Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Marchioninistr. 15, 81377, Munich, Germany.
Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry II, Medical University Innsbruck, Innsbruck, Austria.
J Neurol. 2020 Dec;267(Suppl 1):136-142. doi: 10.1007/s00415-020-10088-y. Epub 2020 Aug 14.
Acute 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.
We 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.
Forty-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.
In 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.
急性复视对临床医生来说是一个诊断挑战，特别是在急诊科。急性复视最常见的原因是眼运动神经麻痹（OMP）。在这项前瞻性研究中，我们专注于确定区分周围性和中枢性 OMP 的最关键体征和症状。
我们前瞻性评估了 56 例非连续就诊于我院急诊科的急性双眼复视（≤10 天）患者。使用标准化问卷采集患者病史，患者接受了神经科、神经眼科和神经耳科检查，包括主观垂直视觉（SVV）测量、Harms 切线屏幕测试和颅 MRI。
56 例患者中有 46 例诊断为眼运动颅神经麻痹（OMP），21 例为周围性，23 例为中枢性；在 2 例患者中，病因仍不清楚。周围性和中枢性 OMP 之间存在以下不同特征：（1）眩晕/头晕在中枢性（43.5%）比周围性（9.5%）OMP 更常见。（2）中枢性眼球运动体征，如扫视平滑追踪、附加核间眼肌麻痹、斜偏和扫视麻痹，在中枢性比在周围性组中也更常见（86.7%对 33.3%）。（3）进一步，非受累眼的单眼测试中出现病理性 SVV 偏差在中枢性（77.3%）比在周围性 OMP 中更常见（38.9%）。这三个因素的存在对中枢病变的存在具有 100%的阳性预测值（CI 50-100%）。
在由中枢性 OMP 引起的急性复视中，最重要的伴随症状是眩晕/头晕，最重要的临床体征是中枢性眼球运动障碍（需要检查非麻痹眼）和非麻痹眼的 SVV 偏差。
