Diplopia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Farman Khan, MD, MRCP [2]

Synonyms and Keywords: Double vision

Overview

Diplopia is the perception of two images from a single object. The images may be horizontal, vertical, or diagonal.

Causes[1][2]

Common Causes

  • Misalignment of the eyes


Causes by Organ System

Cardiovascular Subclavian Artery Disease
Chemical / poisoning No underlying causes
Dermatologic No underlying causes
Drug Side Effect Abciximab, Acute anticholinergic syndrome, Aztreonam, Botulinum toxin, Citalopram, Clobazam, Conjugated estrogens/bazedoxifene, Cytarabine, Eslicarbazepine acetate, Ezogabine, Gabapentin, Lacosamide, Latanoprost, Methocarbamol, Mitotane, Oxcarbazepine, Pralidoxime, Ropinirole, Rufinamide, Temozolomide, Topiramate, Trazodone, Trimethadione, Vigabatrin
Ear Nose Throat Pansinusitis, Trochleitis
Endocrine Diabetes mellitus type 2, Diabetic neuropathy, Graves' disease, Hypoglycemia, Insulinoma
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease Orbital cellulitis, Treponema pallidum
Musculoskeletal / Ortho Frontal sinus osteoma, Myositis, Tenosynovitis
Neurologic 3rd cranial nerve disorder, Acquired Brown's syndrome associated with underaction of the ipsilateral superior oblique muscle, Berry aneurysm, Brain Stem Gliomas, Brain tumor, Brown's superior oblique tendon sheath syndrome, Chiasmal syndrome, Colloid cyst, Congenital fourth nerve palsy, Episodic ataxia, Miller Fisher syndrome, Fourth cranial nerve palsy, Guillain-Barré syndrome, Idiopathic intracranial hypertension, Internuclear ophthalmoplegia, Intracranial berry aneurysm, Lateral medullary syndrome, Medulloblastoma, Midbrain pseudo-sixth nerve palsy, Millard-Gubler syndrome, Multiple sclerosis, Myasthenia gravis, One-and-a-half syndrome,Peribulbar anesthesia, Poliomyelitis, Progressive external ophthalmoplegia syndromes, Raised intracranial pressure, Rising eye syndrome, Silent sinus syndrome, Sixth cranial nerve palsy, Sphenoid wing meningioma, Stroke, Supranuclear monocular elevation paresis, Thalamic esotropia, Third cranial nerve palsy, Transient ischemic attack, Vertebrobasilar insufficiency, Vertical one-and-a-half syndrome, Vertigo, Wernicke's syndrome
Nutritional / Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic Maxillary sinus carcinoma, Metastasis to the superior oblique muscle, Metastatic infiltration of extraocular muscles, Nasopharyngeal carcinoma
Opthalmologic Acquired motor fusion deficiency, Acute acquired comitant esotropia, Amblyopia, Aniseikonia, Anisometropia, Asthenopia, Blepharoplasty, Cataracts, Change of angle of preexisting childhood strabismus or loss of suppression scotoma, Childhood strabismus syndromes, Chronic Progressive External Ophthalmoplegia, Congenital "double elevator"palsy, Congenital inferior rectus fibrosis, Congenital strabismus syndromes, Consecutive esotropia, Consecutive exotropia, Convergence insufficiency, Convergence micropsia, Corectopia, Cyclic esotropia, Decompensation of a long-standing esophoria, Decompensation of a long-standing exophoria, Decompensation of a long-standing phoria, Dissociated vertical deviation, Divergence insufficiency or paralysis, Double depressor paralysis, Dry eyes, Dystonia, Esophoria, Esotropia, Exophoria, Exopthalmos, Exotropia, Fictitious vertical diplopia, Fixation disparity, Foveal displacement syndrome, Hemifield slide phenomena, Hemifield slip phenomenon resulting from dense bitemporal hemianopsia or heteronymous altitudinal field defects, Hemifield slip, retinal disease, and fictitious diplopia, Hypertropia, Iridodialysis, Isolated paresis of a vertical-acting extraocular muscle, superior oblique, inferior oblique, superior rectus, or inferior rectus, Isolated weakness of lateral rectus muscle, Isolated weakness of medial rectus muscle, Keratoconus, Lens dislocation, Misalignment of the eyes, Nystagmus, Ocular myasthenia, Ocular neuromyotonia, Ophthalmoplegia, Ophthalmoplegic migraine, Optic neuritis, Orbital inflammation and pseudotumor, Orbital mass, Orbital myositis, Orbital tumors Fallen eye syndrome, Paroxysmal superior rectus and levator palpebrae spasm with multiple sclerosis, Periodic alternating esotropia, Physiologic hyperdeviation on lateral gaze, Polycoria, Proptosis, Refractive error, Sensory esotropia, Sensory exotropia, Skew deviation, Spasm of the near reflex, Strabismus, Strabismus fixus, Superior oblique myokymia, Superior oblique tendon sheath syndrome, Superior oblique tuck, Superior orbital fissure syndrome
Overdose / Toxicity Alcohol intoxication, Botulism, Toxidrome
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal / Electrolyte

Hypophosphatemia

Rheum / Immune / Allergy

Temporal arteritis

Sexual No underlying causes
Trauma Blowout fracture, Brain or head injury, Direct trauma to the extraocular muscles, Injury to the eye, Medial orbital wall fracture, Orbital floor blow-out fracture,Orbital fracture, Post-concussion syndrome, Superomedial orbital trauma, Traumatic brain injury
Urologic No underlying causes
Dental No underlying causes
Miscellaneous Adhesions, Decompression sickness, Maxillofacial or sinus surgery, Postoperative sequelae, Postsurgical esotropia, Postsurgical exotropia, Snakebites, Vitamin E deficiency

Causes in Alphabetical Order


Binocular Diplopia

Monocular Diplopia

Diagnosis

Binocular Diplopia

Double vision can occur when the two eyes are not correctly aligned while aiming at an object, such as in esotropia and exotropia - these result in uncrossed diplopia and crossed diplopia, respectively (i.e. "crossed eyes", in esotropia, result in uncrossed diplopia). When the eyes are misaligned and aimed at different targets, two non-matching images are sent to the viewer's brain. When the viewer's brain accepts and uses two non-matching images simultaneously, double vision results.

Double vision is dangerous to survival, therefore, the brain naturally guards against its occurrence. In an attempt to avoid double vision, the brain can ignore one eye (suppression). Due to the brain's ability to suppress one eye, double vision can appear to go away without medical evaluation or treatment. The causes of the double vision are very likely still present and loss of vision in one eye can occur due to lack of treatment. The loss of vision in one eye can be temporary or permanent depending on detection and treatment. It is in this way, that diplopia contributes to loss of depth perception and binocular vision, amblyopia (lazy eye), and/or strabismus (deviating eye).

Monocular Diplopia

Diplopia can also occur when viewing with only one eye; this is called monocular diplopia, or where the patient perceives more than two images, monocular polyopia. In this case, the multiple vision can be caused by a structural defect in the vision system, such as cataracts, subluxation of the crystalline lens or Keratoconus causing irregularities in the refraction of light within the eye.

Temporary Diplopia

Temporary diplopia can also be caused by intoxication from alcohol or head injuries, such as concussion. If temporary double vision does not resolve quickly, one should see an eye doctor immediately. It can also be a side effect of the anti-epileptic drugs Phenytoin and Zonisamide, and the anti-convulsant drug Lamotrigine, as well as the hypnotic drug Zolpidem.

Treatment for Binocular Diplopia

Treatment for binocular diplopia includes prism lenses and/or vision therapy. Daily wear of prism lenses is the passive compensatory treatment. Vision therapy is an active treatment which retrains the visual and vestibular systems (brain, eye muscles, and body). Vision therapy may eliminate the need for daily wear of prism lenses.

Voluntary Diplopia

Some people are able to consciously uncouple their eyes, inducing double vision on purpose. These people do not consider their double vision dangerous or harmful, and may even consider it enjoyable.

References

  1. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  2. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016

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