1. Monocular
2. Binocular

Monocular Diplopia
Almost all due to eye problems
Dislocated lens
Corneal ( Ketoconus, corneal scars)
Refractive (astigmatism)
Rx opthamology referral / malingering

Binocular Diplopia
Disconjugate eye alignment
👉MG myasthenia :Intermittent muscle weakness / diplopia/ptosis/inc weakness on repetition/ bulbar s/s
👉CN palsy: 3,4,6
👉infiltration / tumor/ MS : focal Neurologic s/s.
👉 pseudotumor/ thyroid opthamopathy
👉Aneurysm : sudden worst HA, pupillary dilation, ptosis , 3rd N palsy, eye deviated laterally
👉CN 4: verticals diplopia, inc on downgaze, tilting head to compensate
👉CN 6: Lateral rectus weakness, pulling eye medically,
👉CVS: Diabetic, older, HTN, Atherosclerosis
👉MLF: MS, brainstem stroke: weak adduction + Nystagmus in contra lateral , converge normally
👉Infection/inflammation /orbital myositis/Graves exophthalmos : Cavernous sinus, thrombosis : Proptoconstant pain increases on eye movement, fever, facial paresthesia, photophobia
👉MS: – Intermittent, INO, visual / bladder dysfunction, other MS s/s
👉 Trauma H/O
👉Miller- Fisher +/- GBS: ataxia, absent DTR, Albumino cytology dissociation,
👉 Botulinum: acute bilateral CN palsies, symmetric descending weakness, afebrile, blurred vision (fixed dilated pupils), Diplopia / nystagmus 3.,4,6 CN palsies, dysphagia, dysarthria, facial, generalized weakness. EMG: reduce muscle action potential& M wave amplitude, inc action potentials / frequency due to repetitive nerve stimulation. BUT normal : MSE/ Sensory exam /BP/HR/neuro imaging/spinal tap occasionally Inc protein. Dx: C difficil toxin in in serum, stool, food, vomit or isolation from food, vomit, stool & wound.
RX: ANTITOXIN, Ventilation support. Antibiotics (in wound botulinum only).

👉Trauma: H/O
👉Wernicke’s : Alcohol + Ataxia+ Altered mental status+ abnormal eye muscle. (Malnutrition / Dialysis/ poor diet). Midline petechial hemorrhage. Thiamine def: 500 mg IV over 30 minutes X 2 then 250 mg I’m for 5 d then PO. ? Sq test dose ? Angioedema etc.

W/U & exam for Diplopia:
👉Acute diplopia : r/o stroke / Aneurysm / MS /Tumor do MRI or CT

👉TSH/ free T4 : + weight loss + heat hypersensitivity + palpitation
👉CTA : suspect aneurysm
👉Intemitent S/S : MG / MS
👉Goiter : Grave
👉Diplopia + bladder prob: w/u for MS
👉Vission changes CN 2
👉 N+ V +Diarrhea+ Diplopia / CN involvement/ History: Botulinum
👉CN 9, 12: +Diplopia+ Dysphagia +Dysphasia
👉CN 5 : + abn sensation face any 5 n branch
👉CN 7 : + facial weakness
👉CN 8 : + dizziness + ataxia +hearing loss
👉Alcohol: +ataxia+abn eye muscle + altered mental status : Werneckes
👉Stroke : + s/s + older + Diabetes+HTN+ Hypercholestrolemia
👉Isolated pupil sparing CN weakness + no other s/s : will resolve
👉ANY RED FLAG : do imaging

💊Rx Treat the cause, treat the treatable, prevent the preventable, cure the curable.

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