1. WHAT IS DIPLOPIA?

Diplopia is the medical term for double vision. Diplopia causes a person to see two images of
the same object. There are primarily two types of diplopia: monocular and binocular.

 Monocular: Double vision that affects only one eye. If one eye is covered, the double
vision continues.
 Binocular: Double vision that affects both eyes. If either eye is covered, the double
vision stops.

Besides monocular and binocular disruption, double vision can be vertical or horizontal.
Patients with vertical diplopia complain of seeing two diagonally displaced images, one atop
the other. In horizontal diplopia, the images appear side by side.

2. A 50 years old woman complains of diplopia. Discuss the possible causes, diagnosis and
management of her diplopia.

CAUSES OF DIPLOPIA

In adults, if binocular double vision develops suddenly, there is a high likelihood that it is a
sign of disease. Monocular double vision is rarer than binocular double vision. Conditions that can
cause binocular and monocular double vision are listed below.

 Thyroid disease that affects the external eye muscles.

 Disease of the arteries that supply blood to the brain.
 Diabetes. This can cause double vision by damaging the nerves that control eye
movement. The damaged nerves often re-grow after several months and, as they do,
your double vision will gradually disappear.
 Myasthenia gravis, a condition that causes the body’s muscles to become weak and to
tire easily.
 Multiple sclerosis, a neurological condition that affects the central nervous system.
 Aneurysm, bulging of the arteries in the brain.
 A blood clot behind the eye that prevents normal eye movement.
 Stroke.
 Brain tumour, or cancer in or behind the eye that distorts the image produced by the
eye.
 Astigmatism. This is an abnormal curvature of the front surface of the cornea.
 Keratoconus. The cornea gradually becomes thin and cone-shaped.
 Pterygium. This is a thickening of the conjunctiva, the thin mucous membrane that
lines the inner surface of the eyelids and the whites of the eyes. The thickening
extends on the cornea, the clear part of the surface of the eye.
 Cataracts. The lens gradually becomes less transparent. Risk factors include being
older than 65, having eye trauma or long-term diabetes, smoking, using steroid
medications or having radiation treatments.
 A dislocated lens. The ligaments that hold the lens in place are broken, and the lens
moves out of place or wiggles. This can be caused by trauma to the eye or a condition
known as Marfan's syndrome.
  A mass or swelling in the eyelid. This condition can press on the front of the eye.

DIAGNOSIS OF DIPLOPIA.

A clear and comprehensive history is the single most useful evaluation in treating patients
with diplopia. Three important symptoms should be elicited, as follows:

 Does covering either eye make the diplopia disappear? This test helps to rule out
monocular diplopia, which persists in one eye even if the other eye is covered.
 Is the deviation the same in all directions of gaze or by tilting and rotating the head
into different positions? This suggests a comitant deviation, with no difference in
separation of the images in all directions of gaze. When the extent of deviation
changes (and indeed possibly disappears in a given direction), then the deviation is
incomitant and suggests a problem with innervation, most likely a paretic muscle.
 Is the second object displaced horizontally (side-by-side images) or vertically (images
above each other)? Oblique diplopia (images separated horizontally and vertically)
should be considered as a manifestation of vertical diplopia.

 The traditional and detailed evaluation of the chief complaint includes onset (abrupt
or slow), severity, duration, location, associated symptoms, and aggravating and
relieving factors. Other significant aspects include a review of systems (e.g., history
of diabetes, vascular disease, or hypertension; headache and other neurologic
complaints; muscle fatigue or weakness; medications and drugs being used ), as well
as a past medical and surgical history.
 Inquire about recent trauma to the face and the head to rule out injury to the orbit and
sixth cranial nerve weakness.
 Confirm that the symptom is monocular or binocular. Does covering each eye in turn alleviate
the problem, or does the diplopia persist despite covering the "good" opposite eye?
Monocular diplopia is very uncommon. Possible causes include severe corneal deformity or
marked astigmatism (keratoconus), multiple pupils or openings in the iris, refractive
anomalies within the eye (early cataracts or partially displaced lenses as in Marfan
syndrome), as well as retinal abnormalities (macular scarring and distortion).
 Determine the visual acuity in each eye separately, with and without spectacle correction and
with a pinhole. Does a pinhole improve the visual acuity, or does it improve monocular
diplopia? Major improvement in visual acuity with a pinhole suggests intraocular or refractive
problems.
 Evaluate the visual field by confrontation testing or formal visual field mapping to detect
possible space occupying masses impinging on the visual pathways and/or cranial motor
nerves. With severely constricted fields, the peripheral clues for fusion may be lacking,
resulting in diplopia.
 Evaluate the integrity of the other cranial nerves (e.g., facial sensation [trigeminal nerve],
facial muscle movements).
 Determine that other ocular motor functions are normal. The anatomical evaluation includes
inspection, palpation, percussion, and auscultation.
MANAGEMENT OF DIPLOPIA.

With double vision, the most important step is to identify and treat the underlying cause. In
some cases, double vision can be improved by managing or correcting its cause.

 Patching one eye: Patching is often required, since the patient has to continue
functioning while awaiting resolution or intervention.
 Fresnel prisms: These prisms can be stuck to glasses. Although these prisms
are only appropriate if a stable deviation is present across all directions of
gaze, they severely blur the image from that eye and function in many ways
like an occlusive lens.
 Treatment of myasthenia gravis: Mestinon or other long-acting anticholinergic
agent, as well as corticosteroids, may be required.
 Strabismus surgery is occasionally necessary. The typical recession/resection
is rarely indicated due to the one muscle often being permanently weak, and
any standard surgery will lose effect over time. Exceptions include a blow-out
fracture when the release of the entrapped soft tissues from the fracture in the
floor of the orbit can be very effective.