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Diplopia

(Double Vision)

By

Christopher J. Brady

, MD, Wilmer Eye Institute, Retina Division, Johns Hopkins University School of Medicine

Last full review/revision May 2021| Content last modified May 2021
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Diplopia is the perception of 2 images of a single object. Diplopia may be monocular or binocular. Monocular diplopia is present when only one eye is open. Binocular diplopia disappears when either eye is closed.

Etiology of Diplopia

Monocular diplopia can occur when something distorts light transmission through the eye to the retina. There may be > 2 images. One of the images is of normal quality (eg, brightness, contrast, clarity); the rest are of inferior quality. The most common causes of monocular diplopia are

Other causes include corneal scarring and dislocated lens. Complaints also may represent malingering.

Binocular diplopia suggests disconjugate alignment of the eyes. There are only 2 images, and they are of equal quality. There are many possible causes of binocular diplopia (see table Some Causes of Binocular Diplopia Some Causes of Binocular Diplopia Diplopia is the perception of 2 images of a single object. Diplopia may be monocular or binocular. Monocular diplopia is present when only one eye is open. Binocular diplopia disappears when... read more ). The most common are

Most commonly, the eyes are misaligned because of a disorder affecting the cranial nerves innervating the extraocular muscles (3rd, 4th, or 6th cranial nerves). These palsies may be isolated and idiopathic or the result of various disorders involving the cranial nerve nuclei or the infranuclear nerve or nerves. Whether pain is present depends on the disorder. Other causes involve mechanical interference with ocular motion (which often cause pain) or a generalized disorder of neuromuscular transmission (which typically do not cause pain).

Table
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Evaluation of Diplopia

History

History of present illness should determine whether diplopia involves one or both eyes, whether diplopia is intermittent or constant, and whether the images are separated vertically, horizontally, or both. Any associated pain is noted, as well as whether it occurs with or without eye movement.

Review of systems should seek symptoms of other cranial nerve dysfunction, such as vision abnormalities (2nd cranial nerve); numbness of forehead and cheek (5th cranial nerve); facial weakness (7th cranial nerve); dizziness, hearing loss, or gait difficulties (8th cranial nerve); and swallowing or speech difficulties (9th and 12th cranial nerves). Other neurologic symptoms, such as weakness and sensory abnormalities, should be sought, noting whether these are intermittent or constant. Nonneurologic symptoms of potential causes are ascertained. They include nausea, vomiting, and diarrhea (botulism); palpitations, heat sensitivity, and weight loss (Graves disease Etiology Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free thyroid hormones. Symptoms are many and include tachycardia, fatigue, weight loss, nervousness, and tremor... read more Etiology ); and difficulty with bladder control (multiple sclerosis Multiple Sclerosis (MS) Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more Multiple Sclerosis (MS) ).

Physical examination

Examination begins with a review of vital signs for fever and general appearance for signs of toxicity (eg, prostration, confusion).

Eye examination begins with noting the initial position of the eyes, followed by measuring visual acuity (with correction) in each eye and both together, which also helps determine whether diplopia is monocular or binocular. Eye examination should note presence of bulging of one or both eyes, eyelid droop, pupillary abnormalities, and disconjugate eye movement and nystagmus during ocular motility testing. Ophthalmoscopy should be done, particularly noting any abnormalities of the lens (eg, cataract, displacement) and retina (eg, detachment).

Ocular motility is tested by having the patient hold the head steady and track the examiner’s finger, which is moved to extreme gaze to the right, left, upward, downward, diagonally to either side, and finally inward toward the patient’s nose (convergence). However, mild paresis of ocular motility sufficient to cause diplopia may escape detection by such examination.

If diplopia occurs in one direction of gaze, the eye that produces each image can be determined by repeating the examination with a red glass placed over one of the patient’s eyes. The image that is more peripheral originates in the paretic eye; ie, if the more peripheral image is red, the red glass is covering the paretic eye. If a red glass is not available, the paretic eye can sometimes be identified by having the patient close each eye. The paretic eye is the eye that when closed eliminates the more peripheral image.

The cover test and cover-uncover test can also be used to determine whether a deviation or strabismus is present with both eyes open (manifest/tropia), or only when one eye is open (latent/phoria). Both tests are done on both eyes. For the cover test, the patient is asked to fixate on an object with both eyes open, and one eye is covered. The other eye is observed for a refixation movement, which would indicate it had previously been misaligned, indicating a manifest deviation or tropia. The cover-uncover test is conducted similarly, except the eye being tested is covered for a few seconds and then the cover is removed. The same eye is observed for a refixation movement, which would indicate a latent deviation or phoria. The patient may also see the object "jumping" with the refixation movement during either test.

The other cranial nerves are tested, and the remainder of the neurologic examination, including strength, sensation, reflexes, cerebellar function, and observation of gait, is completed.

Relevant nonneurophthalmologic components of the examination include palpation of the neck for goiter and inspection of the shins for pretibial myxedema (Graves disease Etiology Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free thyroid hormones. Symptoms are many and include tachycardia, fatigue, weight loss, nervousness, and tremor... read more Etiology ).

Red flags

The following findings are of particular concern:

  • More than one cranial nerve deficit

  • Pupillary involvement of any degree

  • Any neurologic symptoms or signs besides diplopia

  • Pain

  • Proptosis

Interpretation of findings

Findings sometimes suggest which cranial nerve is involved.

  • 3rd: Eyelid droop, eye deviated laterally and down, sometimes pupillary dilation

  • 4th: Vertical diplopia worse on downward gaze (patient tilts head to improve vision)

  • 6th: Eye deviated medially, diplopia worse on lateral gaze (patient turns head to improve vision)

Intermittent diplopia suggests a waxing and waning neurologic disorder, such as myasthenia gravis or multiple sclerosis Multiple Sclerosis (MS) Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more Multiple Sclerosis (MS) , or unmasking of a latent phoria (eye deviation). Patients with latent phoria do not have any other neurologic manifestations.

Internuclear ophthalmoplegia Internuclear Ophthalmoplegia Internuclear ophthalmoplegia is characterized by paresis of ipsilateral eye adduction in horizontal gaze but not in convergence. It can be unilateral or bilateral. (See also Overview of Neuro-ophthalmologic... read more (INO) results from a brain stem lesion in the medial longitudinal fasciculus (MLF). INO manifests on horizontal gaze testing with diplopia, weak adduction on the affected side (usually cannot adduct eye past midline), and nystagmus of the contralateral eye. However, the affected eye adducts normally on convergence testing (which does not require an intact MLF).

Pain suggests a compressive lesion or inflammatory disorder.

Testing

Patients with monocular diplopia are referred to an ophthalmologist for evaluation of ocular pathology; no other tests are required beforehand.

For binocular diplopia, patients with a unilateral, single cranial nerve palsy, a normal pupillary light response, and no other symptoms or signs can usually be observed without testing for a few weeks. Many cases resolve spontaneously. Ophthalmologic evaluation is recommended to monitor the patient and help further delineate the deficit, particularly for a third nerve palsy, because it can also progress to involve the pupil.

Most other patients require neuroimaging with MRI to detect orbital, cranial, or central nervous system (CNS) abnormalities. CT may be substituted if there is concern about a metallic intraocular foreign body or if MRI is otherwise contraindicated or unavailable. Imaging should be done immediately if findings suggest infection, aneurysm, or acute stroke.

Treatment of Diplopia

Treatment is management of the underlying disorder.

Key Points

  • Isolated, pupil-sparing single cranial nerve palsy in patients with no other symptoms may resolve spontaneously.

  • Imaging is required for patients with red flag findings.

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