University of Toronto, Faculty of Medicine, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada; University of Toronto, Department of Medicine (Division of Neurology), Toronto, Ontario, Canada.
J Neurol Sci. 2020 Oct 15;417:117055. doi: 10.1016/j.jns.2020.117055. Epub 2020 Aug 5.
This article presents an overview of the most important points a neurologist must remember when dealing with a patient complaining of diplopia. Patients with monocular diplopia and those with full ocular motility and comitant misalignment should be referred to an ophthalmologist and do not require further testing. Patients with recent onset of binocular diplopia who have associated "brainstem" symptoms should have an urgent brain MRI. All patients with 3rd cranial nerve palsy require urgent brain CTA to rule out compressive aneurysmal lesion. Management of patients over 50 years of age with microvascular risk factors with new onset of 6th nerve palsy is controversial: some image these patients at presentation while others choose a short period of observation as most of these patients would have a microvascular etiology for the 6th nerve palsy which should improve spontaneous in 2-3 months. All others with 6th nerve palsy require brain MRI with contrast. Patients with 4th palsy with hyperdeviation that worsens in downgaze should have an MRI with contrast and all others referred to an ophthalmologist. If there is more than one cranial nerve palsy, urgent neuroimaging should be performed with attention to cavernous sinus and superior orbital fissure. Ocular myasthenia should be suspected in patients with eye misalignment that does not fit a pattern for any cranial nerve palsy. Orbital pathology (most commonly thyroid eye disease) can result in restriction of ocular motility and has specific clinical signs associated with it.
本文概述了神经科医生在处理主诉复视的患者时必须记住的最重要的几点。单眼复视且眼球运动和斜视完全一致的患者应转至眼科，无需进一步检查。最近出现双眼复视且伴有“脑干”症状的患者应立即进行脑部 MRI。所有出现第 3 对颅神经麻痹的患者都需要立即进行脑部 CTA，以排除压迫性动脉瘤病变。对于 50 岁以上有微血管危险因素且新发第 6 对颅神经麻痹的患者，管理存在争议：一些患者在出现症状时进行影像学检查，而另一些患者则选择短期观察，因为这些患者中的大多数第 6 对颅神经麻痹的病因是微血管性的，应该会在 2-3 个月内自发改善。其他所有第 6 对颅神经麻痹的患者都需要进行脑部 MRI 增强检查。第 4 对颅神经麻痹伴眼球上转时高偏且下视时加重的患者需要进行 MRI 增强检查，其他患者均转至眼科。如果存在不止一对颅神经麻痹，应立即进行神经影像学检查，注意海绵窦和眶上裂。如果眼球位置异常与任何一对颅神经麻痹的模式不相符，应怀疑眼肌重症肌无力。眼眶病变（最常见的是甲状腺眼病）可导致眼球运动受限，并有其特定的临床特征。
