Can double vision be a side effect of an old ocular (eye) stroke?

Double Vision as a Potential Side Effect of an Old Ocular Stroke

Yes, double vision (diplopia) can be a side effect of an old ocular stroke, particularly when the stroke affects areas involved in eye movement control or causes changes in ocular alignment over time.

Mechanisms of Diplopia After Ocular Stroke

Diplopia following an ocular stroke can occur through several mechanisms:

1. Direct damage to ocular motor pathways:

   • Cerebellar strokes can disrupt ocular motor control pathways, leading to persistent diplopia 1
   • Strokes affecting the brainstem where cranial nerves controlling eye movements originate can cause diplopia

2. Fixation switch diplopia:

   • A common delayed complication after ocular stroke
   • Occurs when visual acuity in the previously dominant eye declines due to the stroke
   • Fixation preference switches to the previously non-dominant eye
   • The previously dominant eye doesn't have a suppression scotoma, resulting in double vision 2

3. Decompensation of pre-existing strabismus:

   • An ocular stroke can cause decompensation of previously well-controlled or asymptomatic strabismus
   • According to the American Academy of Ophthalmology, this is a common cause of diplopia in older adults 2

Clinical Presentation and Diagnosis

When evaluating diplopia potentially related to an old ocular stroke:

• Determine if the diplopia is binocular (disappears when either eye is covered) or monocular (persists when the affected eye views alone) 3
• Assess for associated symptoms such as:
  • Visual field defects
  • Other cranial nerve palsies
  • Ataxia or balance problems 1
• Evaluate ocular alignment and eye movements
• Check for evidence of previous retinal or ophthalmic artery occlusion 2

Management Options

Management of diplopia following an ocular stroke depends on the underlying mechanism and may include:

1. Optical correction:

   • Prism correction in glasses can realign images and eliminate diplopia in stable cases 2, 1
   • "Spot patching" techniques may eliminate diplopia without the limitations of traditional patching 4

2. Medical interventions:

   • Botulinum toxin injections may be considered for persistent diplopia 1

3. Surgical options:

   • Strabismus surgery may be appropriate after the condition has stabilized (typically 2-3 years after the event) 2
   • Surgical management has shown modest success in cases with stabilized deviation 2

4. Visual rehabilitation:

   • Compensatory scanning training can improve functional outcomes 2

Important Considerations

• Timing: Diplopia may develop months to years after the initial ocular stroke as visual compensation mechanisms fail or as fixation preference changes
• Prognosis: The prognosis varies, with some patients experiencing spontaneous resolution while others have persistent diplopia requiring long-term management 1
• Associated conditions: Patients with a history of ocular stroke should be monitored for other complications, including neovascular glaucoma 2

Pitfalls to Avoid

• Misdiagnosis: Don't assume all new-onset diplopia in patients with previous stroke is directly related to the old stroke; new pathologies (including new strokes) must be ruled out
• Delayed treatment: Persistent diplopia significantly impacts quality of life and should be addressed promptly
• Overlooking systemic risk factors: Patients with previous ocular stroke remain at high risk for additional vascular events and require ongoing risk factor management 2, 5

Double vision following an ocular stroke can significantly impact quality of life but can often be effectively managed with appropriate interventions once the condition has stabilized.