Differential Diagnosis and Management of Double Vision with Dizziness

High-Risk Differential Diagnoses

The American Academy of Ophthalmology recommends that brainstem lesions affecting the pons, which produce both 6th nerve palsy and vestibular symptoms, should be considered in the differential diagnosis of double vision with dizziness 2, 3
Red flags mandating immediate neuroimaging include associated neurologic deficits, downbeat or direction-changing nystagmus, severe headache, and failure to respond to appropriate BPPV treatment, as suggested by the American Academy of Ophthalmology 4, 1

The American Academy of Neurology suggests that the HINTS examination (Head Impulse, Nystagmus, Test of Skew) should be performed to differentiate stroke from vestibular neuritis in patients with continuous symptoms 1
The American Academy of Otolaryngology recommends that Dix-Hallpike and supine roll testing should be performed to diagnose BPPV in patients with triggered brief episodes of vertigo 1

The American Academy of Ophthalmology recommends that prism glasses and eye patching may be used for temporary relief of diplopia while awaiting recovery, and botulinum toxin or strabismus surgery may be considered for persistent cases after 6 months 4, 8, 1
The American College of Rheumatology suggests that immediate high-dose corticosteroids should be administered to patients with giant cell arteritis to prevent vision loss 6, 2

Failure to perform both Dix-Hallpike and supine roll testing can miss lateral canal BPPV in 30% of cases, as noted by the American Academy of Otolaryngology 1
Assuming BPPV when double vision is present can lead to misdiagnosis, as BPPV does not cause diplopia, and coexisting diplopia suggests central pathology, as suggested by the American Academy of Ophthalmology 1
CT scans can miss posterior fossa pathology, and MRI should always be used for suspected central causes, as recommended by the American Academy of Neurology 1