Algorithm for the Diagnostic Approach to Diplopia in the Emergency Department-a Guideline - Flowchart
Algorithm for the Diagnostic Approach to Diplopia in the Emergency Department-a Guideline - Flowchart Diplopia Diplopia
«Flowchart»

Monocular?
Persists with unaffected eye closed?

Monocular?
Persists with unaffected eye closed?

Monocular?
Persists with unaffected eye closed?

Monocular?

YES

YES

YES

NO

NO

NO

POTENTIAL DIAGNOSIS


Refraction problem in cornea, lens, vitreous; retinal wrinkle

POTENTIAL DIAGNOSIS


Refraction problem in cornea, lens, vitreous; retinal wrinkle

POTENTIAL DIAGNOSIS


Refraction problem in cornea, lens, vitreous; retinal wrinkle


Refraction problem in cornea, lens, vitreous; retinal wrinkle

WORK-UP


Slit lamp exam
Consider ophthalmology consult or referral

WORK-UP


Slit lamp exam
Consider ophthalmology consult or referral

WORK-UP


Slit lamp exam
Consider ophthalmology consult or referral


Slit lamp exam
Consider ophthalmology consult or referral

End

End

End

Restrictive mechanical orbitopathy?

Restrictive mechanical orbitopathy?

Restrictive mechanical orbitopathy?

YES

YES

YES

NO

NO

NO

Involving both eyes

Involving both eyes

Involving both eyes

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Orbital cellulitis or abscess

URGENT


Orbital myositis
Idiopathic orbital inflammatory syndrome ("orbital pseudotumor")
Maxillofacial or orbital tumor

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Orbital cellulitis or abscess

URGENT


Orbital myositis
Idiopathic orbital inflammatory syndrome ("orbital pseudotumor")
Maxillofacial or orbital tumor

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT

CRITICAL or EMERGENT


Orbital cellulitis or abscess


Orbital cellulitis or abscess

URGENT

URGENT


Orbital myositis
Idiopathic orbital inflammatory syndrome ("orbital pseudotumor")
Maxillofacial or orbital tumor


Orbital myositis
Idiopathic orbital inflammatory syndrome ("orbital pseudotumor")
Maxillofacial or orbital tumor

Involving only one eye?

Involving only one eye?

Involving only one eye?

YES

YES

YES

NO

NO

NO

WORK-UP


Contrast-enhanced MRI (or CT) of the orbits

WORK-UP


Contrast-enhanced MRI (or CT) of the orbits

WORK-UP


Contrast-enhanced MRI (or CT) of the orbits


Contrast-enhanced MRI (or CT) of the orbits

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


N/A

URGENT


Graves disease

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


N/A

URGENT


Graves disease

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT

CRITICAL or EMERGENT


N/A


N/A

URGENT

URGENT


Graves disease


Graves disease

WORK-UP


Contrast-enhanced MRI (or CT) of the orbits

WORK-UP


Contrast-enhanced MRI (or CT) of the orbits

WORK-UP


Contrast-enhanced MRI (or CT) of the orbits


Contrast-enhanced MRI (or CT) of the orbits

Isolated palsy of CN 3, 4, or 6?

Isolated palsy of CN 3, 4, or 6?

Isolated palsy of CN 3, 4, or 6?

YES

YES

YES

NO

NO

NO

WORK-UP


Consider discharge with neuro-ophthalmology referral

WORK-UP


Consider discharge with neuro-ophthalmology referral

WORK-UP


Consider discharge with neuro-ophthalmology referral


Consider discharge with neuro-ophthalmology referral

Typical microvascular ischemia?


Chronic diabetes or hypertension
Associated pain

Typical microvascular ischemia?


Chronic diabetes or hypertension
Associated pain

Typical microvascular ischemia?

Typical microvascular ischemia?


Chronic diabetes or hypertension
Associated pain


Chronic diabetes or hypertension
Associated pain

YES

YES

YES

NO

NO

NO

WORK-UP


MRA/CTA/DSA brain

WORK-UP


MRA/CTA/DSA brain

WORK-UP


MRA/CTA/DSA brain


MRA/CTA/DSA brain

WORK-UP


MRI brain + orbits with gad + high-res cuts through brainstem + fat-suppressed orbital imaging

WORK-UP


MRI brain + orbits with gad + high-res cuts through brainstem + fat-suppressed orbital imaging

WORK-UP


MRI brain + orbits with gad + high-res cuts through brainstem + fat-suppressed orbital imaging


MRI brain + orbits with gad + high-res cuts through brainstem + fat-suppressed orbital imaging

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Intracranial aneurysm

URGENT


Skull-base brain tumor, other lesion

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Intracranial aneurysm

URGENT


Skull-base brain tumor, other lesion

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT

CRITICAL or EMERGENT


Intracranial aneurysm


Intracranial aneurysm

URGENT

URGENT


Skull-base brain tumor, other lesion


Skull-base brain tumor, other lesion

“Aneurysmal” CN 3 palsy?


Pupillary involvement?

“Aneurysmal” CN 3 palsy?


Pupillary involvement?

“Aneurysmal” CN 3 palsy?

“Aneurysmal” CN 3 palsy?


Pupillary involvement?


Pupillary involvement?

YES

YES

YES

NO

NO

NO

POTENTIAL DIAGNOSIS

URGENT


Skull-base brain tumor, other lesion

POTENTIAL DIAGNOSIS

URGENT


Skull-base brain tumor, other lesion

POTENTIAL DIAGNOSIS

URGENT

URGENT


Skull-base brain tumor, other lesion


Skull-base brain tumor, other lesion

Isolated palsy of CN 4 or 6?

Isolated palsy of CN 4 or 6?

Isolated palsy of CN 4 or 6?

YES

YES

YES

NO

NO

NO

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Septic cavernous sinus thrombosis
Cavernous internal carotid artery aneurysm
Carotid-cavernous fistula
Cavernous sinus vasculitis

URGENT


Orbital apex mass or infiltrative process (e.g., sarcoidosis)

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Septic cavernous sinus thrombosis
Cavernous internal carotid artery aneurysm
Carotid-cavernous fistula
Cavernous sinus vasculitis

URGENT


Orbital apex mass or infiltrative process (e.g., sarcoidosis)

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT

CRITICAL or EMERGENT


Septic cavernous sinus thrombosis
Cavernous internal carotid artery aneurysm
Carotid-cavernous fistula
Cavernous sinus vasculitis


Septic cavernous sinus thrombosis
Cavernous internal carotid artery aneurysm
Carotid-cavernous fistula
Cavernous sinus vasculitis

URGENT

URGENT


Orbital apex mass or infiltrative process (e.g., sarcoidosis)


Orbital apex mass or infiltrative process (e.g., sarcoidosis)

Orbital apex syndrome or cavernous sinus?


Retroorbital pain?
Exophthalmos?
Conjunctival injection or chemosis?
No other neuro deficits except facial numbness?

Orbital apex syndrome or cavernous sinus?


Retroorbital pain?
Exophthalmos?
Conjunctival injection or chemosis?
No other neuro deficits except facial numbness?

Orbital apex syndrome or cavernous sinus?

Orbital apex syndrome or cavernous sinus?


Retroorbital pain?
Exophthalmos?
Conjunctival injection or chemosis?
No other neuro deficits except facial numbness?


Retroorbital pain?
Exophthalmos?
Conjunctival injection or chemosis?
No other neuro deficits except facial numbness?

YES

YES

YES

NO

NO

NO

WORK-UP


Contrast-enhanced MRI (or CT) of the orbits (± brain)

WORK-UP


Contrast-enhanced MRI (or CT) of the orbits (± brain)

WORK-UP


Contrast-enhanced MRI (or CT) of the orbits (± brain)


Contrast-enhanced MRI (or CT) of the orbits (± brain)

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Impending basilar artery thrombosis
Basilar meningio-encephalitis
Brainstem lacunar stroke
Vertebral artery dissection

URGENT


Multiple sclerosis
Ophthalmoplegic migraine
Intracranial tumor

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Impending basilar artery thrombosis
Basilar meningio-encephalitis
Brainstem lacunar stroke
Vertebral artery dissection

URGENT


Multiple sclerosis
Ophthalmoplegic migraine
Intracranial tumor

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT

CRITICAL or EMERGENT


Impending basilar artery thrombosis
Basilar meningio-encephalitis
Brainstem lacunar stroke
Vertebral artery dissection


Impending basilar artery thrombosis
Basilar meningio-encephalitis
Brainstem lacunar stroke
Vertebral artery dissection

URGENT

URGENT


Multiple sclerosis
Ophthalmoplegic migraine
Intracranial tumor


Multiple sclerosis
Ophthalmoplegic migraine
Intracranial tumor

Deficits isolated to the brainstem?


Skew deviation?
Dysarthria?
Vertigo?
Other cranial neuropathies?

Deficits isolated to the brainstem?


Skew deviation?
Dysarthria?
Vertigo?
Other cranial neuropathies?

Deficits isolated to the brainstem?

Deficits isolated to the brainstem?


Skew deviation?
Dysarthria?
Vertigo?
Other cranial neuropathies?


Skew deviation?
Dysarthria?
Vertigo?
Other cranial neuropathies?

YES

YES

YES

NO

NO

NO

WORK-UP


Vascular causes: MRI brain (with DWI) + MRA or CTA brain and neck
Others: MRI brain with gad + hi-res cuts through brainstem
Consider LP for meningitis

WORK-UP


Vascular causes: MRI brain (with DWI) + MRA or CTA brain and neck
Others: MRI brain with gad + hi-res cuts through brainstem
Consider LP for meningitis

WORK-UP


Vascular causes: MRI brain (with DWI) + MRA or CTA brain and neck
Others: MRI brain with gad + hi-res cuts through brainstem
Consider LP for meningitis


Vascular causes: MRI brain (with DWI) + MRA or CTA brain and neck
Others: MRI brain with gad + hi-res cuts through brainstem
Consider LP for meningitis

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Botulism (Dysarthria? Dry mouth? Dysphagia?...)
Wernicke encephalopathy (Nystagmus? Altered mental status? Malnutrition?...)

URGENT


Miller-Fisher syndrome (Ataxia? Areflexia? Recent illness?...)

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Botulism (Dysarthria? Dry mouth? Dysphagia?...)
Wernicke encephalopathy (Nystagmus? Altered mental status? Malnutrition?...)

URGENT


Miller-Fisher syndrome (Ataxia? Areflexia? Recent illness?...)

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT

CRITICAL or EMERGENT


Botulism (Dysarthria? Dry mouth? Dysphagia?...)
Wernicke encephalopathy (Nystagmus? Altered mental status? Malnutrition?...)


Botulism (Dysarthria? Dry mouth? Dysphagia?...) (Dysarthria? Dry mouth? Dysphagia?...) (
Wernicke encephalopathy (Nystagmus? Altered mental status? Malnutrition?...) (Nystagmus? Altered mental status? Malnutrition?...)

URGENT

URGENT


Miller-Fisher syndrome (Ataxia? Areflexia? Recent illness?...)


Miller-Fisher syndrome (Ataxia? Areflexia? Recent illness?...) (Ataxia? Areflexia? Recent illness?...)

Neuropathic syndrome with brainstem/cranial nerve involvement?


Brainstem findings + other neuro signs?

Neuropathic syndrome with brainstem/cranial nerve involvement?


Brainstem findings + other neuro signs?

Neuropathic syndrome with brainstem/cranial nerve involvement?

Neuropathic syndrome with brainstem/cranial nerve involvement?


Brainstem findings + other neuro signs?


Brainstem findings + other neuro signs?

YES

YES

YES

NO

NO

NO

WORK-UP


Treat empirically
Consider screening MRI
Consider LP for Miller-Fisher syndrome

WORK-UP


Treat empirically
Consider screening MRI
Consider LP for Miller-Fisher syndrome

WORK-UP


Treat empirically
Consider screening MRI
Consider LP for Miller-Fisher syndrome


Treat empirically
Consider screening MRI
Consider LP for Miller-Fisher syndrome

Consider other diagnoses

Consider other diagnoses

Consider other diagnoses

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Myasthenia gravis

URGENT


N/A

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT


Myasthenia gravis

URGENT


N/A

POTENTIAL DIAGNOSIS

CRITICAL or EMERGENT

CRITICAL or EMERGENT


Myasthenia gravis


Myasthenia gravis

URGENT

URGENT


N/A


N/A

Neuromuscular process?

Neuromuscular process?

Neuromuscular process?

YES

YES

YES

NO

NO

NO

WORK-UP


Ice test
Edrophonium challenge

WORK-UP


Ice test
Edrophonium challenge

WORK-UP


Ice test
Edrophonium challenge


Ice test
Edrophonium challenge

Combined palsy of CN 3, 4, or 6?

Combined palsy of CN 3, 4, or 6?

Combined palsy of CN 3, 4, or 6?

YES

YES

YES

NO

NO

NO

Other neurological deficits?

Other neurological deficits?

Other neurological deficits?

YES

YES

YES

NO

NO

NO