What is the evaluation and treatment approach for patients presenting with dizziness and distance double vision?

Evaluation and Treatment of Dizziness and Distance Double Vision

The most effective approach for patients with dizziness and distance double vision is to first determine if these symptoms are related, with skew deviation being a key consideration as it can cause both symptoms simultaneously, requiring a complete sensorimotor evaluation and the three-step test for diagnosis, followed by appropriate referrals to neurology or otolaryngology specialists. 1, 2

Initial Diagnostic Approach

History Assessment

• Focus on timing and triggers of dizziness rather than symptom quality 1, 3:

  • Acute vestibular syndrome: continuous dizziness lasting days to weeks
  • Triggered episodic vestibular syndrome: episodes triggered by position changes, lasting <1 minute
  • Spontaneous episodic vestibular syndrome: untriggered episodes lasting minutes to hours
  • Chronic vestibular syndrome: dizziness lasting weeks to months

• For double vision assessment:

  • Confirm if binocular (disappears when one eye is covered) or monocular
  • Determine onset (sudden vs. gradual)
  • Assess if worse at distance or near
  • Note any associated pain, head tilt, or perceived tilting of visual world 1, 2

Physical Examination

For Dizziness:

• Orthostatic blood pressure measurement
• Assessment for nystagmus (direction, pattern)
• Dix-Hallpike maneuver for positional vertigo
• HINTS examination (Head-Impulse, Nystagmus, Test of Skew) if acute vestibular syndrome is present 4, 3

For Double Vision:

• Complete sensorimotor evaluation
• Three-step test for vertical diplopia
• Upright-supine test
• Check for neuro-ophthalmic signs: Horner's syndrome, cranial nerve palsies, internuclear ophthalmoplegia, nystagmus
• Fundus examination for papilledema or optic atrophy
• Visual field testing 1, 2

Diagnostic Testing

Imaging

• MRI orbits with and without contrast: First-line imaging for double vision with suspected orbital or skull base lesion 1, 2
• CT orbits: Complementary to MRI, especially when evaluating orbital trauma or bony abnormalities 1
• MRI brain with contrast: When brainstem, cavernous sinus, or cranial nerve pathology is suspected 2
• CT/MR angiography: For suspected aneurysm, especially with pupil-involving 3rd nerve palsy 2

Additional Testing

• Lights on/off test, double Maddox rod testing, Lancaster red-green testing for torsional misalignment
• Laboratory testing is generally not required for dizziness but may be indicated based on clinical suspicion 2, 4

Common Diagnoses to Consider

When Both Symptoms Present Together:

• Skew deviation (vertical misalignment with vestibular dysfunction)
• Sagging eye syndrome (age-related degeneration of connective tissue bands)
• Abducens (6th) nerve palsy (can cause horizontal diplopia and dizziness)
• Vertebrobasilar insufficiency
• Demyelinating diseases
• Posterior fossa mass lesions 1, 2

For Dizziness Alone:

• Benign paroxysmal positional vertigo (BPPV)
• Vestibular neuritis/labyrinthitis
• Ménière's disease
• Vestibular migraine
• Postural hypotension 1, 4

For Distance Double Vision Alone:

• Divergence insufficiency (esotropia greater at distance)
• Myopic strabismus fixus
• Cranial nerve palsies (III, IV, VI)
• Thyroid eye disease
• Myasthenia gravis 1, 2

Treatment Approach

For Skew Deviation (Combined Symptoms):

1. Refer to neurology or otolaryngology specialists based on likely cause
2. Initial treatment with prism to manage diplopia while awaiting recovery
3. Consider botulinum toxin, prism, or strabismus surgery for persistent cases 1

For BPPV:

• Canalith repositioning procedures (e.g., Epley maneuver) 1, 4

For Distance Double Vision:

• Temporary measures:

  • Occlusion of one eye (patch)
  • Prism glasses (for small deviations)
  • Botulinum toxin injections while awaiting resolution 1, 2

• Definitive treatment:

  • Strabismus surgery if diplopia persists beyond 6 months
  • Lateral rectus recession for divergence insufficiency
  • Recession of restrictive muscles for mechanical causes 1, 2

For Vestibular Disorders:

• Vestibular rehabilitation therapy
• Limited use of vestibular suppressants (can delay central compensation) 4, 3

Follow-Up and Monitoring

• Regular monitoring to evaluate resolution of symptoms
• Adjust prisms or plan surgery if diplopia persists
• Inform patients that the goal is to eliminate diplopia in primary position and downgaze, but it may persist in extreme positions 2

Pitfalls to Avoid

1. Relying solely on symptom quality descriptions rather than timing and triggers for dizziness
2. Failing to perform the three-step test for vertical diplopia
3. Missing central causes of dizziness by not performing HINTS examination when indicated
4. Overuse of vestibular suppressant medications, which can delay central compensation
5. Prolonged observation of abducens palsy without recovery by 6 months (40% have serious underlying pathology) 1, 3