From the Guidelines
Diplopia in an 80-year-old requires immediate medical evaluation by an ophthalmologist or neurologist to rule out serious underlying conditions such as stroke, cranial nerve palsy, or myasthenia gravis, as highlighted in the adult strabismus preferred practice pattern 1. The patient's symptom of double vision could be indicative of various conditions, and a thorough diagnosis is necessary to determine the underlying cause.
- Potential causes of diplopia in this age group include:
- Stroke or cranial nerve palsy
- Myasthenia gravis
- Age-related conditions such as cataracts
- Sagging eye syndrome, a common cause of acquired binocular diplopia in patients between 60 and 80 years old 1
- While awaiting medical care, the patient can temporarily patch one eye to alleviate the double vision.
- No specific medication can be recommended without proper diagnosis, but potential treatments may include:
- Prisms in glasses for stable muscle imbalances
- Corticosteroids for inflammatory conditions
- Pyridostigmine for myasthenia gravis
- Urgent intervention for stroke
- The urgency of evaluating diplopia in this age group stems from its potential as a warning sign of serious vascular events like stroke or aneurysm, particularly common due to atherosclerosis and hypertension 1.
- Diabetes, a common condition in older adults, can also cause temporary diplopia through cranial nerve palsies.
- The patient should not drive or perform hazardous activities until the diplopia is evaluated and managed, as emphasized in the adult strabismus preferred practice pattern 1.
- According to the most recent study 1, the goal of treatment should be broader and include sensory recovery, as well as gains in psychosocial and functional domains of vision-related quality of life.
- Success rates of treatment depend on the subpopulation studied and the goals of surgery, but overall, they are approximately 80% after one procedure and may exceed 95% if a second procedure is performed on eyes failing the first intervention 1.
From the Research
Causes of Diplopia in an 80-Year-Old
- Diplopia can be caused by benign or life-threatening etiologies, and it is essential to assess the patient promptly to determine the underlying cause 2.
- In patients over 60 years old, inflammatory markers should be obtained to rule out giant cell arteritis, especially if they present with a recent history of diplopia 2.
- Giant cell arteritis can cause diplopia, ptosis, and third nerve palsy, and it is essential to consider this diagnosis in older adults with these symptoms 3.
Diagnostic Approach
- A logical and localization-driven approach is necessary to evaluate patients with diplopia, including a comprehensive history and examination to determine the underlying cause 4.
- Clinical assessment of diplopia includes taking a comprehensive history and examination to pinpoint the etiology, which is crucial for further management 5.
- Simple clinical tests can detect ocular misalignment or strabismus, which is a common cause of binocular diplopia 6.
Management and Referral
- Patients with isolated fourth and sixth nerve palsies without other neurological signs should be referred to Neurology or Ophthalmology for further work-up 2.
- All patients presenting with an acute isolated third nerve palsy should be imaged with CT and CT angiography of the brain to rule out a compressive aneurysm 2.
- Patients with diplopia of acute onset should be investigated urgently, and those with a headache or pupillary involvement need to be referred for same-day urgent imaging 6.