For patients older than 50 years with vasculopathic risk factors, imaging is not always necessary during the initial evaluation. An anatomic and systematic approach to the clinical evaluation of diplopia can lead to an accurate diagnosis without extensive laboratory investigation. Understanding and evaluating diplopia sreedhar a, menon a. Diplopia was minimal when looking to the left and pronounced when looking to the right. May 21, 2019 diplopia is the subjective complaint of seeing 2 images instead of one and is often referred to as doublevision in lay parlance. Neuroanatomy three pairs of extraocular muscles move each eye in three directions. The assessment of the patients perception of diplopia must exclude other symptoms that can be misunderstood by the patient, such as image distortion, vision field. Guidelines for application of surgical options, 117 step 4. Uncorrected diplopia is a condition that may make it unsafe for a person to operate a motor vehicle.
The neurologist determines whether the lesion affects the optic, ocular motor, or vestibular system, and confirms that the problem is neural. Stephen huff, md patient looking at target straight ahead 6. Diplopia is when one object appears double and is often the first manifestation of many systemic muscular or neurologic disorders. Double vision emergency department diagnosis and management j. A logical, easytofollow approach to the clinical evaluation of patients with diplopia is helpful in ensuring accurate localization, a comprehensive differential diagnosis, and optimal patient care. Also includes an algorithm for the evaluation of diplopia, and common causes of diplopia.
Diagnosing double vision in adults nyu langone health. The preliminary differential diagnosis is based on a few basic questions, which can be answered by simple clinical tests. For the most part, patients with monocular diplopia do not warrant a neurologic evaluation since a careful ophthalmic evaluation will reveal the cause see table. An anatomic and systemic approach find, read and cite all the research. Jun 02, 2015 a case of diplopia due to myasthenia gravis. Patients with monocular diplopia are referred to an ophthalmologist for evaluation of ocular pathology. Diplopia, or double vision, is a symptom resulting from the perception of 2 images of a single object figure 1. If unilateral, single cranial nerve palsy, normal pupillary reflexes, no other ss. Monocular diplopia persists when one eye is covered. The diplopia mechanism monocular or binocular, its type horizontal, vertical, or oblique, and its temporal progression and accompanying symptoms are important for its etiological diagnosis 1,2. Diplopia may be a symptom of a functional eye movement disorder.
Monocular monocular if diplopia present even when only 1 eye open vs binocular binocular only when both eyes open. The diplopia did not change significantly on head tilt right and left, each measuring as 5 pd of left hypertropia. Our team of neurologists and neuroophthalmologistsdoctors who manage visual problems related to the nervous systemprovides a thorough evaluation and develops a treatment plan for people experiencing double vision. An anatomic and systemic approach find, read and cite all the research you need on researchgate. Thus, images of an object fall on different locations of the retinae of the 2 eyes, giving rise to the impression of 2 objects rather than 1. To assess the diagnostic accuracy of the edinburgh diplopia diagnostic algorithm. Describe the appropriate steps to take in evaluating diplopia in the emergency department. Our team of neurologists and neuroophthalmologistsdoctors who manage visual problems related to the nervous systemprovides a thorough evaluation and develops a. In primary gaze, the diplopia was 4 prism diopters pd of constant left hypertropia.
In some patients with binocular diplopia, the extraocular motility may appear full but. Double vision, or diplopia, may be the first sign of life threatening pathology, or it may be completely benign. The diagnostic methods of evaluating neuroparalytic strabismus and the techniques. Stephen huff, md departments of emergency medicine and neurology university of virginia charlottesville 2.
The diplopia mechanism monocular or binocular, its type horizontal, vertical, or oblique, and its temporal progression and accompanying symptoms are important for its etiological diagnosis 1, 2. To present a report of the ocular motility disorders, treatment and outcomes of myasthenia gravis mg. Mar 28, 2018 in the patient with a complaint of new vertical diplopia, the threestep test is critical in looking for a fourth nerve palsy fig. Complete ophthalmological and orthoptic assessment should be carried out in a case of monocular diplopia. May 21, 2019 oblique diplopia images separated horizontally and vertically should be considered as a manifestation of vertical diplopia. Evaluation of acute headaches in adults american family. Diplopia or double vision is a frequent reason for ophthalmology consultation. Patient evaluation, 81 diagnostic considerations for strabismus with restrictions, 90 differential intraocular pressure test, 98 step 2. For example, most patients with convergence spasm will report double vision. Evaluation of motor vehicle driving performance in. Neuroophthalmic disease symposium diagnosis and management pearls mountain west council of optometrists las vegas, nevada april 24, 2010 andrew g.
This article provides a foundation for formulating an approach to the. Wessels, mmed, frcse, frcophth, facs, department of ophthalmology, university of tennessee college of medicine, chattanooga unit. Imaging evaluation of csf shunts diplopia, and weakness are less frequent presentations 17. Aaen, md, dph, clinical assistant professor of family practice, university of north dakota family physicians, minot air. Jun, 2018 a normal human eye can see a single, clear image. The traditional and detailed evaluation of the chief complaint includes onset abrupt or slow, severity, duration, location, associated. Jan 01, 2015 in primary gaze, the diplopia was 4 prism diopters pd of constant left hypertropia.
Diplopia and eye movement disorders journal of neurology. Pdf neurological evaluation of acute vertical diplopia. A diagnostic challenge with common and rare etiologies. Gross evaluation revealed a mild ptosis of the right lid. Diagnosing double vision in adults nyu langone specialists are experts at diagnosing double vision, also called diplopia, in which a person sees two images instead of one. Diplopia is the experience of seeing more than a single image. Conducting a detailed historytaking and physical examination often. In the majority of cases, it is due to the fact that the 2 eyes are not pointing at the same location in space ocular misalignment. Organic diplopia is typically binocular disappears when one eye is covered and is the result of dysconjugate gaze. Mar 18, 2016 to assess the diagnostic accuracy of the edinburgh diplopia diagnostic algorithm.
The latter may indicate a life threatening cause 1. Evaluation of motor vehicle driving performance in patients. Diplopia eye disorders msd manual professional edition. The 7 gaze positions assessed by the new questionnaire remained unchanged from the original questionnaire. Proptosis eye disorders msd manual professional edition.
Typically, this vision problem is the result of an underlying condition. To demonstrate feasibility of nearrealtime oculodynamic magnetic resonance imaging odmri in depicting extraocular muscles and correlate quantitatively the motion degree in comparison with clinical testing in patients with diplopia. Diplopia or double visioncausessymptomsteststreatment. An accurate initial assessment is extremely helpful in assessing the urgency of the situation and determining the appropriate course of action. In this masked study, 10 patients of varying ages with stable diplopia of greater than 6 months duration and 10 agematched control subjects were placed. Neurological evaluation of acute vertical diplopia m a. Diplopia, or double vision, is a symptom resulting from the perception of 2. These images can be horizontal, vertical or diagonal. Diplopia causes you to see two images of one object. The sensory and motor integration of vision and the physiology of ocular movement are essential in the diagnosis and treatment of diplopia. The incidence of deterioration of diplopia dod was calculated by dividing the number of patients with preoperative grade 0, 1, or 2 diplopia who postoperatively had a higher grade of diplopia by. She was tested for serum and cerebrospinal fluid evaluation and. Bronstein, in handbook of clinical neurology, 2016. Efficacy and side effects of swinging eyelid orbital.
Edward hebert school of medicine, bethesda, maryland. Ophthalmoplegia secondary to a neuropathy, myopathy, or neuromuscular junction disorder reveals slowed saccades. 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. Nyu langone specialists are experts at diagnosing double vision, also called diplopia, in which a person sees two images instead of one. Because there is a right hyperdeviation in straightahead gaze, there must be a deficit in the depressor muscles of the right eye inferior rectus, superior oblique or the elevator muscles of the. Stephen huff, md objectives questions what is the differential diagnosis of diplopia. 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. Otherwise the patient is referred to the ophthalmologist. A rapid and systematic assessment is, therefore, crucial. Acute vertical diplopia requires an immediate neurological evaluation. Alternate cover test diplopia persists when one eye occluded monocular diplopia b.
Jun 02, 2017 diplopia causes you to see two images of one object. Details of consecutive patients referred to ophthalmology clinics at falkirk. It is very important to distinguish monocular from binocular diplopia because their possible causes differ significantly. Thus, images of an object fall on different locations of the retinae of the 2 eyes, giving rise to the impression of 2. The diagnostic methods of evaluating neuroparalytic strabismus and the techniques of measurement of ocular deviations are the first steps in the visual rehabilitation of the diplopic patient. The evaluation of binocular diplopia begins with examining the saccades and pursuit of the eyes individually ductions and together versions. In 30 odmris eye movements were tracked in the horizontal and sagittal plane using a a truefisp sequence with high temporal resolution. Diplopia or double vision is a condition where a person perceives two images of a single object.
In children, a bulging fontanelle or splaying of the cranial sutures may be observed 6. Straumannl neurology department, zurich university hospital summary palla a, straumann d. Traditional guidelines for imaging patients with newonset diplopia include imaging all patients younger than 50 years with other neurologic findings, with a progressive course of diplopia, or with a history of cancer. Because driving simulators are not specifically designed to assess diplopia and peripheral visual stimuli, future studies should include an onroad driving evaluation component and enhanced simulator tests. Neurologic examination may show papilledema, focal deficits, hyperactive reflexes, and ataxia 6. Apr, 2015 diplopia, or double vision, is a symptom resulting from the perception of 2 images of a single object figure 1. It lessened on right gaze to 3 pd and increased to 7 pd on left gaze. Trouble with any part of the vision system can cause double vision.
Stephen huff, md neurologists diagnostic approach is there a problem of the nervous system. Etiology and management of diplopia definition and differential diagnosis diplopia, as defined in dorlands illustrated medical dictionary, is the perception of two images of a single object. This was diagnosed with magnetic resonance imaging. Monocular diplopia is usually ocular or retinal in origin, whereas. Cerebellar ischemia manifesting as vertical diplopia. Pinhole test have patient look at distant object through pinhole with eye with monocular diplopia and the other eye occluded. Proptosis can be confirmed with exophthalmometry, which measures the distance between the lateral angle of the bony orbit and the cornea. In the patient with a complaint of new vertical diplopia, the threestep test is critical in looking for a fourth nerve palsy fig. In some jurisdictions, physicians are required by law to report the person with diplopia to the appropriate authority. Double vision is an important symptom with a large number of possible causes. Monocular diplopia is usually caused by intraocular pathology. The accuracy of the edinburgh diplopia diagnostic algorithm. The accuracy of the edinburgh diplopia diagnostic algorithm eye. Neurological evaluation of acute vertical diplopia.