnostic accuracy of clinical assessment and of head computed tomography. Eur J Emerg Med 21(2):118–124. https://doi.org/10.1097/MEJ.0b013e3283636120CrossRefPubMed

Cornblath WT (2014) Diplopia due to ocular motor cranial neuropathies. Continuum (Minneap Minn) 20(4):966–980. https://doi.org/10.1212/01.CON.0000453309.44766.b4CrossRef

Rucker JC, Tomsak RL (2005) Binocular diplopia. A practical approach. Neurologist 11(2):98–110. https://doi.org/10.1097/01.nrl.0000156318.80903.b1CrossRefPubMed

Comer RM, Dawson E, Plant G, Acheson JF, Lee JP (2007) Causes and outcomes for patients presenting with diplopia to an eye casualty department. Eye (Lond) 21(3):413–418. https://doi.org/10.1038/sj.eye.6702415CrossRef

O'Colmain U, Gilmour C, MacEwen CJ (2014) Acute-onset diplopia. Acta Ophthalmol 92(4):382–386. https://doi.org/10.1111/aos.12062CrossRefPubMed

Kirsch CF, Black K (2017) Diplopia: what to double check in radiographic imaging of double vision. Radiol Clin N Am 55(1):69–81. https://doi.org/10.1016/j.rcl.2016.08.008CrossRefPubMed

De Lott LB, Kerber KA, Lee PP, Brown DL, Burke JF (2017) Diplopia-related ambulatory and emergency department visits in the United States, 2003–2012. JAMA Ophthalmol 135(12):1339–1344. https://doi.org/10.1001/jamaophthalmol.2017.4508CrossRefPubMedPubMedCentral

Park UC, Kim SJ, Hwang JM, Yu YS (2008) Clinical features and natural history of acquired third, fourth, and sixth cranial nerve palsy. Eye (Lond) 22(5):691–696. https://doi.org/10.1038/sj.eye.6702720CrossRef

Tamhankar MA, Biousse V, Ying GS, Prasad S, Subramanian PS, Lee MS, Eggenberger E, Moss HE, Pineles S, Bennett J, Osborne B, Volpe NJ, Liu GT, Bruce BB, Newman NJ, Galetta SL, Balcer LJ (2013) Isolated third, fourth, and sixth cranial nerve palsies from presumed microvascular versus other causes: a prospective study. Ophthalmology 120(11):2264–2269. https://doi.org/10.1016/j.ophtha.2013.04.009CrossRefPubMed

10.

Choi KD, Choi SY, Kim JS, Choi JH, Yang TH, Oh SY, Kim SH, Lee HS, Lee SH, Jeong SH, Kim HJ, Choi JY (2019) Acquired ocular motor nerve palsy in neurology clinics: a prospective multicenter study. J Clin Neurol 15(2):221–227. https://doi.org/10.3988/jcn.2019.15.2.221CrossRefPubMedPubMedCentral

11.

Jung JS, Kim DH (2015) Risk factors and prognosis of isolated ischemic third, fourth, or sixth cranial nerve palsies in the Korean population. J Neuroophthalmol 35(1):37–40. https://doi.org/10.1097/WNO.0000000000000214CrossRefPubMed

12.

Chou KL, Galetta SL, Liu GT, Volpe NJ, Bennett JL, Asbury AK, Balcer LJ (2004) Acute ocular motor mononeuropathies: prospective study of the roles of neuroimaging and clinical assessment. J Neurol Sci 219(1–2):35–39. https://doi.org/10.1016/j.jns.2003.12.003CrossRefPubMed

13.

Merino P, Fuentes D, Gomez de Liano P, Ordonez MA (2017) Binocular diplopia in a tertiary hospital: aetiology, diagnosis and treatment. Arch Soc Esp Oftalmol 92(12):565–570. https://doi.org/10.1016/j.oftal.2017.05.008CrossRefPubMed

14.

Dieterich M, Brandt T (1993) Ocular torsion and perceived vertical in oculomotor, trochlear and abducens nerve palsies. Brain 116(Pt 5):1095–1104CrossRef

15.

Dieterich M, Brandt T (1993) Ocular torsion and tilt of subjective visual vertical are sensitive brainstem signs. Ann Neurol 33(3):292–299. https://doi.org/10.1002/ana.410330311CrossRefPubMed

16.

Tyedmers M, Roper-Hall G (2006) The harms tangent screen test. Am Orthopt J 56:175–179. https://doi.org/10.3368/aoj.56.1.175CrossRefPubMed

17.

Zwergal A, Rettinger N, Frenzel C, Dieterich M, Brandt T, Strupp M (2009) A bucket of static vestibular function. Neurology 72(19):1689–1692. https://doi.org/10.1212/WNL.0b013e3181a55ecfCrossRefPubMed

18.

Galtrey CM, Schon F, Nitkunan A (2015) Microvascular non-arteritic ocular motor nerve palsies-what we know and how should we treat? Neuroophthalmology 39(1):1–11. https://doi.org/10.3109/01658107.2014.963252CrossRefPubMed

19.

Buracchio T, Rucker JC (2007) Pearls and oysters of localization in ophthalmoparesis. Neurology 69(24):E35–40. https://doi.org/10.1212/01.wnl.0000291013.26249.74CrossRefPubMed

20.

Johnson LN, Stetson SW, Krohel GB, Cipollo CL, Madsen RW (2000) Aspirin use and the prevention of acute ischemic cranial nerve palsy. Am J Ophthalmol 129(3):367–371CrossRef

21.

Strupp M, Kremmyda O, Adamczyk C, Bottcher N, Muth C, Yip CW, Bremova T (2014) Central ocular motor disorders, including gaze palsy and nystagmus. J Neurol 261(Suppl 2):S542–558. https://doi.org/10.1007/s00415-014-7385-9CrossRefPubMed

22.

Büttner U, Büttner-Ennever JA (2006) Present concepts of oculomotor organization. Prog Brain Res 151:1–42. https://doi.org/10.1016/S0079-6123(05)51001-XCrossRefPubMed

23.

Cnyrim CD, Newman-Toker D, Karch C, Brandt T, Strupp M (2008) Bedside differentiation of vestibular neuritis from central "vestibular pseudoneuritis". J Neurol Neurosurg Psychiatry 79(4):458–460. https://doi.org/10.1136/jnnp.2007.123596CrossRefPubMed

24.

Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE (2009) HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 40(11):3504–3510. https://doi.org/10.1161/STROKEAHA.109.551234CrossRefPubMedPubMedCentral

25.

Saber Tehrani AS, Kattah JC, Mantokoudis G, Pula JH, Nair D, Blitz A, Ying S, Hanley DF, Zee DS, Newman-Toker DE (2014) Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology 83(2):169–173. https://doi.org/10.1212/WNL.0000000000000573CrossRefPubMedPubMedCentral

26.

Choi JH, Oh EH, Park MG, Baik SK, Cho HJ, Choi SY, Lee TH, Kim JS, Choi KD (2018) Early MRI-negative posterior circulation stroke presenting as acute dizziness. J Neurol 265(12):2993–3000. https://doi.org/10.1007/s00415-018-9097-zCrossRefPubMed

27.

Dieterich M, Brandt T (2019) Perception of verticality and vestibular disorders of balance and falls. Front Neurol 10:172. https://doi.org/10.3389/fneur.2019.00172CrossRefPubMedPubMedCentral

28.

Zwergal A, Büttner-Ennever J, Brandt T, Strupp M (2008) An ipsilateral vestibulothalamic tract adjacent to the medial lemniscus in humans. Brain 131(Pt 11):2928–2935. https://doi.org/10.1093/brain/awn201CrossRefPubMed

29.

Wilker SC, Rucker JC, Newman NJ, Biousse V, Tomsak RL (2009) Pain in ischaemic ocular motor cranial nerve palsies. Br J Ophthalmol 93(12):1657–1659. https://doi.org/10.1136/bjo.2008.155150CrossRefPubMedPubMedCentral

30.

Kang MJ, Shin DJ, Choi KD, Kim JS, Shin DH (2016) Pupil-sparing isolated fascicular third cranial nerve palsy due to infarction: report of a case and literature review. J Neurol Disord 4(7):1–4CrossRef

Title: Acute binocular diplopia: peripheral or central?
Authors: Olympia Kremmyda
Claudia Frenzel
Katharina Hüfner
Nicolina Goldschagg
Christian Brem
Jennifer Linn
Michael Strupp
Publication date: 01-12-2020
Publisher: Springer Berlin Heidelberg
Keywords: Diplopia
Ophthalmoparesis
Published in: Journal of Neurology / Issue Special Issue 1/2020
Print ISSN: 0340-5354
Electronic ISSN: 1432-1459
DOI: https://doi.org/10.1007/s00415-020-10088-y

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Acute binocular diplopia: peripheral or central?

Abstract

Objectives

Methods

Results

Conclusions

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Abstract

Objectives

Methods

Results

Conclusions

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