Diplopia - Double Vision - Differential Diagnosis Algorithm

Clinical Pearls:

 • Diplopia is almost always binocular.

 • CN VI palsy is a red flag for intracranial masses.

 • Look for ptosis with CN Ill palsy.

 • Examine both eyes to determine which is affected.

 • Neurologic symptoms suggest a mass as the cause.

 • Myasthenia Gravis is fatiguable.

 • Migraine is a diagnosis of exclusion.



Monocular

 • Refractive Error

 • Cataract/Lens Dislocation

 • Functional

 • Corneal Distortion/Scarring

 • Vitreous Abnormalities

Neuromuscular Junction

 • Myasthenia Gravis

Extraocular Muscle - Restriction/Entrapment

 • Orbital Inflammation

 • Orbital Tumor

 • Orbital Floor Fracture

Strictly Horizontal (Cranial Nerve VI problem) - Cannot Abduct

 • Ischemia

 • Diabetes Mellitus

 • Aneurysm

 • Tumor

 • Trauma

Cranial Nerve Ill - Eye depressed, abducted, ptosis, large/unreactive pupil

 • Ischemia

 • Diabetes Mellitus

 • Aneurysm

 • Trauma

Cranial Nerve IV - Eye cannot depress when looking medially

 • Ischemia

 • Diabetes Mellitus

 • Aneurysm

 • Trauma

 • Subdural Hemorrhage

Grave's Ophthalmopathy

 • Hyperthyroidism



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