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**Table 1: Diplopia**
Differential list for diplopia
Neoplastic	Intraorbital meningioma Pituitary adenoma (GH secreting, or apoplexy) Metastasis Carcinomatosis
Vascular	Giant cell arteritis Giant intracranial aneurysm Microvascular disease
Infectious	Meningitis Sphenoid sinusitis (CN VI palsy) Botulism
Metabolic	Wernicke’s encephalopathy
Inflammatory	Multiple sclerosis Myasthenia gravis GBS Miller-Fisher syndrome Orbital pseudotumor Orbital myositis
Miscellaneous	Traumatic neuropathy (orbital apex fracture, blowout fracture of orbital wall) Increased intracranial pressure (CN III and VI palsy) INO (lesion of MLF) Graves’ disease (thyroid orbitopathy) Corneal disease Cataracts Idiopathic intracranial hypertension (CN VI palsy)

**Table 2: Ptosis**
Differential list for true ptosis
Neoplastic	Infantile rhabdomyosarcoma Hemangioma Optic glioma Dermoid cyst Metastatic neuroblastoma
Neurologic	Ophthalmoplegia Unilateral ptosis Mydriasis Cranial nerve nuclear lesions
Endocrine	Thyroid orbitopathy
Congenital	Congenital Horner’s syndrome Marcus Gunn phenomenon Jaw Winking syndrome Blepharophemosis syndrome Neonatal myasthenia
Inflammatory	Myasthenia gravis Orbital pseudotumor Tolosa-Hunt syndrome Polymyositis
Miscellaneous	Trauma (post-surgical) Third Cranial Nerve Palsy Chronic topical steroid drops

**Table 3: Monocular Blindness**
Differential list for acute or chronic monocular blindness
Neoplastic	Intraorbital neoplasm Tuberculum sella meningioma
Vascular	Amaurosis fugax (carotid bifurcation, great vessel, or cardiogenic thromboembolism) Carotid cavernous aneurysm rupture AION Central or branch retinal artery occlusion Central retinal vein occlusion Takayasu’s arteritis Temporal arteritis Hypoperfusion (hypovolemia, hypotension, hyperviscosity)
Inflammatory	Optic neuritis Retrobulbar neuritis Multiple sclerosis
Miscellaneous	Trauma Ocular migraine Retinal detachment Papilledema Vitreous hemorrhage

**Table 4: Binocular Blindness**
Differential list for binocular blindness. The distinction of cortical blindness from a pathway lesion is the preservation of the pupillary light reflex in the setting of cortical blindness.
Neoplastic	Multifocal malignant glioma Occipital lobe metastases
Vascular	Anoxia (cortical infarction, hemorrhage) AION
Infectious	Multifocal abscess
Metabolic	Hypovitaminosis (B1, folic acid, B12)
Toxic	Methanol (acute loss) Ethanol (progressive)
Inflammatory	Optic neuritis
Miscellaneous	Traumatic neuropathy

**Table 5: Transient Blindness**
Differential list for causes of transient blindness. Cerebrovascular occlusion often involves either a branch or the central retinal artery.
Vascular	Cerebrovascular embolism (carotid bifurcation, cardiogenic, calcific, atrial myxoma, air, adipose, amniotic fluid) Hypoperfusion Hemorrhage Central retinal vein occlusion AION Takayasu’s arteritis
Inflammatory	Multiple sclerosis Optic neuritis Papilledema
Miscellaneous	Typical migraine Psychogenic

**Table 6: Argyll Robertson Pupil**
Differential list for the Argyll Robertson Pupil, which can be defined as bilateral miotic pupils that constrict to accommodation but are non-reactive to light.
Neoplastic	Pinealoma
Infectious	Meningovascular syphilis Brainstem encephalitis
Endocrine	Diabetes Mellitus
Toxic	Alcoholism

**Table 7: Marcus Gunn Pupil (Afferent defect)**
Differential list for a Marcus Gunn pupil, which can be defined as a pupil which demonstrates greater pupillary sphincter contraction consensually than by direct exposure. The etiology of this finding is a prechiasmal disruption of the optic pathway.
Neoplastic	Olfactory groove meningioma Optic glioma
Vascular	Hemorrhage (vitreous)
Inflammatory	Multiple sclerosis Optic neuritis
Miscellaneous	Retinal detachment Macular degeneration

**Table 8: Adie Tonic Pupil**
Differential list for Adie tonic pupil, which can be defined as a pupil that is tonically dilated and slowly reactive to light exposure. Tonic accommodation is commonly observed. Etiology of this condition relates to neurodegeneration within the ciliary ganglion.
Neoplastic	Midbrain tegmental tumors
Vascular	Ischemia Amyloidosis
Infectious	Meningovascular syphilis Herpes zoster Measles Influenza Cellulitis Other viral agents
Toxic	Alcohol
Congenital	Familial dysautonomia CMT disease
Inflammatory	Sarcoidosis Rheumatoid arthritis GBS Miller-Fisher syndrome Sjogren syndrome Shy-Drager syndrome Orbital vasculitis
Miscellaneous	Trauma Ocular migraine Post-orbital surgery Paraneoplastic syndrome Ross syndrome Oculomotor nerve palsy

**Table 9: Hippus**
Differential list for Hippus, which can be defined as alternating miosis and mydriasis of the pupil under a consistent light source.
Vascular	Infarction (contralateral)
Infectious	Meningitis
Inflammatory	Multiple sclerosis
Miscellaneous	Idiopathic Cataracts (during initial stages) Oculomotor palsy recovery Hysteria

**Table 10: Miosis**
Differential list for miosis. Those causes that induce a unilateral miosis are specifically noted.
Vascular	Hemorrhage (pontine)
Infectious	Neurosyphilis (rarely unilateral)
Toxic & Pharmacologic	Cannabinoids MAOI Guanethidine Opioids Phentolamine Cholinergics Cholinesterase inhibitors Barbiturates Reserpine
Miscellaneous	Horner’s syndrome (unilateral) Argyll Robertson pupil Advanced age

**Table 11: Mydriasis**
Differential list for mydriasis. Those causes that induce a unilateral mydriasis are noted.
Neoplastic	Supratentorial mass induced rostrocaudal deterioration Tectal mass inducing Parinaud’s syndrome
Vascular	Aneurysm (PCA, P-comm, SCA)
Infectious	Acute ciliary ganglionitis
Endocrine	Thyrotoxicosis
Toxic & Pharmacologic	Epinephrine Phenylephrine Cocaine Amphetamines LSD TCA Anticholinergics Cyclopentolate Antihistamines Thiopental
Miscellaneous	Cluster headaches (unilateral) Uncal herniation (unilateral) Adie pupil syndrome (unilateral) Pseudodilation (from a contralateral constriction syndrome) Epilepsy (post-ictal) Hyperemotional state

**Table 12: Internuclear Ophthalmoplegia**
Differential list for internuclear ophthalmoplegia, which is a syndrome resulting from a lesion of the medial longitudinal fasciculus between the 3^rd and 6^th cranial nerves nuclei. This disorder manifests as diplopia on lateral gaze and disconjugate eye movements.
Neoplastic	Intra-axial brainstem tumors Extra-axial brainstem tumors 4th ventricular tumors Metastasis
Vascular	Brainstem infarction
Infectious	Brainstem encephalitis Tertiary syphilis
Metabolic	Hepatic encephalopathy Maple syrup urine disease
Toxic	TCA Barbiturates Phenothiazines Phenytoin Wernicke’s encephalopathy (pINO)
Congenital	Chiari II (syringobulbia associated) Chiari III (syringobulbia associated)
Inflammatory	Multiple sclerosis SLE Myasthenia gravis (pINO) GBS (pINO) Miller-Fisher syndrome (pINO)
Miscellaneous	Trauma Exotropia (pINO) Progressive supranuclear palsy

**Table 13: Vertical Gaze Palsy**
Differential list for vertical gaze palsy
Neoplastic	Pineal tumors 3^rd ventricular tumors Intra-axial midbrain tumors Infarction (dorsal midbrain) Hemorrhage (dorsal midbrain)
Vascular	Infarction (dorsal midbrain) Hemorrhage (dorsal midbrain)
Endocrine	Thyroid-associated orbitopathy (mimic)
Metabolic	Hypovitaminosis B1 or B12 Niemann-Pick disease, type C Gaucher’s disease
Congenital	Congenital oculomotor apraxia Congenital upward gaze limitation (mimic)
Inflammatory	Multiple sclerosis GBS (mimic) Miller-Fisher syndrome
Miscellaneous	Trauma Hydrocephalus

**Table 14: Acute Ophthalmoplegia**
Differential list for acute ophthalmoplegia. Oculomotor nerve palsy is most commonly observed with the presence of an aneurysm at the interface between the P-Comm and ICA. Abducens nerve palsy is more commonly observed with aneurysms of AICA or the basilar artery.
Neoplastic	Pituitary adenoma Brainstem glioma Craniopharyngioma Pineal tumors Lymphoma Nasopharyngeal carcinoma Optic glioma Orbital dermoid cyst Orbital rhabdomyosarcoma Cavernous hemangioma of the orbit Metastatic neuroblastoma
Vascular	Aneurysm (AICA, basilar, P-Comm, ICA terminus) Hemorrhage (brainstem) Inferior petrosal sinus thrombosis Cavernous sinus thrombosis Carotid-cavernous sinus fistula
Infectious	Encephalitis Botulism Diphtheria
Endocrine	Thyrotoxicosis
Toxic	TCA Antiepileptic drugs
Inflammatory	Myasthenia gravis Orbital pseudotumor Pseudotumor cerebri Tolosa-Hunt syndrome Sarcoidosis
Miscellaneous	Trauma Idiopathic cranial nerve palsy Ophthalmoplegic migraine

**Table 15: Papilledema**
Differential for papilledema
Neoplastic	Melanocytoma Hemangioma Hemangioblastoma Metastatic (lung, breast, leukemia) Meningeal carcinomatosis Tumors that compress the intraorbital optic nerve
Vascular	Hematoma (epidural, subdural, parenchymal) AION
Infectious	Cerebral abscess Meningoencephalitis Lyme disease Neurosyphilis
Congenital	Congenital disk elevation (pseudopapilledema)
Endocrine	Juvenile diabetes (unilateral)
Inflammatory	Sarcoidosis Papillitis (unilateral) Arteritis (SLE)
Miscellaneous	Post-traumatic cerebral edema Foster-Kennedy syndrome (unilateral) Acute obstructive hydrocephalus

**Table 16: Optic Nerve Enlargement**
Differential for enlargement of the optic nerve
Neoplastic	Optic nerve sheath meningioma Intracranial meningioma (extension to optic nerve) Optic nerve glioma Plexiform neuroma Metastasis (breast, prostate, lung, Ewing’s sarcoma, leukemia, neuroblastoma)
Infectious	Lyme disease Syphilis Tuberculosis Whipple’s disease Toxoplasmosis Histoplasmosis Cryptococcus Viral encephalitis Poliomyelitis Herpes zoster Measles Mumps Rubella Mononucleosis
Metabolic	Adrenoleukodystrophy
Inflammatory	Multiple sclerosis Optic neuritis Neuromyelitis optica Sarcoidosis Idiopathic inflammatory pseudotumor Inflammatory bowel disease (CD, UC) Reiter’s syndrome

**Table 17: Horner’s Syndrome**
Differential list for Horner’s syndrome. The specific neuron involved in the pathway (first, second, or third order) is listed along with each etiology as 1, 2, or 3, respectively. The first-order neuron connects the hypothalamus with the intermediolateral cell column in the upper thoracic cord. The second-order neuron connects the intermediolateral cell column to the superior cervical ganglion. The third-order neuron completes the pathway from the superior cervical ganglion to the orbit.
Neoplastic	Pontine glioma (1) Upper cord glioma (1) Upper cord ependymoma (1) Upper cord neurofibroma (2) Upper cord schwannoma (2) Pancoast tumors of the lung (2) Cervical paravertebral mass (2) Axillary metastasis (2)
Vascular	Infarction (lateral medullary, dorsolateral pontine, hemisphere) (1) Cavernous sinus lesion (3) Carotid artery dissection (3) Carotid artery trauma (3)
Infectious	Encephalitis Bulbar poliomyelitis (1)
Congenital	Cervical rib syndrome
Inflammatory	Multiple sclerosis (1) ALS (1)
Miscellaneous	Cervical cord trauma (1) Lower brachial plexus trauma (2) Cervical disk herniation (2) Cluster headache (3) Syringobulbia (1) Superior orbital fissure lesions (3) Iatrogenic surgical injury during ACDF, pharyngeal, laryngeal, or thyroid surgery (2)

DOI: https://doi.org/10.18791/nsatlas.v2.02.1.2

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