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An 82-year-old man with binocular oblique diplopia
Digital Journal of Ophthalmology 2015
Volume 21, Number 3
September 12, 2015
DOI: 10.5693/djo.03.2015.05.003
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Gaurav Jindal, MD | Yale–New Haven Hospital, New Haven, Connecticut
Aubrey Gilbert, MD, PhD | Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
Rafeeque Bhadelia, MD | Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Nurhan Torun, MD | Division of Ophthalmology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Differential Diagnosis
The differential diagnosis for this case includes myasthenia gravis, Graves’ ophthalmopathy, Miller-Fisher syndrome and leptomeningeal disease causing multiple cranial neuropathies. If the patient had myasthenia gravis, his symptoms and examination findings might fluctuate, and his examination might show a fatiguable ptosis and/or a Cogan’s lid twitch. Graves’ ophthalmopathy would classically be associated with restrictive limitation in extraocular movement and could include other signs, including proptosis, lid retraction, and/or scleral show. Miller-Fisher syndrome, like myasthenia, can cause extraocular motility impairment that may be difficult to localize anatomically but is typically associated with ataxia and areflexia. Leptomeningeal disease causing multiple cranial neuropathies would likely have other neurologic and possibly systemic manifestations.