CLINICAL DIAGNOSTIC MANUAL
Strabismus and diplopia due to ocular paralysis are ophthalmologic conditions that occur when one or more of the muscles controlling eye movement are weakened or paralysed. This dysfunction can lead to abnormal eye deviation (strabismus) and the perception of double vision (diplopia), significantly affecting the patient’s quality of life.
Oculomotor paralysis can be caused by various conditions, including neurological disorders, autoimmune diseases, infections, and tumours. A detailed evaluation is essential to identify the underlying cause and provide appropriate treatment.
Condition | Clinical Symptoms and Signs | Suspected Diagnosis | Confirmatory Diagnosis |
Oculomotor nerve palsy (III CN) | Ptosis, dilated non-reactive pupil, eye deviated outward and downward | Clinical history and physical exam | Brain CT or MRI, EMG |
Trochlear nerve palsy (IV CN) | Difficulty looking down and inward, head tilt to compensate | Clinical history and physical exam | Brain CT or MRI, neurological function tests |
Abducens nerve palsy (VI CN) | Inability to move the eye outward, horizontal diplopia | Clinical history and physical exam | Brain CT or MRI, nerve conduction studies |
Myasthenia gravis | Progressive muscle fatigue, ptosis, diplopia worsening with activity | Clinical history, ice pack test, edrophonium test | Antibody tests (AChR, MuSK), EMG, repetitive nerve stimulation test |
Graves’ disease | Ophthalmopathy, exophthalmos, restricted eye movements | Clinical history, physical exam, signs of hyperthyroidism | Thyroid function tests (TSH, free T4), orbital CT or MRI |
Orbital cellulitis | Eye pain, periorbital erythema and swelling, fever, limited eye movements | Clinical history, physical exam, signs of infection | Orbital CT or MRI, blood or orbital secretion cultures |
Tumour | Proptosis, vision loss, diplopia, eye pain or discomfort | Clinical history, physical exam, focal neurological signs | Brain and orbital CT or MRI, biopsy if needed |
Internuclear ophthalmoplegia | Diplopia, dissociated eye movements, nystagmus in abducting eye | Clinical history, physical exam, neurological evaluation | Brain MRI |
Intracranial aneurysms | Sudden severe headache, diplopia, ptosis, loss of consciousness | Clinical history, physical exam, neurological signs | Cerebral angiography, brain CT or MRI |
Head trauma | Diplopia, eye misalignment, bruising, signs of fracture | Trauma history, physical exam | Cranial CT, ophthalmologist evaluation |
Infections (meningitis/encephalitis) | Fever, neck stiffness, altered mental state, meningeal signs, diplopia | Clinical history, physical exam, meningeal signs | Lumbar puncture, cultures, brain CT or MRI |
Stroke (CVA) | Sudden neurological deficit, diplopia, ocular muscle paralysis, weakness, speech or gait difficulties | Clinical history, neurological exam | Brain CT or MRI, cerebral angiography |
Diabetes mellitus | Diplopia, peripheral neuropathy, vision changes, signs of hyperglycaemia | Clinical history, physical exam, signs of diabetic neuropathy | Blood glucose tests, HbA1c, neurological evaluation |
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