Title: Seeing Double?<br/>Author: Danya Khoujah<br/><a href='http://umem.org/profiles/faculty/739/'>[Click to email author]</a><hr/><p>
        Diplopia can be a challenging complaint to address in the ED. Although not all patients will require imaging, use the simplified table below to help guide the imaging study needed:</p>
<p>
         </p>
<table border="1" cellpadding="0" cellspacing="0" width="469">
        <tbody>
                <tr>
                        <td colspan="2" style="width:223px;">
                                <p align="center">
                                        <strong>Clinical Situation</strong></p>
                        </td>
                        <td style="width:270px;">
                                <p align="center">
                                        <strong>Suspected Diagnosis</strong></p>
                        </td>
                        <td style="width:132px;">
                                <p align="center">
                                        <strong>Imaging Study</strong></p>
                        </td>
                </tr>
                <tr>
                        <td colspan="2" style="width:223px;">
                                <p>
                                        Diplopia + cerebellar signs and symptoms</p>
                        </td>
                        <td style="width:270px;">
                                <p>
                                        Brainstem pathology</p>
                        </td>
                        <td style="width:132px;">
                                <p>
                                        MRI brain</p>
                        </td>
                </tr>
                <tr>
                        <td colspan="2" style="width:223px;">
                                <p>
                                        6th CN palsy + papilledema</p>
                        </td>
                        <td style="width:270px;">
                                <p>
                                        Increased intracranial pressure (e.g. idiopathic intracranial hypertension or cerebral venous thrombosis)</p>
                        </td>
                        <td style="width:132px;">
                                <p>
                                        CT/CTV brain</p>
                        </td>
                </tr>
                <tr>
                        <td colspan="2" style="width:223px;">
                                <p>
                                        3rd CN palsy (especially involving the pupil)</p>
                        </td>
                        <td style="width:270px;">
                                <p>
                                        Compressive lesion (aneurysm of posterior communicating or internal carotid artery)</p>
                        </td>
                        <td style="width:132px;">
                                <p>
                                        CT/CTA brain</p>
                        </td>
                </tr>
                <tr>
                        <td colspan="2" style="width:223px;">
                                <p>
                                        Diplopia + thyroid disease + decreased visual acuity</p>
                        </td>
                        <td style="width:270px;">
                                <p>
                                        Optic nerve compression</p>
                        </td>
                        <td style="width:132px;">
                                <p>
                                        CT orbits</p>
                        </td>
                </tr>
                <tr>
                        <td colspan="2" style="width:223px;">
                                <p>
                                        Intranuclear ophthalmoplegia</p>
                        </td>
                        <td style="width:270px;">
                                <p>
                                        Multiple sclerosis</p>
                        </td>
                        <td style="width:132px;">
                                <p>
                                        MRI brain</p>
                        </td>
                </tr>
                <tr>
                        <td colspan="2" style="width:223px;">
                                <p>
                                        Diplopia + facial or head trauma</p>
                        </td>
                        <td style="width:270px;">
                                <p>
                                        Fracture causing CN disruption</p>
                        </td>
                        <td style="width:132px;">
                                <p>
                                        CT head (dry)</p>
                        </td>
                </tr>
                <tr>
                        <td rowspan="2" style="width:104px;">
                                <p>
                                        Diplopia + multiple CN involvement (3,4,6) + numbness over V1 and V2 of trigeminal nerve (CN5) +/- proptosis</p>
                        </td>
                        <td style="width:119px;">
                                <p>
                                        Unilateral, decreased visual acuity</p>
                        </td>
                        <td style="width:270px;">
                                <p>
                                        Orbital apex pathology</p>
                        </td>
                        <td style="width:132px;">
                                <p>
                                        CT orbits with contrast</p>
                        </td>
                </tr>
                <tr>
                        <td style="width:119px;">
                                <p>
                                        Uni- or bi-lateral, normal visual acuity</p>
                        </td>
                        <td style="width:270px;">
                                <p>
                                        Cavernous sinus thrombosis</p>
                        </td>
                        <td style="width:132px;">
                                <p>
                                        CT/CTV brain</p>
                        </td>
                </tr>
        </tbody>
</table>
<p>
        C.N.: cranial nerve</p>
<p>
         </p>
<fieldset><legend>References</legend>

                <p>
        Margolin E, Lam C. Approach to a Patient with Diplopia in the Emergency Department. <span style="font-family: arial, helvetica, clean, sans-serif; font-size: 11.0045px;"><span style="border-bottom-style: initial; border-bottom-color: initial;">J Emerg Med.</span> 2018 Jun;54(6):799-806</span></p>
</fieldset>