What are the treatment options for diplopia (double vision)?

Treatment Options for Diplopia (Double Vision)

The treatment of diplopia should be directed first toward identifying and addressing the underlying cause, followed by management of the diplopia itself through non-surgical and surgical interventions as appropriate. 1

Diagnostic Evaluation

Before initiating treatment, a proper diagnostic workup is essential:

• Determine if diplopia is monocular (persists with one eye covered) or binocular (resolves with one eye covered)

• Assess associated symptoms:

  • Pupil involvement (concerning for aneurysm)
  • Headache, especially with thunderclap onset
  • Ptosis
  • Facial numbness or weakness
  • Dizziness or vertigo

• Red flags requiring immediate attention:

  • Pupil-involving 3rd nerve palsy (urgent neuroimaging to rule out aneurysm)
  • Signs of increased intracranial pressure
  • Progressive neurological deficits

Treatment Algorithm

1. Immediate Management

• Temporary relief measures while awaiting diagnosis or resolution:
  • Occlusion of one eye (patch, occluder contact lens, or MIN lens)
  • Prism correction for small, stable deviations
  • Chemodenervation (botulinum toxin) of antagonist extraocular muscles 1

2. Non-Surgical Options

• Optical correction:

  • Fresnel press-on prisms for temporary use
  • Ground-in prisms for more permanent correction of small to moderate deviations 1
  • Uniocular progressive lenses or bifocals for patients with accommodative deficits 1

• Compensatory techniques:

  • Head positioning to find a field of single vision
  • Occlusive contact lens for bothersome diplopia in specific situations 1

3. Surgical Management

Surgical intervention is typically considered when:

• Diplopia persists for more than 6 months
• The angle of strabismus has been stable for at least 4-6 months (especially in thyroid eye disease)
• Non-surgical methods have failed to provide adequate relief 1

Surgical options based on etiology:

• For 3rd nerve palsy:

  • For partial palsy: Recession of lateral rectus muscle with resection of medial rectus muscle
  • For complete paralysis: Weakening procedures of the lateral rectus (supramaximal recession, extirpation, or suturing to periosteum) 1

• For restrictive strabismus (e.g., thyroid eye disease):

  • Recessions of restricted muscles are the mainstay
  • Resections generally avoided but may be useful in select cases 1

• For divergence insufficiency/sagging eye syndrome:

  • Bilateral lateral rectus resection
  • Bilateral medial rectus recession
  • Unilateral medial rectus recession with lateral rectus resection 1

Special Considerations

• Timing of surgery:

  • For most causes, wait until the condition has stabilized (typically 6 months)
  • In thyroid eye disease, orbital decompression should precede strabismus surgery 1

• Age-related concerns:

  • In patients over 60 years with recent diplopia, check ESR and CRP to rule out giant cell arteritis
  • Higher risk of anterior segment ischemia with strabismus surgery in older patients with vascular risk factors 2

• Innovative approaches:

  • "Spot patch" techniques that eliminate diplopia without the limitations of traditional patching may be considered for patients who cannot tolerate other treatments 3

Prognosis and Expectations

• The primary goal is to eliminate diplopia in primary position and reading position
• Patients should be advised that diplopia may persist in extreme gaze positions despite treatment
• Some conditions may not improve spontaneously and require long-term management 2

Follow-up

• Regular monitoring for resolution of diplopia
• Adjustment of prisms or surgical planning if diplopia persists
• Continued evaluation for underlying conditions 2

By following this structured approach to the treatment of diplopia, clinicians can effectively manage this potentially debilitating condition while addressing the underlying cause to optimize morbidity, mortality, and quality of life outcomes.