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A 40-year-old woman presents with sudden diplopia and bad headache while at work. She notes that the left image is higher than the right one and that the images get further apart when she looks up, down, or to the left. On examination, she has an exotropia and left hypotropia when looking straight ahead, and there is reduced adduction, depression, and elevation of the right eye.
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- What additional signs should you look for?
- What nerve, muscle, or structure has been affected?
- What is your chief worry in a case like this, and how would you investigate it?
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Diplopia is the experience of seeing more than a single image. In the majority of cases, it is due to the fact that the 2 eyes are not pointing at the same location in space (ocular misalignment). Thus, images of an object fall on different locations of the retinae of the 2 eyes, giving rise to the impression of 2 objects rather than 1.
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Binocular diplopia stems from dysfunction of a broad range of motor structures, ranging from muscle, neuromuscular -junction, nerves in their course within and outside the brainstem, and prenuclear brainstem control problems. This anatomic division is a useful approach to evaluation and differential diagnosis.
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Differential Diagnosis
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