To image or not to image is a critical question in patients with isolated acute-onset ocular motility disorders (AOMD), without any neurological symptoms/signs. Imaging may help in diagnosis; but is associated with risks and costs. The study aimed to evaluate radiological findings in patients with apparently isolated AOMD on clinical exam, and identify patient/disease characteristics more likely to be associated with positive imaging.

A retrospective review of patient charts with isolated AOMD (<3 months onset), who were examined by an ophthalmologist and had imaging at a tertiary-care center over a period of 18 months, was conducted. Ophthalmology exam and diagnostic imaging findings were recorded. Radiological findings were classified as “clinically relevant”, “non-relevant”, and “normal/no positive” findings.

46 patients were included (3–91 years; 27 males, 19 females). 19 were clinically classified as nerve palsy (1 third, 10 fourth, and 8 sixth nerve), 14 acute-onset esotropia, 3 acute-onset exotropia, 7 acute-onset vertical strabismus inconsistent with nerve palsy, and 3 limitation of elevation/suspected dorsal midbrain syndrome. We found 8/46 (17%) with clinically relevant imaging findings; of these, 5/46 (11%) had positive neuro-imaging findings (mass, malformation, aneurysm, infarct) and 3/46 (7%) had positive orbital imaging findings (thyroid eye disease). Positive neuro-imaging was more common in patients with certain symptoms (headache), in certain clinical diagnostic entities (dorsal midbrain syndrome spectrum, acute-onset esotropia), and in younger patients (<40 years).

Positive neuro-imaging findings may be seen even in patients with apparently isolated ocular symptoms/signs on clinical exam. This data may help institutions with decision-making and policy formulation for imaging patients with isolated AOMD.