Definition of Diplopia Our Double Vision Main Article provides a comprehensive look at the who, what, when and how of Double Vision Definition of Diplopia Diplopia: A condition in which a single object appears as two objects. Also known as double vision . Last Editorial Review: 5/13/2016 Use the pill finder tool on RxList. Suggested Reading on Double Vision by Our Doctors Related Diseases & Conditions Get the latest health and medical information delivered direct to your inbox! Trending on MedicineNet Get the Latest health and medical information delivered direct to your inbox! From ©1996-2017 MedicineNet, Inc. All rights reserved. Terms of Use. MedicineNet does not provide medical advice, diagnosis or treatment. See additional information . Health Categories Double Vision (Diplopia): Causes, Symptoms, Diagnosis, and Treatment Weakness in your eyes or anywhere else Droopy eyelids How Is It Diagnosed? Double vision that's new or unexplained needs medical care right away. With so many potential causes, it's important to discover the reason without delay. Your doctor will most likely use more than one method to find out what’s causing your problem.

He might try blood tests, a physical exam , and maybe an imaging test like computed tomography (CT) or magnetic resonance imaging (MRI). One of the most effective tools for your doctor is the information you provide. Think about these questions before your appointment. When did the double vision start? Have you hit your head, fallen, or been unconscious? Were you in a car accident? Is the double vision worse at the end of the day or when you're tired? Have you had any other symptoms besides double vision? Do you tend to tilt your head to one side? Look at old pictures, or ask family -- you may not even be aware of the habit. Now, focus on something in your field of vision that isn’t moving, like a window or a tree. Are the two objects side by side, or is one on top of the other? Or are they slightly slanted? Which one is higher or lower? Are both images clear but not in line? Or is one blurry and the other clear? Cover one eye, then switch. Does the problem go away when either eye is covered? Pretend your field of vision is a clock face. Move your eyes around the clock, from noon to six and around to 12 again.

Is your vision worse at any clock position? Does any position make it better? Tilt your head to the right, then to the left. Do any of these positions improve your eyesight or make it worse? Continued Double Vision (Diplopia): Causes, Symptoms, and Treatments - Medical News Today Double Vision (Diplopia): Causes, Symptoms, and Treatments Written by Tim Newman Reviewed by University of Illinois-Chicago, School of Medicine 3.5 20 When an individual sees a double image where there should only be one, it is referred to as double vision or diplopia. The two images can be side by side, one on top of the other, or a combination of both. Double vision can affect just one eye (monocular) or both eyes (binocular). Treatments vary depending on the cause and type but include eye exercises, specially designed glasses, and surgery. Other than the obvious difficulties of navigating the world while viewing a double image, double vision can also cause disruptions in balance, movement and reading ability. There are a number of potential causes for double vision. As a result, the treatment depends on the particular patient. Some of the underlying causes are minor, others are serious.

For this reason, any instances of double vision should be checked by a doctor sooner rather than later. This article will take a look at the potential causes, diagnosis, and treatment of double vision. Fast facts on double vision (diplopia) Here are some key points about double vision (diplopia). More detail and supporting information is in the main article. Double vision can be caused by a number of underlying conditions Diplopia can affect just one eye or both A childhood squint can sometimes recur and cause double vision Temporary double vision can be caused by alcohol or other recreational drugs Treatments can include surgery, eye exercises, or corrective lenses Causes of binocular double vision Double vision can be caused by a number of conditions. Each eye creates its own image of the environment. These two representations are combined by the brain so that they are be perceived as one clear picture. If damage occurs to the muscles that move the eyes or the nerves that control that movement, a double image can be created. It is necessary for both eyes to be functioning together to create depth of field. Alternatively, the muscles moving the eyes can become weakened by certain illnesses and produce double vision. Squint In some cases, the eyes may not be properly aligned.

This condition is referred to as a squint or strabismus. Squints are relatively common in children but do not necessarily result in double vision. Squints cause the eyes to look in slightly different directions. This might be because the affected eye muscle(s): Are paralyzed or weak Are too strong Have abnormal nerves controlling them Sometimes, a squint can recur in people who had a squint as a child. In some cases, the treatment of a squint can actually cause double vision, despite the individual's vision being normal before the squint was treated. This is because the brain had been suppressing signals from one of the eyes in an attempt to maintain normal vision. Temporary double vision In some cases, double vision can be temporary. Temporary double vision is often caused by alcohol intoxication, benzodiazepines, opioids, or certain types of drugs for seizures and epilepsy . Head injuries, like concussions , can also cause temporary double vision. Being particularly tired or having strained eyes can bring on temporary double vision. If normal vision does not come back quickly, medical attention should be sought as soon as possible. Other causes of double vision Other than a squint, there are a number of potential conditions that can cause double vision.

These include: Certain thyroid problems can cause double vision. Thyroid: the thyroid gland is situated in the neck and produces a hormone called thyroxine. Changes in thyroid function can affect the external muscles that control the eye. This includes Grave's disease . Stroke or transient ischemic attack: blood vessels supplying the brain or nerves controlling the eye muscles can be affected. Aneurysm: an aneurysm is a bulge in a blood vessel. This can press on the nerve of the eye muscle. Convergence insufficiency : a condition where the eyes do not work together correctly. The cause is unknown, but it is thought to be due to the muscles that control the eye not lining up properly. Keratoconus : a degenerative condition of the eye that causes the cornea to thin and become cone-shaped. Diabetes: the blood vessels that supply blood to the retina at the back of the eye can be affected by diabetes . Myasthenia gravis: this condition can cause weakness in the body's muscles, including those controlling the eyes. Brain tumor/cancer: a tumor or growth behind the eye can interfere with free movement or damage the eye's nerves.

Multiple sclerosis: a disease that affects the central nervous system , including nerves that supply the eyes. Head injury: physically damaging the brain, nerves, muscles, or eye socket can restrict the movement of the eye and its muscles. Causes of monocular double vision If double vision is noted when one eye is covered and not when the other eye is covered, this is referred to as monocular double vision . Monocular double vision is less common than binocular double vision and can be caused by the following conditions: Astigmatism: the cornea is irregularly shaped (the transparent layer at the front of the eye). This causes a refractive error; in other words, the light is bent more, or less, than it should be. Dry eye: the eye does not produce enough tears, or it dries out too quickly Black eye: an injury can cause blood and fluid to collect around the eye. This can press on the eye itself or the muscles and nerves around it. Abnormality of the lens: for instance, cataracts , which are cloudy patches over the lens Abnormality of the retina: for example, macular degeneration , where the center of an individual's field of vision slowly disappears.

Diagnosing double vision Diagnosing double vision can be challenging for an ophthalmologist (eye specialist) because of the vast array of potential causes. An article on the American Academy of Ophthalmology 's website states the problem: "The patient who complains of double vision can have something as benign as dry eye or as life-threatening as an intracranial tumor. The cause may be as rare as Wernicke encephalopathy or as common as convergence insufficiency." Miriam Karmel The first question a specialist will ask to reduce the number of potential causes is whether the double vision is monocular or binocular. If the double vision is monocular, it means that the problem is more likely to be within the eye, rather than in the nerves and therefore less serious. Diagnosing double vision in children Because children cannot express what they are perceiving, diagnosing double vision in children can be more difficult.

Things to watch out for include: Squinting or narrowing the eyes to see Covering one eye with their hand Turning their head in an unusual way Looking at objects from the side rather than facing forward Flicking eyes side to side, between images Treatments for double vision The course of treatment for double vision depends on the underlying cause: Astigmatism Astigmatism refers to an abnormally curved cornea. In many cases, corrective lenses (glasses or contact lenses) can counteract the curvature and correct the passage of incoming light into the eye. Laser surgery is another option. This treatment involves reshaping the cornea with a laser. Cataracts Cataracts occur in more than half of Americans over the age of 80 and can sometimes cause double vision. In most cases, surgery is the best option. The surgical procedure removes the clouding and the cause of the double vision. Unfortunately, the operation itself can sometimes lead to double vision.

Treatments for binocular double vision Depending on the cause, the treatments for binocular vision vary, but they include: Wearing glasses Wearing an opaque contact lens Fixing thin, plastic, see-through prisms to glasses Botulinum toxin (Botox) injections into the eye muscles cause them to remain relaxed Wearing an eye patch Surgery on the muscles of the eye to correct their positioning Opaque intraocular lens Opaque intraocular lenses are an option for people with cataracts. They are only used once other methods to treat binocular double vision have failed. The procedure involves removing the lens of the eye and replacing it with an implant. Although the procedure is considered relatively safe, there are some associated risks. For instance, the intraocular lens can break up after it has been inserted. Dry eye syndrome If the eyes do not produce enough tears or dry out too quickly, the eyes can become inflamed and sore. This can result in double vision. Often, a prescription for tear substitute eye drops will clear up the condition. Only in very rare cases will surgery be needed.

Click the stars to rate this article Double Vision (Diplopia): Causes, Symptoms, and Treatments Public / Patient Diplopia Definition - Double Vision Double Vision By Troy Bedinghaus, OD Updated April 10, 2016 Are you seeing double? Double vision is the simultaneous perception of two images of a single object. The images may be displaced horizontally, vertically, diagonally, or rotationally in relation to each other. What is double vision? Double vision usually occurs when the eyes are misaligned, or not pointed at the same object, causing us to see two different images. Both images are sent to the brain which we process as double vision. Most of the time, both of our eyes are pointed at the same object. This produces a clear, single image with just enough difference between the two images to give us a slightly different line of sight. This subtle difference gives us depth perception , often referred to as stereo vision. In fact, the farther apart an animals eyes are, the better depth perception it has. Double vision can cause problems in life, including great difficulty in completing simple tasks. Luckily, the brain naturally guards against double vision by suppressing, or ignoring, one of the two images.

We have a complex set of eye muscles and nerves that communicate with each other to keep both eyes moving along together. Causes of Double Vision The medical term for double vision is diplopia. Diplopia can be intermittent or constant. Because the pathway for the three main nerves that control eye muscle movement is long, complex and originates in the brain, double vision can be a sign of a serious neurological problem. A defect anywhere along these pathways can possibly cause double vision. Some defects are caused by an injury to the head, stroke, aneurysm, brain tumor or brain swelling. Diabetes, hypertension and multiple sclerosis are common diseases that can cause a temporary paralysis of the nerves that control the eye muscles, which may cause double vision. Another cause of double vision is strabismus . Strabismus is a condition that causes the eyes to be misaligned, often referred to as an "eye turn." Most people with strabismus are born with it and have an eye that tends to move inward or outward. Strabismus can also cause one eye to be pointed up or down. In many infants, it is difficult to find a true cause.

Sometimes strabismus is caused by a large refractive error (need for prescription glasses) and sometimes eye tumors. Most young children do not suffer from double vision even though their eyes are misaligned. Our brain often compensates and prevents us from seeing double by suppressing one of the images and making it disappear. Our brain learns to ignore the extra image, known as suppression. Children seem to adapt quickly and their brains suppress one of the images quickly. However, when one image is suppressed, a child is at risk for developing amblyopia, often referred to as lazy eye, because the eye is not being used properly. When strabismus develops in adults, double vision is more likely to occur. An adult brain has difficulty suppression one image at first because for a large part of their life, both eyes were functioning to their fullest potential. Monocular Diplopia For the most part, you must have two fully functioning eyes to experience double vision. However, there is one type of double vision that can occur in one eye, called monocular diplopia. The most common cause of monocular diplopia is a cataract . A cataract is a clouding and opacification of the normally, clear lens inside the human eye.

Most cataracts develop as we age. Some cataracts can be caused by trauma to the eye. Occasionally, the clouding occurs in sharp junctions in the lens which causes light to split into two when it enters the eyes. Some individuals perceive that as double vision. Astigmatism can also cause double vision out of one eye. Astigmatism , a common vision problem that distorts vision, can sometimes elongate or stretch out an image so much that it appears to be double. Treatment of Double Vision Cover It - The simplest form of treatment of double vision is to cover one eye with a patch. This quickly eliminates one image but has the negative side effect of decreasing your dimensional vision or depth perception. Fresnel “Press-on” Prism - Another useful way of treating double vision is to apply a Fresnel prism on top of your eyeglasses. Fresnel prism is a thin sheet of many little prisms that shift light in a certain direction. The prism moves the image that the misaligned eye is seeing into a position so that both eyes can fuse the image into a single, clear image. Fresnel prism has the advantage of being temporary.

The fresnel prism can be peeled off of the glasses easily as the diplopia resolves itself. Fresnel prism is useful when double vision is caused by conditions such as diabetes or hypertension. Most often, the double vision lasts less than 6-9 months and then goes away when the underlying systemic condition is being treated. Ophthalmic Prism - If double vision is more permanent, then regular, ophthalmic prism can be ground into your eyeglass prescription. It occasionally increases the thickness of the lens on one side but is better looking cosmetically than a Fresnel prism. Vision Therapy - Vision Therapy (VT) encompasses a lot of different techniques to correct double vision and strabismus. Sometimes certain machines and computer models are used to give the person behavioral feedback to control the double vision. Other times, specific eye muscle exercises are done to strengthen the eye muscles. Surgery - Surgery for double vision is very successful in most cases. Eye surgeons who specialize in eye muscle surgery use a variety of techniques that involve shortening or moving eye muscles. Adjustable sutures are used to fine tune the eye muscle correction directly after surgery. Botox - Botulinum toxin is injected directly into one of the muscles controlling eye movement.

This temporarily blocks the nerve impulse and causes the muscle to be paralyzed. This muscle relaxes and the other eye muscles take up the slack to straighten the eye. Side effects including a droopy eyelid or worsened double vision. What You Should Know Double vision is a serious health concern. However “sudden onset” double vision is of special concern. When diplopia comes on suddenly, a neurological problem in your brain should always be ruled out before investigating more common causes. If you are experiencing double vision, you should be evaluated by an optometrist, ophthalmologist , neurologist or other medical professional immediately. Upon evaluation, your doctor will ask you the following questions: Did the double vision appear suddenly, or has it been there for some time? Is it constant, or does it seem to come and go? Does the double vision go away when you cover one eye? Do you see double out of one eye, or both eyes? Source: Neuro-Ophthalmology - Textbook of Ophthalmology. Slamovits, Thomas L. and Ronald Burd. Copyright 1994, Mosby-Year Book Europe, Ltd.

Continue Reading Diplopia: Background, Pathophysiology, Epidemiology Pathophysiology Overview Background Diplopia is the subjective complaint of seeing 2 images instead of one and is often referred to as double-vision in lay parlance. The term diplopia is derived from 2 Greek words: diplous, meaning double, and ops, meaning eye. Diplopia (double vision) is a common subjective complaint, or diplopia may be elicited during the course of an eye examination. Diplopia is often the first manifestation of many systemic disorders, especially muscular or neurologic processes. [ 1 ] An accurate, clear description of the symptoms (eg, constant or intermittent; variable or unchanging; at near or at far; with one eye [monocular] or with both eyes [binocular]; horizontal, vertical, or oblique) is critical to appropriate diagnosis and management. [ 2 , 3 ] Binocular diplopia can be corrected by covering either eye; monocular diplopia persists in one eye despite covering the other eye.

Physiologic diplopia is a normal phenomenon depending on the alignment of the ocular axes with the objects of regard (eg, focusing on a finger held close results in distant objects being blurry but double). Polyplopia refers to the perception of more than 2 images and is often a monocular phenomenon caused by refractive aberrations resulting in multiple images of one object. In such cases, the dominant image of the object of regard is accompanied by secondary images that may be less intense, distorted, or fleeting. Causes of polyplopia include irregular corneal astigmatism, lenticular opacities, multifocal lenses, and corneal rings of significantly different focality within the pupil created by refractive surgery or contact lenses. Animal models Unless the visual fields of the eyes overlap, binocular diplopia cannot occur. Among vertebrates, the potential for diplopia (and for stereoscopic depth perception) depends on where the eyes are located in the head. Eyes located on either side of the head provide a wide visual field but with a less overlapped visual field. These animals have less field for binocular vision and less risk for diplopia when one eye becomes misaligned.

However, when both eyes are located in the front of the head, a greater visual field overlap exists and, thus, a better binocular depth perception, as frequently seen in predators. Misalignment of such eyes may result in diplopia. Monocular diplopia is often due to optical aberrations resulting in multiple images. The eyes of birds demonstrate many unique anatomical features, one of which is the presence of multiple foveae and, in some cases, a streak fovea linking 2 foveae. Thus, they may be able to have 2 separate areas of regard without disabling diplopia. How the visual perception occurs in these cases remains debatable. Next: Pathophysiology Binocular diplopia (or true diplopia) is a breakdown in the fusional capacity of the binocular system. The normal neuromuscular coordination cannot maintain correspondence of the visual objects on the retinas of the 2 eyes. Rarely, fusion cannot occur because of dissimilar image size, which can occur after changes in the optical function of the eye following refractive surgery (eg, LASIK) or after a cataract is replaced by an intraocular lens.

The distortion of one image may be interpreted as diplopia by the patient; however, the same object does not appear to be in 2 places but rather appears differently with each eye. Monocular diplopia may occur from abnormal ocular media (eg, corneal distortion or scarring, multiple openings in the iris, cataract or subluxation of the natural lens or pseudophakic lens implant, vitreous abnormalities, retinal conditions). Monocular diplopia must be distinguished from metamorphopsia, in which objects appear misshapen. Previous No figures are available as to prevalence of diplopia in the United States. International International incidence rates of diplopia are unknown. The incidence of diplopia as a chief complaint in emergency departments is low. One study of a specialist eye hospital in London, United Kingdom, reported the incidence of diplopia as the chief complaint in only 1.4% of the presenting cases. [ 4 ] Mortality/Morbidity Divergent pathological processes, each with its own morbidity and mortality, can cause diplopia.

However, irrespective of cause, diplopia has significant morbidity in terms of difficulty with depth perception and confusion with orientation of objects, especially when performing visually demanding tasks, such as driving a vehicle or operating tools. Therefore, in assessing visual disability after injuries, loss of binocularity accounts for a major percentage of loss of function. Race No information is available regarding differences in various racial groups. Sex No information is available suggesting differences in prevalence with respect to sex. Age Diplopia is encountered almost exclusively in adults or in those with mature visual systems. Young children may not be able to express this symptom. More importantly, the immature visual system deals with diplopia by suppressing the poorer image, possibly resulting in irreversible amblyopia. Children with obvious and marked ocular malalignment from strabismus are comfortable and content because the visual image from the deviating eye is suppressed and not noticed. In contrast, adults who have mature visual processing pathways cannot easily ignore the second image. Wearing a patch over one eye to prevent visual confusion usually is the only option for these patients. Previous References Rucker JC. Oculomotor disorders. Semin Neurol. 2007 Jul. 27(3):244-56.

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Modification of the classification of the eye changes of Graves' disease: recommendations of the Ad Hoc Committee of the American Thyroid Association. J Clin Endocrinol Metab. 1977 Jan. 44(1):203-4. [Medline] . Woods RL, Bradley A, Atchison DA. Monocular diplopia caused by ocular aberrations and hyperopic defocus. Vision Res. 1996 Nov. 36(22):3597-606. [Medline] . Media Gallery What Is Diplopia? - Definition, Causes & Treatment | Study.com What Is Diplopia? - Definition, Causes & Treatment Watch short & fun videos Start Your Free Trial Today Instructor: Marisela Duque Marisela teaches nursing courses at the college level. She also works as a unit educator, teaching experienced nurses about changes in nursing practice. Add to Add to Add to Want to watch this again later? Log in or sign up to add this lesson to a Custom Course. Custom Courses are courses that you create from Study.com lessons. Use them just like other courses to track progress, access quizzes and exams, and share content.

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A short quiz follows this lesson so that you can test your new knowledge. Seeing Double Sallie is looking forward to her first day of high school. But when she gets to her first freshman class, she has a sense that something is very wrong! Sallie tries to concentrate on her teacher's lecture, but she is seeing two of him! In fact, she is seeing two of everything. She pinches herself hard, expecting to wake up from a nightmare. To her horror, this is really happening! She excuses herself and runs out of class to see the nurse. The school nurse tells Sallie the she has diplopia. As if being a freshman wasn't hard enough! Defining Diplopia Diplopia is a medical term for seeing two of a single object. There are two types of diplopia: monocular and binocular. Monocular diplopia affects only one eye, and binocular is a problem with the alignment of both eyes. Double vision can be a symptom of different eye problems, such as strabismus (crossed-eyes), or it can happen after an accident, like a head injury.

Diplopia may be a symptom of something minor, or it could be a major health concern, so it is important to seek medical advice if you are experiencing double vision. Causes Monocular diplopia is caused by a structural defect in the eye. In this case, the light from a single image is split in two because of a defect in the eye. Cataracts are a common cause of this type of double vision. If cataracts are present, they are easily correctable with minor surgery. Monocular diplopia can also be caused by astigmatism, corneal scars, and corneal shape problems. Binocular diplopia occurs when both eyes cannot focus on the same object you are viewing. This is called ocular misalignment. Normally, each of your eyes looks at a single object and that image is fused into one picture by your brain. When your eyes cannot focus on the same thing, then the image may appear double. Muscle problems affecting the eyes can cause this type of diplopia, such as myasthenia gravis and Graves' disease. Conditions that cause nerve damage, such as diabetes, multiple sclerosis, and Guillain-Barre syndrome, can also cause binocular diplopia.

Stroke, brain tumors, increased pressure inside the brain, and aneurysm are additional causes. Treatment Treatment of diplopia involves diagnosing and treating the underlying cause. For example, if cataracts are causing your double vision, then correcting this will improve your vision. There are some cases where diplopia cannot be reversed. Luckily, there are treatment options available to help you live with double vision. These include: × Double Vision Causes, Symptoms & Treatment Medical Author: Patricia S. Bainter, MD Patricia S. Bainter, MD Dr. Bainter is a board-certified ophthalmologist. She received her BA from Pomona College in Claremont, CA, and her MD from the University of Colorado in Denver, CO. She completed an internal medicine internship at St. Joseph Hospital in Denver, CO, followed by an ophthalmology residency and a cornea and external disease fellowship, both at the University of Colorado. She became board certified by the American Board of Ophthalmology in 1998 and recertified in 2008. She is a fellow of the American Academy of Ophthalmology. Dr.

Bainter practices general ophthalmology including cataract surgery and management of corneal and anterior segment diseases. She has volunteered in eye clinics in the Dominican Republic and Bosnia. She currently practices at One to One Eye Care in San Diego, CA. Medical Editor: William C. Shiel Jr., MD, FACP, FACR William C. Shiel Jr., MD, FACP, FACR Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology. Share Your Story There are dozens of causes of double vision ranging from benign to life-threatening. Therefore, it is important for the doctor to carefully review the history and the examination to determine the cause and initiate appropriate treatment when necessary. Sometimes, emergency treatment is needed. Most causes of monocular diplopia stem from poor focusing of light by the eye. Refractive errors ( myopia , hyperopia , astigmatism ) are common.

Dry eye (from a variety of causes such as meibomitis, Sjögren's syndrome , and decreased tear production following refractive surgery) can produce diplopia that varies with blinking. Cataracts (clouding of the natural lens ) and posterior capsule opacification (after cataract surgery ) are common in people over 60 years of age. Other conditions that interfere with proper focusing of light include corneal irregularity from swelling or scars and retinal conditions, such as epiretinal membranes. Rarely is the underlying cause a medical emergency in cases of monocular diplopia. Binocular diplopia on the other hand is produced by a misalignment of the eyes, which can be caused by life-threatening conditions. For example, aneurysms, strokes, trauma ( head injury ), and brain swelling (such as from brain cancer ) can interfere with the nerves that control the extraocular muscles. The extraocular muscles move the eyes in different direction of gaze, much like the strings on a marionette, and when one or more muscle is weakened or paralyzed, it is referred to as cranial nerve palsy.

In multiple sclerosis , lesions in regions of the brain that control eye alignment may result in diplopia that varies over time. Guillain-Barré syndrome can produce diplopia from restricted eye movement due to nerve damage. Migraine headaches can cause a sudden but temporary eye misalignment. Diseases such as myasthenia gravis can interfere with the communication between the nerves and the eye muscles to cause diplopia. And the eye muscles themselves can be damaged or compressed by conditions such as Graves' disease (often associated with thyroid disease ), orbital inflammations, vascular disease (as seen with diabetes and high blood pressure ), and others. Following traumatic fracture of the orbital bones, muscles and orbital tissue may be trapped in the fracture, leading to restriction of eye movement in certain directions of gaze. Sometimes the cause is relatively harmless, such as when the eye muscles or neurologic signals to the muscles weaken with fatigue or illness. Inability to align the eyes when focusing on a near object (convergence insufficiency) is a common benign cause of intermittent binocular diplopia that can often be treated with prism glasses.

Medically Reviewed by a Doctor on 5/26/2016 Deciphering Diplopia - American Academy of Ophthalmology Deciphering Diplopia Download PDF The symptom is diplopia. But what’s the diagnosis? When your patient sees two images, you may need to consider 20 possible causes, and ruling out 19 of those can be a headache. The various etiologies of diplopia comprise one of the most sweeping differential diagnoses in all of ophthalmology. The patient who complains of double vision can have something as benign as dry eye or as life-threatening as an intracranial tumor. The cause may be as rare as Wernicke encephalopathy or as common as convergence insufficiency. “It’s a huge differential diagnosis,” said Nurhan Torun, MD, director of the neuro-ophthalmology service at Beth Israel Deaconess Medical Center and an instructor of ophthalmology at Harvard Medical School in Boston. “Diplopia tends to be intimidating for many practitioners.” Intimidation may even turn to dread. “When most ophthalmologists see a patient with a chief complaint of diplopia, they hate it,” said Michael S.

Lee, MD, associate professor of ophthalmology, neurology and neurosurgery at the University of Minnesota in Minneapolis. “They often don’t know what to do with the patient.” What they do know, of course, is that the proper workup will take longer than a standard office visit. A multidisciplinary monster. Eric Eggenberger, DO, professor of neurology at Michigan State University in East Lansing, noted that diplopia challenges neurologists as well. “Ophthalmologists are not as comfortable with it as they are with vision loss because many of the diagnoses are neurologic. And neurologists are not comfortable with it because they’re not trained in techniques to measure ocular alignment.” But the consequences of a delayed or incorrect diagnosis are not comfortable, either. “Most double vision is not dangerous. But some is super dangerous,” said Andrew G. Lee, MD. “You have to do a complete and thorough exam to look for the distinctive dangerous sign. That sign could suggest a life-threatening diagnosis. It’s a red flag,” he said. Dr.

Lee is professor of ophthalmology, neurology and neurosurgery at Weill Cornell Medical College in New York as well as chairman of ophthalmology at The Methodist Hospital in Houston, adjunct professor of ophthalmology at the University of Iowa in Iowa City and clinical professor of ophthalmology at the University of Texas in Galveston. The exam of a diplopic patient demands a meticulous history and the posing of questions pertinent to the disposition of double images in various positions of gaze: Is the diplopia monocular or binocular? Are the images horizontal or vertical? Answers to these may determine whether the pathology is neurological or mechanical—involving a nerve, an extraocular muscle or a neuromuscular junction. Question: Monocular or Binocular? The first step in cornering diplopia is to determine whether it is monocular or binocular, said Karl C. Golnik, MD, professor of ophthalmology, neurology and neurosurgery at the University of Cincinnati. If it’s monocular, the patient sees double with only one eye open, and the extra image typically appears as a ghost, Dr. Golnik said.

Causes of this include media or refractive problems, dry eye, warped cornea, cataract, unstable tear film, IOL decentrations, media opacities, the wrong glasses and even uveitis. With binocular diplopia, however, the patient sees double only if both eyes are open. Cover either eye and the patient’s problem disappears—though the physician’s trouble may have just begun. Surprisingly, many doctors assume the diplopia is binocular, without considering monocular, though the differential diagnosis is different for each, Dr. Golnik said. In fact, he explains to referring colleagues that he does not need to see patients with monocular double vision because they typically don’t require a neurological evaluation. “Once you’ve determined it’s monocular, your level of anxiety goes down and your diagnostic techniques switch.” Dr. Michael Lee agreed. “It’s really reassuring if someone has monocular double vision,” he said, explaining that the cause must be within the eye itself. Binocular Dangers Binocular diplopia can be a cause for alarm. It may be a symptom of aneurysm, stroke, neoplasm, myasthenia gravis or trauma.

Even certain infections, such as sinus disease with a fungal infection, can present with double vision, especially in an immune-compromised patient. “There are literally hundreds of potential diagnoses,” Dr. Eggenberger said, and many of them are life-threatening. “Begin by localizing,” he said. “Once you’ve determined location you need to incorporate the patient’s age, demographics, history and other findings on exam to help with understanding the pathophysiology. This keeps you from jumping to conclusions.” Dr. Torun added that an assessment of ocular motility will help narrow things down. “That requires a very careful exam of the misalignment in different positions of gaze and looking for restriction of motility in any position of gaze,” she said. “Unless we make a correct diagnosis of the underlying eye movement problem, our differential is not going to be appropriate.” Dr. Golnik agreed. After the physician establishes binoc- ular diplopia, the next step is to figure out whether there’s a pattern to the misalignment. For example, he said, if it’s comitant—the double vision is the same no matter where the patient turns his head—the problem is less worrisome.

On the other hand, if it’s incomitant—the double vision goes away when the patient turns his head to the left but remains bad when turned right—then it’s time to worry. There are exceptions and nuances, but, said Dr. Golnik, “You can guide diagnostic evaluation better if you can find the pattern.” Five to Fear “There are clearly some life-threatening causes of double vision. Those are the ones an ophthalmologist can’t afford to miss,” Dr. Andrew Lee said. Following are five especially worrying possibilities. Dangerous Sign: Pupil involvement suggesting third-nerve palsy. Dangerous Diagnosis: Aneurysm. Dangerous Prognosis: “The one that’s going to kill you is the third-nerve palsy,” said Dr. Michael Lee, explaining it’s the most common presentation of an aneurysm of the posterior communicating artery. Dr. Golnik added that a third-nerve palsy with a large and poorly reactive pupil is a big red flag, and he doesn’t let the technician dilate the patient until he does the exam. Sometimes, however, the red flag turns out to be a false alarm.

While third-nerve palsy is a warning sign for aneurysm, it could also be associated with high blood pressure or diabetes. For example, Dr. Eggenberger said, an 85-year-old with high blood pressure, diabetes and normal pupils is probably not harboring a compressive lesion, but in a 25-year-old with pain and pupil involvement, the safer assumption would be that it’s compressive. As for those in-between cases, he said, “There’s no cookbook answer. It takes some time. It’s not a quick evaluation. And it’s very individualized. The challenge is in knowing which patient is going to get better in three months and which harbors a life-threatening diagnosis.” Dangerous Sign: Problem with more than one of the following: lid, pupil or eye movement. Dangerous Diagnosis: Horner syndrome (ptosis with small pupil), third-nerve palsy (ptosis with big pupil) or inflammatory disease, such as Guillain-Barré or Miller Fisher variant. Dangerous Prognosis: If any one of the lid, pupil or motility appears abnormal, you have to check the other two, said Dr. Andrew Lee.

“You’re not allowed to have more than one of these neuro-ophthalmic problems at a time.” More than one abnormality requires a referral or a more aggressive evaluation for the life-threatening etiologies, he said. The biggest dangers are aneurysmal third-nerve palsy and Horner syndrome from carotid dissection. Even mild third-nerve palsy could be due to aneurysm, which can kill the patient. Guillain-Barré also can cause death, or systemic paralysis. Dangerous Sign: More than one cranial nerve palsy. Dangerous Diagnosis: Multiple cranial neuropathy. Dangerous Prognosis: Intracranial or meningeal-based tumors, meningitis or polyneuropathy. Involvement of more than one nerve is a huge red flag, Dr. Andrew Lee said. Sixth-nerve involvement by itself in a diabetic patient probably indicates an ischemic mononeuropathy. Likewise, an isolated, complete and pupil-spared third nerve may indicate a benign and isolated ischemic palsy. But involvement of both the third and the sixth is dangerous and could be a cavernous sinus lesion. Dr.

Golnik remembers one patient referred to him with a diagnosis of unilateral sixth-nerve palsy who actually had metastatic lung cancer in the skull base. Dr. Golnik’s exam found involvement with the fifth and seventh nerves, something the referring physician might have found by checking facial sensation and facial muscle strength. Dangerous Sign: Weakness or fatigue, often variable. Dangerous Diagnosis: Myasthenia gravis. Dangerous Prognosis: Respiratory failure or aspiration. Myasthenia gravis can mimic almost any ophthalmoplegia and should be considered in the differential diagnosis of any pupil-spared motility disturbance, said Dr. Andrew Lee. “An ophthalmologist doesn’t have to be a neurologist but does have to ask the neurologic questions,” he said. Those include: Do you have other symptoms? Do you experience weakness in the arms or legs? Hoarseness? Difficulty swallowing? Dr. Torun described a patient who had transient diplopia and a presumed diagnosis of internuclear ophthalmoplegia. Multiple brain scans revealed nothing so the patient was referred to her. Initially, she agreed with the presumptive diagnosis. “But I also saw she had quite variable eye movements.

She had difficulty holding her eyes in an eccentric position, with the eyes drifting toward the center, which is a feature of myasthenia.” The workup for myasthenia was positive, and the patient was later admitted to the hospital in myasthenic crisis. The case illustrated the importance, Dr. Torun said, of early diagnosis of an ocular motility problem, which may be the initial presentation of a serious systemic disorder. Dangerous Sign: Onset of new kind of headache, scalp tenderness, pain with chewing. Dangerous Diagnosis: Giant cell arteritis. Dangerous Prognosis: GCA is a life- and sight-threatening disease that is associated with aortic dissection, cerebral and myocardial infarction. “Remember that giant cell arteritis can cause double vision, either constant or transient,” said Dr. Golnik, who asks every patient over the age of 50 a few giant-cell questions: Have you experienced a new kind of headache? Scalp tenderness? Pain or weakness with chewing? Unexplained weight loss?

Scans Don’t Think, Doctors Do Given the rigors of the diplopia differential diagnosis, it might be tempting to order a scan and let the machine figure it out. But in many situations, costly imaging may not catch a serious problem. For example, myasthenia gravis and giant cell arteritis aren’t apparent on imaging. Alternatively, imaging may indeed yield a life-saving diagnosis but only if the correct scan is aimed at the correct anatomy. Good scan, bad interpretation. CT scans of the orbit can rule out diplopia secondary to thyroid eye disease and orbital tumors, according to Dr. Golnik. “But beware the reportedly ‘normal’ MRI or CT scan when you are looking for an extraocular muscle abnormality,” he warned, because he routinely sees scans that are misread as normal. Pointless scan, pinhole better. What’s more, Dr. Golnik frequently sees patients with monocular diplopia who had had an MRI. “Thousands of dollars were spent, and all I needed was a pinhole test to tell it’s not a neurological problem,” he said. “If you just throw up the pinhole and the second image is gone, the patient can understand they don’t have a brain tumor.” Two bottom lines.

So when are scans warranted? “If it’s not neurologically isolated, you have to image,” Dr. Andrew Lee said. “For example, if you identify a sixth-nerve palsy, you have to also check the fifth and seventh nerves. If one of those is also affected, you have to image.” Age is a guide. In a patient under the age of 50, an image is advised unless there’s a long history of vasculopathic problems, Dr. Golnik said. Conversely, an isolated cranial nerve palsy in a patient over 50 who has high blood pressure and vascular risk factors but no other findings is probably not urgent, Dr. Golnik said. But he advised a six-week follow-up exam. “Hopefully they’ll start to improve. If not, then you need to image.” Transient Diplopia: Dr. Torun’s Differential Diagnosis Decompensated phoria Etiologies Overlooked Some causes of diplopia are easily missed, including: An extra hole in the iris from an iridotomy may cause diplopia, said Dr. Michael Lee.

Double vision may occur if the laser hole falls within the palpebral fissure rather than being hidden underneath the upper lid or if the prismatic effect of the tear meniscus allows light into a superiorly placed iridotomy. “I don’t think it’s something someone would normally think of,” he said. “When you talk about the major causes of monocular double vision, you think of refractive error, dry eye, warped cornea, cataract. The iridotomy is less common.” Thiamine deficiency can cause double vision, Dr. Torun said. Diplopia may be the earliest symptom of Wernicke encephalopathy, which consists of confusion and ataxia, along with ophthalmoplegia. The disease is typically associated with malnutrition and alcoholism, but it can also be seen in patients with gastric bypass procedures, as well as those with eating disorders—bulimia and anorexia. “These patients may have nystagmus or what mimics a sixth-nerve palsy. In severe cases, they may not be able to move their eyes at all,” Dr. Torun said. Untreated, the condition can lead to coma and eventually death.

If treated too late, it can cause neurological problems. But timely administration of intravenous thiamine (vitamin B1) may prevent permanent neurologic sequelae. Convergence spasm is a nonorganic cause of double vision, but it might easily be mistaken for a unilateral or bilateral sixth-nerve palsy or myasthenia, said Dr. Michael Lee. On first glance, the patient’s eyes are crossed and the complaint is double vision. But if the pupils are constricted, it’s likely the patient is deliberately crossing his eyes. “Miotic pupils, in a patient with variable esotropia and abduction deficits, can suggest convergence spasm,” Dr. Lee said. “When evaluating versions, there may be an abduction deficit and the pupils are miotic from convergence. When ductions are performed, the abduction deficit resolves.” He once saw a patient on referral who had undergone a few strabismus surgeries, but the diagnosis was convergence spasm. Skew deviation is a prenuclear vertical misalignment that results from brainstem or cerebellar lesions. It may be com- itant or incomitant, but a diagnostic feature is a marked decrease in the vertical misalignment with the patient in supine position.

Patients may give history of a stroke before onset of diplopia, said Dr. Torun. “If there are no associated brainstem signs and the misalignment is relatively small, it is easy to overlook, especially since motility is usually full.” An epiretinal membrane in one or both eyes can sometimes cause central binocular vertical diplopia, Dr. Torun said. Visual acuity could be quite good, though patients typically describe distortion on an Amsler grid. Motility is full. “This is easy to overlook if the maculopathy is subtle.” Meet the Experts

Question: Diplopia is the medical term for which condition of the human body?
Answer: Double vision