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Diplopia

Diplopia is commonly described as the simultaneous perception of two images of a single object or seeing double

 A common complaint in both inpatient and outpatient neurological practice De Lott LB et al have shown in a study that almost 805000 ambulatory and 50000 emergency room visits in the US yearly where the main complaint was diplopia

Underlying cause can be both neurological and ophthalmological The causes can studied based on if the diplopia is monocular or binocular

 

Monocular diplopia – If the symptom persist with one eye closed – it is monocular The causes of monocular diplopia are usually ophthalmological with refractive error being the most common Causes of include
- cataract
- corneal shape problems like keratoconus
- astigmatism
- corneal scarring
- dislocated lens
- dry eyes
- poorly centered intraocular lenses
- severe structural retinal pathology
- macular disease Primary or secondary visual cortex disorder ( usually bilateral monocular diplopia )

 

This happens due to misalignment of the eyes / visual axis and must be considered neurological in origin Binocular diplopia resolves when one eye is closed Causes of binocular diplopia includes

Cranial -isolated cranial nerve 3rd , 4th , 6th palsy
combined cranial neuropathy

Neuromuscular ( myasthenia gravis , botulism )

Oribital infiltration – e.g thyroid infiltrative ophthalmology , orbital pseudomotor

Other causesCVA affecting pons / midbrain
Compressive lesions e.g aneurysms , tumour
Trauma -orbital fracture , haematoma , inflammation / infectious , orbital myositis , tumours near base of skull / sinuses / orbits , GBS , Miller Fiser , MS , Wernicke’s encephalopathy.

 

Patient c/o Diplopia- first step is to establish if this is monocular or binocular –What does the patient mean When did it start Is the vision affected Previous h/o diplopia Associated symptoms H/O trauma H/O previous eye problems for e.g in childhood squint amblyopia ,
eye muscle surgery , new glasses Medical history Medications – some medications.

 

To test if this is monocular or binocular you could use -
 Cover test – cover each eye and ask the patient if they see single or double Pinhole test – monocular diplopia is most likely to resolve.

 

Eyelids -R/O ptosis ( 3rd N palsy or myasthenia ) Eyeball R/ proptosis ( protrusion of eyeball ) Check VA Pupil size and responses Examine eye movements ( nystagmus ) Cranial nerve and peripheral nervous system Papilloedema Scalp tenderness ( if associated headache GCA ) hearing loss ( CN VIII )

 

Monocular diplopia – Patient is seeing double with one eye open Two images are viewed by a single eye Monocular diplpoia persists in one eye despite covering the other eye Monocular diplpoia can usually be corrected by using a pinhole It can be uni or bilateral The second image appears as an overlap , ghost , shadow , haze image This can happen due to three conditions
- light diffraction
- cerebral polyopia
- metamorphopsia Ensure patient is not experiencing metamorphosia – in which the objects appear mis-shapen ( distinguishing between the two can be difficult )

 

Binocular diplopia -Patient is seeing double with both eyes open It can be corrected by covering either eye -diplopia would resolve Causes of ocular misalignment are are broadly localised to supranuclear , internuclear , infranuclear , neuromuscular junction , extraocular muscle or orbital dysfunction Ask about
- constant or intermittent
- direction ( horizontal , vertical or oblique )
-present at near , distance or both
- ocular fatigue Ask about h/o head trauma Assess for brainstem symptoms and any patient with who presents with acute onset
binocular diplopia with symptoms as vertigo , dizziness , dysarthria , 
crossed motor or sensory symptoms , ataxia , imbalance etc Check for ptosis H/O excessive alcohol Check is associated with headache , pain with attempted eye movement , ptosis , dyspnoea , weakness or in patients > 55 with symptoms suggestive of GCA Arrange TSH / fT4 if thyroid disease suspected

References

  1. Diagnostic Approach to Diplopia Marc Dinkin, MD Continuum (Minneap Minn) 2014;20(4):942–965 American Academy of Neurology
  2. Approach to Diplopia
    By Christopher C. Glisson, DO, MS, FAAN American Academy of Neurology October 2019
  3. Diplopia from https://neurology.uams.edu/wp-content/uploads/sites/49/2018/03/diplopia-evaluation-humaira.pdf
  4. Management of diplopia
    Iliescu Daniela Adriana, Timaru Cristina Mihaela, Alexe Nicolae, Gosav Elena,
    De Simone Algerino, Batras Mehdi, Stefan Cornel
    Ophthalmology Department, “Dr. Carol Davila” Central Military University Emergency Hospital,
    Bucharest, Romania Romanian Journal of Ophthalmology, Volume 61, Issue 3, July-September 2017. pp:166-170 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710033/pdf/RomJOphthalmol-61-166.pdf
  5. Danchaivijitr CKennard C
    Diplopia and eye movement disorders
  6. Binocular Diplopia
    A Practical Approach
    Janet C. Rucker, MD, and Robert L. Tomsak, MD, PhD (The Neurologist 2005;11: 98 –110 )
  7. Back to the Basics, Part 4: The Diagnosis Behind Diplopia Double vision may be due to a simple refractive error or something more ominous, so any complaint is cause for concern and requires a careful work-up. Nadine Girgis, O.D. https://www.reviewofoptometry.com/article/back-to-the-basics-part-4-the-diagnosis-behind-diplopia

  8. Najem K, Margolin E. Diplopia. [Updated 2020 Jul 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441905/
  9. THE TWO-MINUTE APPROACH TO MONOCULAR DIPLOPIA AK Tan1,2 MD; HA Faridah1 MS(UKM) Malaysian Family Physician 2010; Volume 5, Number 3
    ISSN: 1985-207X (print), 1985-2274 (electronic)
  10. A case of double vision Mohamed-Syarif Mohamed-Yassin, Noorhida Baharudin, Norasyikin Mustafa The Royal Australian College of General Practitioners 2017 https://www.racgp.org.au/download/Documents/AFP/2017/March/AFP-Clinical-Mohamed.pdf
  11. Monocular vs Binocular
    Diplopia BRENDA BODEN, CO
    PARK NICOLLET PEDIATRIC AND ADULT STRABISMUS CLINIC https://www.healthpartners.com/institute/wp-content/uploads/2018/04/3-F-3-Boden.pdf
  12. Double vision BMJ 2015351 doi: https://doi.org/10.1136/bmj.h5385 (Published 18 November 2015)

  13. Alves M, Miranda A, Narciso MR, Mieiro L, Fonseca T. Diplopia: a diagnostic challenge with common and rare etiologies. Am J Case Rep. 2015;16:220-223. Published 2015 Apr 13. doi:10.12659/AJCR.893134 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4410729/#__ffn_sectitle

 

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