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diplopia (double vision)
Etiology:
1) horizontal diplopia:
- images side by side
- cranial nerve 3 palsy or cranial nerve 6 palsy
2) vertical diplopia
- images on top of another
- cranial nerve 3 palsy or cranial nerve 4 palsy
3) diplopia in one eye with the other eye closed
- suggests problem in the cornea or lens (aberrant refraction)
- uncommonly, severe retinal pathology can cause monocular diplopia [4]
4) binocular
a) extraocular muscle paralysis or weakness (cranial nerve 3 palsy, cranial nerve 4 palsy, cranial nerve 6 palsy)
- diabetes
- posterior communicating artery aneurysm
- myasthenia gravis
b) difficulty moving the eyes within the orbit
- tumor
- Graves' disease
- fracture
c) pharmaceuticals [4]
- carbamazepine
- phenytoin
- vincristine
5) binocular diplopia suggests more serious etiology than monocular diplopia
Management:
- isolated cranial nerve 6 palsy can be observed for a few weeks looking for improvement
- with cranial nerve 3 palsy, absence of pupillary involvement suggests a benign process that may be observed over a couple of weeks
- most cranial nerve 4 palsy are traumatic or idiopathic postpone neuroradiology testing until 2 months have passed
- if more than one cranial nerve is involved, referral to a neurologist or ophthalmologist is indicated
- eye patch over affected eye can be useful if cause is benign [3]
General
eye disease (ophthalmopathy)
sign/symptom
References
- Guide to Physical Examination & History Taking, 6th edition,
Bates, B, JB Lippincott, Philadelphia, 1995, pg 35
- Medical Knowledge Self Assessment Program (MKSAP) 11, American
College of Physicians, Philadelphia 1998
- Medical Knowledge Self Assessment Program (MKSAP) 20
American College of Physicians, Philadelphia 2025
- UpToDate, Online version 15.3
http://www.utdol.com
- Geriatrics at your Fingertips, 13th edition, 2011
Reuben DB et al (eds)
American Geriatric Society
- Geriatric Review Syllabus, 10th edition (GRS10)
Harper GM, Lyons WL, Potter JF (eds)
American Geriatrics Society, 2019
- Margolin E.
Approach to patient with diplopia.
J Neurol Sci. 2020;417:117055.
PMID: 32777577