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Snapshot diagnosis - why has this man suddenly developed double vision?

Dr Mike Wyndham describes another intriguing case

Dr Mike Wyndham describes another intriguing case

The patient

This 75-year-old man came to see me at the end of one of my morning surgeries, concerned about his eyesight. He had noticed a sudden onset of double vision since he had woken that morning. The diplopia was constant and there was no history of trauma.

First instinct

People with double vision don't seem to come to my surgery that often! I had to be honest with the patient and explain that I was going to search my favourite medical website for some inspiration. I've known him for 25 years and he was happy to accept my deficiencies that morning.

Differential diagnosis

The website had a long list of possible causes for double vision including:

• orbital tumour

• aneurysm of the intracranial carotid artery

• sinus infection

• palsy of the sixth cranial nerve (abducens).

The hidden clue

The likely diagnosis became apparent when I checked his eye movements. His right eye could not move laterally, confirming a lateral rectus palsy affecting the right eye.

Getting on the right track

The task now was to try and identify the likely cause of this gentleman's sixth cranial nerve palsy. This problem has an extensive differential diagnosis including infection such as Lyme disease, vascular causes, metabolic causes such as vitamin B deficiency, cerebral causes such as tumour and inflammatory causes such as sarcoidosis.

This gentleman was extensively investigated and the diagnosis was that this single cranial nerve palsy was of vascular origin. He was fitted with new glasses containing prisms to help correct for the diplopia.

Dr Mike Wyndham is a GP in Edgeware, north London

What has this man suddenly developed double vision? What has this man suddenly developed double vision?

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