Urgences en neuro-ophtalmologie

[Management of binocular diplopia in the department of ophthalmic emergencies at the Regional University Hospital of Tours]

OBJECTIVES

To describe the etiologies of binocular diplopia for patients presenting to the ophthalmologic emergency department of the Regional University Center Hospital (CHRU) of Tours.

METHODS

This is a retrospective study of the medical records of patients who presented with binocular diplopia in the ophthalmic emergency department of the CHRU of Tours between January 1st and December 31st, 2019. Binocular diplopia was classified as paralytic or non-paralytic according to the ocular motility examination.

RESULTS

One hundred twelve patients were included. The median age was 61 years. Internal referral from other hospital services represented 44.6% of the patients. On ophthalmological examination, 73.2% had paralytic diplopia, 13.4% non-paralytic diplopia and 13.4% normal examination. Neuroimaging was performed in 88.3% of cases, with 75.7% of patients receiving it on the same day. Oculomotor nerve palsy was the most frequent cause of diplopia in 58.9%, the majority represented by abducens nerve palsy (60.6%). The most frequent etiology of binocular diplopia was ischemic, with microvascular damage in 26.8% of cases and stroke in 10.7% of cases.

CONCLUSION

Among patients assessed in an ophthalmological emergency department setting, one in ten patients had stroke. It is essential to inform patients of the urgent nature of ophthalmological evaluation in the case of acute binocular diplopia. Urgent neurovascular management is also mandatory and should be based on the clinical description provided by the ophthalmologist. Neuroimaging should be performed as soon as possible, based on the ophthalmologic and neurological findings.

[Diplopia: An important symptom in internal medicine!]

Diplopia is defined as "double vision" when looking at a single object. Monocular diplopia is related to an ocular disorder and must be differentiated from binocular diplopia which is secondary to ocular misalignment. The examination of the patient with binocular diplopia is often challenging for non-specialists. However, a careful and systematic clinical examination followed by targeted ancillary testing allows the clinician to localize the lesion along the oculomotor pathways. The lesion may involve the brainstem, the ocular motor nerves III, IV or VI, the neuromuscular junction, the extraocular ocular muscles, or the orbit. Causes of binocular diplopia are numerous and often include disorders typically managed by internal medicine such as inflammatory, infectious, neoplastic, endocrine, and metabolic disorders. In addition to treating the underlying disease, it is important not to leave diplopia uncorrected. Temporary occlusion of one eye by applying tape on one lens or patching one eye relieves the diplopia until more specific treatments are offered should the diplopia not fully resolve.