![]() ![]() ![]() ![]() Examination of previous photos of the patient may also assist at determining the duration of any head tilt or prior ptosis or strabismus. ![]() The clinician should inquire about prior strabismus, a ‘‘lazy” or amblyopic eye, patching as a child, childhood eye surgery, and any abnormal head positions. Inquire about any corrective head positions? Any history of congenital strabismus? However, if there is muscle restriction (e.g., thyroid eye disease, orbital fracture, orbital myositis) then the diplopia may be worse in the opposite field of action of the restricted muscle.ģ. The worst position of gaze will typically represent the field of action of the paretic muscle. Which field of gaze provokes / worsens diplopia? Which field(s) of gaze are images closest to each other? The three-step test is utilized to isolate the vertically acting weak muscle – see below.Ģ. Myogenic involvement can occur with disease of the superior rectus, inferior rectus, superior oblique, or inferior oblique muscles alone or in combination. Vertical diplopia (images displaced vertically) can be due to involvement of extraocular muscles, neuromuscular junction (e.g., myasthenia gravis), or cranial nerves (e.g., CN III, IV). Diplopia worse with distance is more typical of sixth nerve palsy because of difficulty with divergence at distance of the eyes while diplopia worse at near is more suggestive of medial rectus palsy because of the need for convergence of the eyes at near. Are the images separated horizontally, vertically, or obliquely/diagonally? How does distance affect diplopia?īinocular horizontal diplopia (images displaced horizontally) is usually due to disease of the medial or lateral rectus muscle, the neuromuscular junction, or the nerves supplying these muscles (e.g., cranial nerves III or VI). In binocular diplopia, key details to ascertain include:ġ. Cortical lesions can produce bilateral monocular polyopia but is rare Monocular diplopia is typically due to an ocular cause and will not be discussed further here. Monocular diplopia can be bilateral or unilateral and sometimes patients with monocular symptoms complain of triplopia or more images. Binocular diplopia resolves with either eye being closed and indicates ocular misalignment as an underlying problem. It is important not to ask the more vague and potentially misleading question: “Does the double vision go away with covering ONE eye?” because if the patient happens to close the affected (monocular diplopia) eye then the response might lead the examiner to conclude that the diplopi is binocular when in fact it is monocular. Thus, the key and differentiating question between monocular and binocular diplopia is: “Does the double vision resolve with closing EITHER eye?”. Monocular diplopia persists when the unaffected eye is closed, but will resolve when the affected eye is closed. The initial stage of diplopia workup is to identify whether it is monocular diplopia or binocular diplopia. This article will outline an approach to understanding diplopia through highlighting key facts in the history and exam to guide further workup. 9.2 Cavernous Sinus and Superior Orbital Fissure Involvementĭiplopia is a common presentation to neurology, neuro-ophthalmology, ophthalmology, and general medicine.6.3 Parinaud Syndrome (Dorsal Midbrain Syndrome).5 Binocular diplopia Diagnostic approach. ![]()
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