What is the appropriate evaluation and treatment approach for a patient with diplopia (double vision), considering their age, medical history, and symptoms?

Evaluation and Management of Diplopia

Diplopia requires immediate systematic evaluation to distinguish between benign and life-threatening causes, with urgent ophthalmologic assessment within hours for any patient presenting with double vision following trauma or acute onset, particularly when accompanied by headache or pupillary abnormalities. 1, 2

Initial Classification: Monocular vs. Binocular

The first critical step is determining whether diplopia persists with one eye covered:

• Monocular diplopia (persists with one eye covered) indicates an optical or ocular media problem requiring refraction and biomicroscopic examination of cornea, lens, and retina 3
• Binocular diplopia (resolves with either eye covered) indicates ocular misalignment from neurologic, muscular, or orbital causes and requires urgent evaluation 3, 4

Urgent Red Flags Requiring Same-Day Imaging

Immediately refer for neuroimaging if any of the following are present:

• Acute onset diplopia with severe headache (concern for posterior communicating artery aneurysm) 3, 2
• Pupillary involvement or afferent pupillary defect 1, 2
• History of recent head or ocular trauma 5, 1
• Progressive symptoms or associated neurological deficits 5, 6

Comprehensive Examination Protocol

Essential Initial Assessment

Every patient with diplopia requires the following systematic evaluation 5, 1:

• Visual acuity testing in both eyes to establish baseline and detect asymmetry 1
• Pupillary examination to identify afferent defects or irregular pupils suggesting optic nerve damage or globe penetration 1
• Intraocular pressure measurement to detect elevated pressure from trauma or orbital pathology 5, 1
• Slit-lamp examination to assess anterior segment and rule out corneal or lens pathology 5, 1
• Dilated fundus examination (when safe) with attention to fundus torsion, retinal tears, or hemorrhage 5, 1

Detailed Sensorimotor Examination

A thorough motility assessment must include 5:

• Versions and ductions in all gaze positions to identify restricted or paretic muscles 5
• Saccades, pursuit, and vergence testing to assess supranuclear control 5
• Alignment testing in multiple gaze positions with attention to primary and secondary deviations 5
• Forced duction testing to distinguish mechanical restriction from muscle paresis 5
• Cover testing and Maddox rod to quantify misalignment 6

Age-Specific Considerations

For patients over 50 years:

• Divergence insufficiency presents with esotropia worse at distance, median age 74 years, more common in Caucasian women 5
• Sagging eye syndrome prevalence increases from <5% under age 50 to 60% over age 90, presenting between 60-80 years with esotropia, mild vertical deviation, and associated blepharoptosis (29%) or deep superior lid sulcus defect (64%) 5

For high myopes (>-8.00 diopters, axial length >27mm):

• Strabismus fixus (heavy eye syndrome) causes progressive large-angle esotropia with hypotropia and limited abduction/elevation, typically presenting in middle age 5

Imaging Protocol

Non-contrast thin-section orbital CT with multiplanar reconstructions is the imaging study of choice for diplopia with trauma or suspected orbital pathology, with 94.9% sensitivity for detecting foreign bodies, fractures, hemorrhage, and globe damage 1

Trauma-Specific Management

Acute Phase (0-6 months)

• Diplopia following orbital trauma is very common after blowout fractures, with 7-24% requiring strabismus surgery 5
• Critical pitfall: Vital signs showing bradycardia, heart block, or symptoms of dizziness/nausea/vomiting may indicate orbital entrapment requiring urgent surgical consultation 5
• Initial examination findings may be obscured by edema and hemorrhage; repeat detailed sensorimotor examination as swelling resolves 5

Prognosis and Timing

Diplopia persisting beyond 6 months after trauma is unlikely to resolve spontaneously and warrants treatment 5, 1

Treatment Approach by Etiology

For Age-Related Causes (Divergence Insufficiency, Sagging Eye, Strabismus Fixus)

These conditions will not resolve spontaneously and are progressive 5:

• Prism correction in glasses as initial conservative management 5
• Strabismus surgery when diplopia, inability to make eye contact, or severe misalignment prevents proper eye examination 5
• Treatment is symptom-directed with goals of reducing diplopia, restoring binocular vision, reconstructing alignment, and reducing compensatory head posture 5

For Retinal Causes (Macular Pathology)

When diplopia develops days to weeks after maculopatia worsening (16-37% of epiretinal membrane patients) 7:

• Observation/monitoring if symptoms are mild or occasional 7
• Prism correction may reduce symptoms in select patients 7
• Fogging the affected eye using surgical tape, Scotch Satin tape, Bangerter filters, or occlusive contact lenses eliminates foveal conflict by creating a central scotoma 7
• Strabismus surgery if improved binocular alignment reduces symptoms not addressed by fogging or optical correction 7
• Epiretinal membrane peeling may be effective but can cause new diplopia in some patients 7

For Microvascular Causes

Diplopia from microvascular cranial neuropathy often spontaneously resolves within 6 months and may be observed during this period 2

Follow-Up Protocol

• Recheck at 4-6 week intervals during observation period 1
• Immediate return for new symptoms including increased floaters, flashes, peripheral visual field loss, or worsening vision 1
• Second examination within 6 weeks for patients with vitreous pigment, hemorrhage, or vitreoretinal traction 1

Common Pitfalls to Avoid

• Never delay imaging in patients with headache, pupillary involvement, or trauma—these require same-day evaluation 1, 2
• Do not attribute all symptoms to a single diagnosis without ruling out concurrent pathology; if vision worsens despite appropriate management, evaluate for optic neuropathy or other retinal disease 8
• Avoid premature surgical intervention for trauma-related diplopia before 6 months, as spontaneous improvement may occur 5
• Do not overlook systemic causes: Test for myasthenia gravis with fatigable upgaze and lid testing when motility patterns are inconsistent or fluctuating 6