Adult with Acquired Vertical Diplopia: Do I Image? Do I Operate? (PDF)

Fourth nerve or superior oblique palsies are exceedingly common in outpatient neurologic and ophthalmic practice. Along with thyroid eye disease they are amongst the most common conditions encountered, particularly in an outpatient setting. When evaluating a patient with acute symptoms consistent with vertical, binocular double vision,both the history and motility exam will generally point to a specific 'localization' before any work up is performed. A critical question on historical evaluation is the setting in which the symptoms develop. Obviously, a previous history of head trauma would be a common setting for acquired fourth nerve palsy as well as orbital trauma as a common setting for injured or entrapped extraocular muscles leading to double vision. The tempo of symptom onset is another critical feature. Although many patients don't recognize the chronic features of longstanding misalignment, most will offer a description of some binocular duress or intermittent double vision for longstanding problems such as congenital fourth nerve palsies. If the patient went from no symptoms at all to having acute vertical double vision,the presentation would be more concerning for an acute skew deviation/brain stem event or vasculopathic fourth nerve palsy. The other important feature is to identify any historical aspects that would suggest thyroid disease or myasthenia gravis, most importantly variability and eyelid changes. Patients should also be questioned as to whether their symptoms are more noticeable or prevalent in certain positions of gaze. The most important features in this setting are the worsening of fourth nerve palsies in contralateral gaze and more specifically acquired fourth note palsies in contralateral down gaze and congenital fourth note palsies generally in contralateral up gaze. A patient with chronic symptoms that are intermittent,usually have this on the basis of good fusional amplitudes and gaze dependent double vision. Also consider asking the patient to review old photographs to look for chronic head tilts to suggest a congenital fourth note palsy.