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Older man presents with new-onset binocular vertical diplopia

Healio Ophthalmology1d ago1 min read

A 76-year-old man presented with a 3-week history of binocular vertical diplopia.He denied change in vision, pain with eye movements, headache, scalp tenderness, jaw claudication, constitutional symptoms, dysarthria, extremity numbness or tingling, facial droop, and prior similar episodes.Ocular history was notable for dry age-related macular degeneration in the right eye, neovascular AMD in the left eye and cataract extraction bilaterally. He had previously received intravitreal anti-VEGF injections at an outside institution but had been lost to follow-up for several years. Medical history

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AI Summary

Quick Take

A 76-year-old male presented with a three-week history of new-onset binocular vertical diplopia, occurring in the absence of pain, vision changes, or systemic neurological symptoms. Despite a history of neovascular age-related macular degeneration (nAMD) and prior anti-VEGF therapy, the patient had been lost to follow-up for several years before this acute presentation.

Why It Matters

New-onset vertical diplopia in an elderly patient is a clinical 'red flag' that necessitates a rapid workup to rule out giant cell arteritis (GCA), microvascular cranial nerve palsies, or orbital pathology. This case is particularly relevant for clinicians managing chronic retinal disease, as it underscores the challenges of patients who drop out of regular care and then return with unrelated or potentially complicating neuro-ophthalmic symptoms. Even when classic symptoms like jaw claudication or scalp tenderness are absent, a systematic approach is required to differentiate between benign and life-threatening etiologies.

Key Details

Patient is a 76-year-old male with a 3-week history of binocular vertical diplopia.
Systemic review was negative for GCA symptoms, including headache, scalp tenderness, and jaw claudication.
Neurological screen was negative for dysarthria, facial droop, or extremity numbness and tingling.
Ocular history includes bilateral pseudophakia and age-related macular degeneration (dry OD, neovascular OS).
The patient had previously received anti-VEGF injections for nAMD but had been lost to follow-up for several years.

Practice Implications

When an elderly patient presents with vertical diplopia, clinicians must perform a comprehensive motility exam and a targeted review of systems for GCA and neurological deficits, even if the patient denies pain. In patients with a history of nAMD who have been lost to follow-up, a thorough fundus examination is also essential to determine if the diplopia is related to a recurrence of choroidal neovascularization or is an independent neuro-ophthalmic event.

Who's Affected

Comprehensive OptometristsOphthalmologistsRetina SpecialistsNeuro-ophthalmologists

Evidence StrengthPreliminary

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