Acute binocular diplopia: peripheral or central?

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

doi:10.1007/s00415-020-10088-y

Abstract

ObjectivesAcute 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.MethodsWe 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.ResultsForty-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.ConclusionsIn 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.

Highlights

Acute diplopia accounts for 0.1% of the patients that present at an emergency department [1]
The importance of a prompt diagnosis in the emergency department is shown in a large prospective study [7], where 16% of the 50,000 emergency department visits due to diplopia were due to a life-threatening underlying disease
We focus on the clinical differentiation of peripheral versus central ocular motor nerve palsies (OMP) in the acute phase in an effort to identify signs and symptoms that would assist a non-specialist in the emergency department in making the correct clinical decision regarding further diagnostic procedures and management

Summary

Introduction

The ocular motor nuclei are located throughout the brainstem, from the midbrain (CNIII) to the pons (CNIV) and the ponto-medullary junction (CNVI). Within the brainstem they have a long (CNIII, CNVI) or short (CNIV) so-called fascicular part [6]. After exiting the brainstem heading towards the eye, they pass through critical structures, such as the cavernous sinus. Because of their complicated anatomy and vicinity to these structures, prompt diagnosis of the localization of the OMP lesion is both very difficult and very important, in particular to diagnose a brainstem stroke.

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