Double Vision in a Five-Year-Old: Urgent Ophthalmologic Referral Required
A 5-year-old child presenting with double vision requires immediate referral to a pediatric ophthalmologist or appropriately trained eye care specialist, as diplopia in this age group is uncommon and may indicate serious underlying pathology including strabismus, amblyopia risk factors, or neurologic disease. 1, 2
Immediate Action Required
- Refer urgently to pediatric ophthalmology for comprehensive evaluation, as early detection and treatment of ocular disorders is critical to prevent lifelong visual impairment 1, 2
- Children who fail vision assessment or have ocular abnormalities should not be managed in primary care alone 2
- Same-day urgent imaging may be necessary if there are concerning features (headache, pupillary abnormalities, acute onset) 3
Key Clinical Distinctions to Document Before Referral
Determine if diplopia is monocular versus binocular by having the child cover each eye separately:
- Binocular diplopia (resolves when either eye is covered) indicates ocular misalignment and is most commonly neurologic in origin 4, 3, 5
- Monocular diplopia (persists when affected eye is open, resolves when that eye is covered) suggests refractive error, cataract, or retinal disease 5
Most Likely Etiologies in This Age Group
Common causes of diplopia in preschool children include:
- Strabismus (ocular misalignment) - affects 5-10% of preschoolers and can be assessed by cover test and Hirschberg light reflex 1
- Amblyopia and amblyogenic risk factors (present in 1-4% of preschool children) including significant refractive error, anisometropia, or media opacities 1
- Refractive errors (myopia, hyperopia, astigmatism) - present in 5-7% of preschoolers 1
Critical Examination Components for Specialist
The pediatric ophthalmologist will perform:
Sensorimotor evaluation including:
- Binocular alignment testing in multiple fields of gaze 1
- Stereoacuity testing (Random Dot E test, Titmus Fly Stereotest, or similar age-appropriate tests) 1
- Worth 4-Dot testing to assess fusion 1
Cycloplegic refraction to accurately determine refractive error:
- Essential in children due to increased accommodative tone 1
- Typically uses cyclopentolate 0.2% with phenylephrine 1% in children under 6 months, or cyclopentolate 1% in older children 1
Funduscopic examination after dilation:
- To identify retinal or optic nerve abnormalities that may produce sensory strabismus 1
- Particular attention to optic nerve for swelling, pallor, or congenital anomalies 1
Treatment Implications
Early intervention is critical because:
- Visual impairment from amblyopia, strabismus, and refractive error affects 5-10% of preschoolers and can harm school performance and future quality of life 1
- There is an early sensitive period when interventions lead to better outcomes 1
- Uncorrected amblyopia may be a risk factor for future total blindness 1
Treatment options (determined by specialist) may include:
- Glasses, contact lenses, or refractive correction for refractive errors 1
- Patching or atropine therapy for amblyopia 1
- Surgery for strabismus or cataracts 1
- Visual training for specific conditions 1
Common Pitfalls to Avoid
- Do not delay referral - traditional vision testing cannot be performed reliably until ages 3-4 years, and specialized testing by trained personnel is required for accurate diagnosis in this age group 1
- Do not assume diplopia is normal - while children often suppress diplopia from strabismus, the active complaint of double vision warrants investigation 1
- Do not attempt primary care management alone - diagnosis and treatment require specialized ophthalmologic expertise and equipment 1, 2