What is Diplopia (Double Vision)?

Diplopia, commonly known as double vision, is when images split either vertically, horizontally, or at an angle. This condition can be classified into two types depending on its origin: monocular or binocular. Monocular diplopia is an optical issue that persists even when you close one eye, while binocular diplopia often results from eye misalignment or strabismus, which could be identified using basic clinical tests.

People with eye misalignment need a comprehensive and systematic assessment to identify any serious conditions. If someone has double vision that develops suddenly, medical examination should be done immediately. Those experiencing headaches or pupil anomalies should be urgently referred for imaging on the same day. In most circumstances, though, double vision due to microvascular causes, often gets better on its own within six months.

What Causes Diplopia (Double Vision)?

Diplopia, commonly known as double vision, can occur due to two main causes: misaligned eyes (binocular) or an optical problem (monocular). Misalignment of the eyes can be due to various factors, and it’s crucial to understand the eye alignment process. For your eyes to be correctly aligned, the muscles controlling the eye movements need to receive equal signals from the nerves. Any problem that affects these muscles or nerves can lead to double vision.

Your eye muscles get their signals from the cranial nerves III, IV, and VI. These nerves start in the brainstem and traverse the brain, eventually exiting and running along the subarachnoid space. They are open to various issues affecting the cerebrospinal fluid, such as inflammation, infections, and malignancies.

All these nerves converge in the cavernous sinus located next to the pituitary gland, filled with venous blood. Any medical condition affecting their neighboring structures, such as the sphenoid sinus, pituitary gland, etc., may affect these nerves. This can cause either a compression or extension leading to diplopia.

The three nerves leave the cavernous sinus and travel close to the optic nerve. If there are any issues in this region, it can cause decreased vision, multiple nerve palsies, and even forward displacement of the eyeball. Any issues at the neuromuscular junction, where the nerve connects with the muscle, or with the eyeball muscles, can also cause a misalignment leading to double vision.

According to a recent South China study, diplopia has been categorised into three categories based on eye muscle function: single muscle, multiple muscles, and comitant strabismus group.

  • Single muscle: This is usually due to a micro injury or trauma, affecting the lateral rectus muscle. It can sometimes be associated with nasopharyngeal carcinoma or radiation therapy.
  • Multiple muscles: This is chiefly due to thyroid-related issues.
  • Comitant strabismus group: The most common cause for this group is acute acquired comitant esotropia.

Monocular diplopia typically originates from cataractous changes in the lens, corneal surface abnormalities, and very rarely, lesions affecting the occipital cortex. If there are no detectable causes, it’s usually considered functional in nature. Also, non-ophthalmic causes, such as COVID-19 infection and post-vaccination, are found to be related to Diplopia.

Other causes include complications from neurosurgical or dental procedures, sinus surgery, some eye procedures and surgical repair from fractures. A review identified microvascular, strokes, neoplastic, myasthenia gravis, traumatic and decompensated phoria as common causes of binocular diplopia. In most cases, double vision is treated by neurologists, followed by ophthalmologists, emergency physicians, and neurosurgeons.

Risk Factors and Frequency for Diplopia (Double Vision)

Diplopia, also known as double vision, is a common reason why people visit the doctor or hospital. In fact, nearly 80,500 outpatient visits and 50,000 emergency room visits in the US each year are due to diplopia. Although it can be very unsettling for the patient, especially if it comes on suddenly, life-threatening causes are relatively rare. Only 16% of diplopia cases are linked to serious conditions.

Recent research has shown that diplopia can also be a significant and debilitating symptom of cancer, often the result of spread of cancer to the eyes or brain or due to local tumour growth. Symptoms can include types of strabismus, which is abnormal alignment of the eyes. The most frequently seen is called sixth nerve palsy. These findings suggest that cancer spread is the most common cause of diplopia in cancer patients and underline the importance of scanning for spread when diplopia occurs in cancer patients, as it can affect their life expectancy.

  • Diplopia is a common reason for both outpatient and emergency room visits.
  • Each year in the US, there are about 80,500 outpatient visits and 50,000 emergency room visits due to diplopia.
  • While it can be very unsettling, especially if it occurs suddenly, it’s not commonly associated with life-threatening conditions. Only 16% of cases fall under this category.
  • Recent studies suggest diplopia can be a significant symptom in cancer patients due to various mechanisms, often because of cancer spreading or local tumour growth.
  • Specific symptoms seen in these patients can include strabismus, especially sixth nerve palsy.
  • Cancer spread is the most common cause of diplopia in cancer patients. This highlights the importance of scanning for cancer spread when diplopia occurs, as it can influence life expectancy.

Signs and Symptoms of Diplopia (Double Vision)

Dealing with a patient suffering from diplopia, or double vision, involves a comprehensive medical history and physical examination. Key pieces of information include the type of diplopia (either affecting one eye or both), when it started, how it has progressed, if there are any other associated symptoms, and what helps alleviate it.

First and foremost, it’s essential to determine if the diplopia is monocular (affecting one eye) or binocular (affecting both eyes). Neglecting this could lead to unnecessary stress for the patient and pointless medical tests.

The following step is to search for symptoms related to brainstem issues. Although strokes isolated to the brainstem are rare, diplopia can be a patient’s main symptom if the stroke affects the diencephalon (the posterior part of the forebrain) or brainstem, involving the third, fourth, and fifth cranial nerve groups, medial longitudinal fasciculus (bundles of axons in the brainstem), or pathways that coordinate eye movements and balance.

Patients with sudden onset binocular diplopia, accompanied by other symptoms indicating brainstem dysfunction such as dizziness, difficulty speaking, mixed up sensory or motor symptoms, lack of coordination, or imbalance, should be sent immediately to the emergency department for a brain MRI, specifically looking at the brainstem. This MRI should include various types of images to detect small areas of stroke or bleeding.

All patients with diplopia should be asked about whether their symptoms get worse with fatigue, fluctuate, or come with symptoms of increased pressure within the skull. Patients over 50 should also be asked about symptoms of a condition called giant cell arteritis. A study found that the main symptom of acquired diplopia in adults was double vision, followed by blurry vision, diplopia in one eye, and eye strain. Significant early life history events included crossed eyes (strabismus) and lazy eye (amblyopia). High blood pressure and weakness of the cranial nerves were also linked with symptomatic crossed eyes, followed by harmless age-related divergence insufficiency esotropia (a type of crossed eyes).

Next, a careful physical examination is necessary, starting with testing eye movement to identify any obvious deficits and determining whether they point to issues with the third or sixth cranial nerves. The test involves slowly moving an object in all directions and testing each eye separately. Following eye movement testing, eye alignment should be checked. If a vertical deviation is discovered, more tests should be done to determine if this pattern matches the 3-step test where a higher position of one eye increases when the patient looks to the opposite side and tilts their head towards the same side. This positive 3-step test suggests fourth nerve weakness.

If full eye movement is obtained, and eye misalignment remains the same in all gaze positions, it is called concomitant. It is almost always due to previously undiagnosed or ‘hidden’ strabismus from infancy. It does not warrant further investigations beyond a referral for an eye specialist’s assessment. Once the assessment of ocular motility and alignment have been done (preferably with percentage estimates of expected movements, e.g. ‘70% of normal lift’ ), other aspects to assess and document include pupil examination, eyelid position and movement, presence of protruding eyes, and eyelid muscle strength. Lastly, a detailed examination of the back of the eye (the fundus) is performed to check for signs of swelling of the optic nerve head or any signs implying disrupted venous blood flow in the retina for all patients with diplopia.

Testing for Diplopia (Double Vision)

If your doctor suspects that you may be suffering from problems with the third, fourth, or sixth cranial nerves, they will initially perform eye tests on each eye separately as well as alignment tests. The management of problems with each of these nerves is different, hence the need for thorough testing. A complete examination of such nerves may help to detect conditions like third nerve palsy and sixth nerve palsy. However, identifying partial third nerve paresis or fourth nerve palsy may require more advanced testing.

If abnormalities are detected across more than one cranial nerve, an MRI of the brain and areas surrounding the eyes is usually necessary. This enables doctors to identify any lesions that may be affecting these areas. In emergency situations, an MRI not only improves the chances of accurate diagnosis but also offers a way to minimize your exposure to ionizing radiation,

Some symptoms could hint at myasthenia gravis, a long-term condition causing muscle weakness that affects the eyes. In such cases, a test for acetylcholine receptor antibodies would be needed, although it is not 100% reliable. If the test comes back negative but suspicions remain, an electromyogram can be performed by an experienced operator to provide a more precise diagnosis.

Patients with third nerve palsy should undergo an immediate CT angiography of the brain to rule out potential complications due to aneurysms. This type of scan is readily available and is particularly effective for detecting larger aneurysms. If normal results are returned but other symptoms persist, a more thorough review might be required.

If the CT scan doesn’t identify any issues, but the patient is over 50 years old or has vasculopathy risk factors, the cause of the third nerve palsy is likely due to a micro-ischemic condition. It is recommended to closely monitor the patient for a few months to track any developments or improvements. Additionally, if the CT scan results are negative, but the patient doesn’t fall into the aforementioned risk categories, further testing via an MRI should be considered.

Patients diagnosed with fourth nerve palsy should be treated with special prisms in their spectacles, or monitored for any spontaneous improvements. Certain symptoms may suggest the need for an MRI of the brain to further examine the fourth cranial nerve.

Similar processes should be followed for patients diagnosed with sixth nerve palsy. Depending on the patient’s medical history, age, and the isolated nature of the problem, an MRI might be performed for a more in-depth analysis.

In the emergency department, several strategies are typically debated. The use of MRI is often favored and unenhanced CT scans are usually not beneficial for diplopia – a condition where two images of a single object are seen.

Treatment options and next steps can vary greatly, making it crucial for patients to consult with a neurologist or an ophthalmologist if isolated fourth and sixth nerve palsies are diagnosed. Patients with third nerve palsy should consider undergoing both brain CT scans and CT angiography to rule out the possibility of dangerous aneurysms. Other imaging techniques may be appropriate for specific conditions, such as suspected cavernous sinus thrombosis.

Lastly, if a patient is over 60 years old and has been experiencing double vision over a period of a month, their doctor may choose to conduct tests for inflammatory markers to rule out conditions like giant cell arteritis.

Treatment Options for Diplopia (Double Vision)

Diplopia, commonly known as double vision, is a condition mainly faced by the elderly and can be a result of issues related to the eyes or nerves. How to manage and treat this condition varies depending on the exact cause. If a person experiences double vision in one eye (monocular diplopia), they might need to have their eyes tested and examined thoroughly. On the other hand, for those experiencing double vision in both eyes (binocular diplopia), the root cause needs to be found urgently. Some of these causes could be quite serious, like aneurysms in the brain, and need immediate attention.

There aren’t many treatment options for double vision.

* If a person has monocular double vision, they might need to go for cataract surgery and get their eye power corrected.
* For those with binocular double vision, using prisms in their glasses to redirect the light entering their eyes could provide some relief. However, this method is usually effective when the eyes are slightly misaligned (up to about 10-12 degrees).

For those with a greater degree of misalignment, a simple solution might be to cover one eye with patch. If the misalignment remains stable, they might be eligible for surgery to correct the misalignment. Another option could be injecting the muscle causing the misalignment with botulinum toxin, although this may not work for everyone and the effects do wear off after some time. Another option is Monovision, which involves fitting a contact lens in one eye to disrupt the binocular view. This could work for those with minor misalignments.

There are also case reports that suggest certain conditions that cause double vision due to a tumor (meningioma) near the brainstem or in the brain’s cavernous sinus could benefit from a specific type of radiation treatment (gamma knife surgery).

In terms of recent developments, research has found that a certain type of double vision which causes the eyes to misalign vertically (skew deviation) could improve when the person goes from standing to laying down. For a certain condition that causes double vision (ocular myasthenia), treatments with steroids or surgical removal of a gland in the chest (thymectomy) have been found to prevent the condition from worsening.

Lastly, a specific surgical technique on one of the muscles controlling eye movement (temporal slant recession of the inferior rectus muscle), could effectively treat minor vertical misalignment causing double vision. This procedure can be performed in an outpatient setting and therefore, might prove beneficial for patients visiting a neuro-ophthalmology clinic.

When someone has binocular diplopia, or double vision when looking with both eyes, many factors might cause it. Doctors usually try to narrow down these factors by considering the patient’s various body parts and the conditions that may affect them. Here are some possibilities:

  • Damage to areas of the brainstem that control vision could cause this problem, as they control certain cranial nerves that help our eyes move and focus.
  • Damage to the centers of the brain that control how our eyes move horizontally or vertically may cause double vision, but this is rare.
  • Conditions such as Posterior Reversible Encephalopathy Syndrome, which causes symptoms like altered awareness, drowsiness, visual impairment, seizures, headaches and double vision.
  • Problems in a part of the brain, the medial longitudinal fasciculus, that connects certain nerves could also lead to double vision.
  • A condition called Superior oblique myokymia, which involves involuntary twitching in one of the eye muscles, can also cause double vision.

There are several diseases and conditions that can cause vision problems, including double vision:

  • Uveomeningitis and myelodysplastic syndrome
  • Any condition that affects the composition of our cerebrospinal fluid, which flows around our brain and spinal cord
  • Guillain-Barré syndrome, a disorder in which the body’s immune system attacks part of the peripheral nervous system, can cause double vision if it affects certain nerves.
  • Thiamine deficiency, as seen in Wernicke encephalopathy
  • Various conditions that cause damage to a part of the brain called the cavernous sinus
  • Lyme neuroborreliosis, a disease caused by a certain kind of bacteria
  • Conditions like tumors affecting various body parts
  • Inflammatory, infection, and bleeding conditions that affect certain areas in the brain

And finally, the following can cause double vision:

  • Orbital disease, such as thyroid eye disease, tumors, or vascular lesions in the eye socket.
  • Gradenigo syndrome, a condition resulting from severe ear infection
  • Convergence insufficiency, a vision disorder where your eyes tend to point outward when trying to see something close.
  • Keratoendotheliitis fugax hereditaria, a rare genetic condition.
  • Conditions affecting the body’s neuromuscular junctions and certain eye muscles

Bear in mind that this list is not exhaustive nor does every cause apply to everyone with double vision. It’s important to speak to your healthcare provider to properly determine and treat the cause.

What to expect with Diplopia (Double Vision)

The outlook for double vision, also known as diplopia, varies greatly and is completely dependent on what is causing it. Minor cases can be long-lasting and may require surgery to resolve. If the root cause is treated effectively, like in most instances of conditions such as myasthenia gravis and Guillain-Barré syndrome, double vision can be corrected. Additionally, double vision resulting from small strokes in the brainstem may improve on its own over time.

Possible Complications When Diagnosed with Diplopia (Double Vision)

The main problem caused by diplopia, or double vision, is that it can make patients feel uncomfortable. It can also affect their ability to drive. Different reasons for having double vision can result in their own unique complications.

Preventing Diplopia (Double Vision)

Patients should be informed about diplopia, also known as double vision, and comprehend that treating this condition can be difficult. Furthermore, it’s also important for patients to understand the doctor’s line of thinking and plan of action toward diagnosing and treating this condition, which will be based on the results from their medical exam.

Frequently asked questions

Diplopia, commonly known as double vision, is when images split either vertically, horizontally, or at an angle.

Diplopia (double vision) is a common reason for both outpatient and emergency room visits.

Signs and symptoms of diplopia (double vision) include: - Double vision, where objects appear as two separate images - Blurry vision - Diplopia in one eye - Eye strain - Dizziness - Difficulty speaking - Mixed up sensory or motor symptoms - Lack of coordination or imbalance - Symptoms that worsen with fatigue - Fluctuating symptoms - Symptoms of increased pressure within the skull - Symptoms of giant cell arteritis (in patients over 50) - History of crossed eyes (strabismus) or lazy eye (amblyopia) - High blood pressure - Weakness of the cranial nerves It is important to note that sudden onset binocular diplopia, accompanied by other symptoms indicating brainstem dysfunction, should be considered a medical emergency and the patient should be sent immediately to the emergency department for further evaluation.

Diplopia, or double vision, can occur due to two main causes: misaligned eyes (binocular) or an optical problem (monocular). Misalignment of the eyes can be due to various factors, such as problems with the muscles or nerves controlling eye movements. Optical problems can include cataractous changes in the lens, corneal surface abnormalities, or lesions affecting the occipital cortex. Other causes of diplopia can include complications from surgeries or procedures, sinus surgery, eye procedures, fractures, and certain medical conditions like cancer.

The doctor needs to rule out the following conditions when diagnosing Diplopia (Double Vision): - Monocular diplopia - Eye misalignment or strabismus - Problems with the third, fourth, or sixth cranial nerves - Myasthenia gravis - Aneurysms - Micro-ischemic condition - Fourth nerve palsy - Sixth nerve palsy - Damage to areas of the brainstem that control vision - Damage to the centers of the brain that control eye movement - Posterior Reversible Encephalopathy Syndrome - Problems in the medial longitudinal fasciculus - Superior oblique myokymia - Uveomeningitis and myelodysplastic syndrome - Conditions affecting the composition of cerebrospinal fluid - Guillain-Barré syndrome - Thiamine deficiency - Conditions that cause damage to the cavernous sinus - Lyme neuroborreliosis - Tumors affecting various body parts - Inflammatory, infection, and bleeding conditions affecting certain areas in the brain - Orbital disease - Gradenigo syndrome - Convergence insufficiency - Keratoendotheliitis fugax hereditaria - Conditions affecting the body's neuromuscular junctions and certain eye muscles

The types of tests that may be needed for Diplopia (Double Vision) include: - Eye tests on each eye separately - Alignment tests - MRI of the brain and areas surrounding the eyes - Test for acetylcholine receptor antibodies - Electromyogram - CT angiography of the brain - Brain CT scans - Inflammatory marker tests These tests are performed to diagnose and identify the underlying cause of the double vision, such as problems with the cranial nerves, aneurysms, myasthenia gravis, or other conditions. The specific tests ordered will depend on the individual patient's symptoms, medical history, and suspected cause of the double vision.

Diplopia, or double vision, can be treated in various ways depending on the cause and type of double vision. For monocular diplopia, cataract surgery and correcting eye power may be necessary. On the other hand, for binocular diplopia, using prisms in glasses or covering one eye with a patch can provide relief. In cases of greater misalignment, surgery to correct the misalignment or injecting the muscle causing the misalignment with botulinum toxin may be options. Monovision, which involves fitting a contact lens in one eye, can disrupt the binocular view and work for minor misalignments. Certain conditions causing double vision, such as meningioma, may benefit from gamma knife surgery. Recent developments have also found that certain types of double vision can improve with changes in position or be prevented from worsening with treatments like steroids or thymectomy. Additionally, a specific surgical technique called temporal slant recession of the inferior rectus muscle can effectively treat minor vertical misalignment causing double vision.

The text does not mention any specific side effects when treating Diplopia (Double Vision).

The prognosis for diplopia (double vision) varies depending on the underlying cause. Here are the possible outcomes: - Minor cases may be long-lasting and require surgery for resolution. - If the root cause is effectively treated, such as in cases of myasthenia gravis and Guillain-Barré syndrome, double vision can be corrected. - Double vision resulting from small strokes in the brainstem may improve on its own over time.

Neurologist, ophthalmologist, emergency physician, or neurosurgeon.

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