Diplopia, Double Vision

  • History
  1. Monocular or binocular
    1. Does it resolve with either eye covered (binocular Diplopia)
      1. Test by covering each eye separately
      2. Monocular Diplopia persists regardless of whether the unaffected eye is open or closed
        1. Contrast with binocular Diplopia, which resolves when one eye is closed
    2. Binocular Diplopia is due to eye misalignment (Cranial Nerve deficit of 3,4 or 6)
    3. Monocular Diplopia is due to tears, Cornea or lens
      1. Emergent evaluation is not needed
  2. Timing red flags
    1. Is it new?
    2. Is it constant?
  3. Does it get worse as the day progresses?
    1. Intermittent Esotropia
    2. Myasthenia Gravis
    3. Decompensated congenital strabsismus
  4. Is the Diplopia vertical, horizontal or both?
    1. Vertical
      1. Third nerve palsy
      2. Fourth nerve palsy
      3. Graves Ophthalmopathy
      4. Myasthenia Gravis
    2. Horizontal
      1. Sixth nerve palsy
      2. Congenital Strabismus
      3. Papilledema
  5. Is the Diplopia the same in all directions?
    1. Distinguishes incomitant vs comitant strabsimus
  6. Is there a childhood history of Strabismus?
    1. Untreated childhood Strabismus persists
  7. Is there a comorbid vascular condition or Diabetes Mellitus
    1. Consider microvascular Cranial Nerve palsy
  8. Are there changes in speech or Swallowing?
    1. Myasthenia Gravis
    2. Temporal Arteritis
    3. Brainstem ischemia
  9. Is there Vision Loss, Headache, or jaw pain?
    1. Temporal Arteritis
  10. Dizziness, Ataxia, whooshing sound, metal taste?
    1. Increased Intracranial Pressure (may demonstrate sixth nerve palsy)
  11. Is there a third nerve palsy (eye looks down and out, Mydriasis, or may be subtle with mild Ptosis)?
    1. Emergently exclude Posterior Communicating Artery aneurysm (with CT and CTA)
  12. Are there other neurologic findings that are not anatomically related?
    1. Multiple Sclerosis
  • Causes
  • Urgent
  1. Aneurysm (Posterior Communicating Artery)
    1. Worst Headache
    2. Third nerve palsy (Ptosis, eye looks down and out)
    3. Mydriasis may be present
  2. Temporal Arteritis (presents with transient Diplopia in 25% of cases)
    1. Fever, Night Sweats, Jaw Claudication
    2. Sixth Cranial Nerve palsy may occur
    3. Associated with Polymyalgia Rheumatica
    4. Obtain CRP, ESR
  3. Increased Intracranial Pressure
    1. Headache, Ataxia, Nausea, whooshing sound in ear
    2. Metallic Taste in mouth
    3. Esotropia or sixth Cranial Nerve palsy
    4. Causes: Mass lesions, Pseudotumor Cerebri
  4. Multiple cranial Neuropathy (CN 2-6)
    1. Cavernous Sinus Thrombosis (MR Venogram or CT Venogram)
    2. Orbital apex syndrome (CT orbits with contrast)
  5. Other Posterior Circulation finding (Vertigo, Aphasia, Ataxia) or multiple adjacent Cranial Nerves
    1. Brainstem or posterior circulation Cerebrovascular Accident or mass
  6. Trauma
    1. Blowout Fracture of orbit
    2. Orbital Congestion
    3. Neurological injury/lesion
  • Causes
  • Non-urgent
  1. Cranial Nerve palsy
    1. Fourth nerve palsy (Image and refer to eye and neuro)
      1. May be due to congenital cause, Trauma or microischemic palsy
      2. Easily missed on exam
      3. Corrected with prisms if symptomatic Vertigo or Diplopia (occurs with Fatigue, stress, aging)
    2. Sixth nerve palsy
      1. Most common Cranial Nerve palsy
      2. Exclude Increased Intracranial Pressure (fundoscopic exam, Eye Ultrasound, or LP opening pressure)
      3. Isolated sixth nerve palsy may be evaluated in outpatient setting with MRI Brain
        1. May delay imaging up to 3 months in adults, and consider MRI if does not resolve
        2. MRI Brain for all children with sixth nerve palsy (25% have compressive tumors)
      4. May be associated with Head Tilt
      5. May resolve spontaneously if microischemic sixth nerve palsy (esp. if age >50 with vascular risks)
        1. Associated with higher risk for future hemispheric stroke
  2. Incomitant Strabismus (not same in all gaze directions)
    1. Graves Ophthalmopathy (restricted EOM)
  3. Comitant Strabismus (same in all gaze directions)
    1. Childhood Strabismus
    2. Increased Intracranial Pressure
    3. Intermittent Exotropia
    4. Accomodative Esotropia
  • References
  1. Claudius, Shoenberger and Margolin in Herbert (2018) EM:Rap 18(12): 8-9
  2. Trobe (2012) Physicians Guide to Eye Care, AAO, San Francisco, p. 38-40