From the Guidelines
To evaluate double vision, start by determining if it's monocular or binocular, and then perform a complete neurological examination, including eye movement testing, pupillary responses, and visual field assessment, as recommended by the most recent study 1. When evaluating double vision, it is essential to consider the patient's medical history, including any previous strabismus surgery or chronic conditions that may be contributing to the diplopia.
- A description of ocular misalignment, including the angle and direction of the strabismus, is crucial in determining the underlying cause of the double vision 1.
- The presence of treatable causes of vision loss should be determined prior to strabismus surgery and treated as possible or appropriate, as suggested by 1.
- A complete sensorimotor examination should be performed, and misalignment should be measured by prism and alternate cover test, if possible, as recommended by 1.
- Consider urgent neuroimaging (MRI or CT) if double vision is sudden, associated with headache, or other neurological symptoms, as this could indicate stroke, aneurysm, or mass lesion, as indicated by 1.
- Blood tests may be needed to check for myasthenia gravis, thyroid dysfunction, or diabetes, and document the pattern of double vision in different gaze directions, as specific patterns can point to particular nerve palsies, as suggested by 1.
- Temporary management includes patching one eye or using prism glasses while awaiting definitive treatment of the underlying cause, and double vision evaluation is critical because it may represent serious neurological conditions requiring prompt intervention, as emphasized by 1.
From the Research
Evaluation of Double Vision
To evaluate double vision, a systematic approach to the history and physical examination is required 2. The following steps can be taken:
- Take a comprehensive history to delineate the exact type of visual disturbance experienced by the patient 3
- Examine the patient to pinpoint the aetiology, which is crucial for further management 3
- Determine if the diplopia is monocular or binocular in origin, as this can help guide the diagnosis 2, 4
- Use simple clinical tests to detect ocular misalignment or strabismus, which can cause binocular diplopia 4
- Consider urgent imaging for patients with acute onset diplopia, especially if accompanied by headache or pupillary involvement 4
Causes of Double Vision
Double vision can have various causes, ranging from benign to sight or life threatening if left untreated 3. Some common causes include:
- Ocular misalignment or strabismus 4
- Neurologic causes, such as cranial nerve palsy 5
- Extraocular muscle disorders 2
- Microvascular causes, which often spontaneously resolve within six months 4
Diagnostic Approach
A logical, localization-driven, and evidence-based approach is the most effective way to arrive at the correct diagnosis and provide the best outcome for the patient 5. This approach includes: