Sleuthing needed to solve cases of adult-onset diplopia

New York-The great fictional detective Sherlock Holmes believed that once you have eliminated the impossible, whatever remains-however unlikely it may be-must be the answer.

According to Dr. Thimons, who is medical director, Ophthalmic Consultants of Connecticut, Fairfield, CT, adult-onset diplopia is one of the more common areas of clinical practice as far as neuro-ophthalmic patients go. Both the presentation and the diagnosis can be complex, or conversely fairly simple, he said, but even the most challenging cases should not be beyond the skill of a well-trained clinical practitioner to diagnose.

The evaluation of patients with diplopia must include a comprehensive, system-wide analysis of function. Start with a thorough history, including personal behavior, pharmaceutical use, recreational drug use, changes in lifestyles, and changes in behavior.

"Listen to your patients, and they will tell you their disease," Dr. Thimons said.

The eventual diagnosis can often come from good observation on the part of the clinician. By recognizing effects (or lack thereof) on a patient's cognitive and motor skills, an optometrist may decide to pursue a more aggressive examination. Be a good observer of the person who's in the chair, Dr. Thimons said, as opposed to examining just the small subset of the ocular findings.

"In patients with possible masquerading syndromes such the neuron-degenerative diseases, Alzheimer's or Parkinson's, or the atypical extraocular muscle function problem, patients with possible systemic concerns such as multiple sclerosis, myasthenia gravis, or thyroid eye disease. Everything is potentially important: every element of history and every nuance of the physical examination need to be viewed from a global perspective," Dr. Thimons said.