Assessment of diplopia

1. DR. ANUPAMA MANOHARAN
FIRST YEAR D.O. 1st PG
RESIDENT
DEPT. OF OPHTHALMOLOGY
GOVT. STANLEY MEDICAL
COLLEGE

2. Definition
It gives a pictorial record of diplopia in cases where
there is separation of 2 images, in the nine positions
of gaze.
 It is Greek word which means double vision.
 It is caused due to the breakdown in the fusional
capacity of the binocular system.
 PRINCIPLE : Each retinal point has its own value
of direction in gazes.

3.  Mechanisms
◦ More than one image of the object of regard is formed in
the retinae of one or both eyes ( monocular diplopia)
◦ The eyes lose their simultaneous alignment with the object
of regard (incomitance of ocular alignment – binocular
diplopia)
◦ The eyes although aligned, send images to the brain which
disallow fusion ( aniseikonia )
◦ Rarely, purely cerebral mechanisms

4. Is the double vision present even on monocular
eye closure?

5.  I. Monocular Diplopia
Diplopia persists on occlusion of one eye.
 1. Refractive – Astigmatism, Anisometropia
 2. Corneal - Pterygium, Corneal Scars, Keratoconus
 3. Lenticular - Dislocated lens, Ectopia lentis
 4. Iridectomy or Iridotomy
 5. Dry Eye
 6. Retinal Maculopathy
 7. Cortical Diplopia
 8. Psychogenic

6.  Binocular Diplopia
Occurs when both the eyes work together and resolved by occlusion of
either eye.
 1. Physiological
 2. Concomitant- decompensating heterophoria(angle of deviation is same in
different directions of gaze)
 3. Inconcomitant
(i) Myogenic - thyroid ophthalmopathy
(ii) Neuromuscular junction disorders - myasthenia,
(iii) Paralytic - Nuclear/Infranuclear
- Supranuclearlesions are not normallyassociated withdiplopia
(iv) Restrictive -blow out fractures, orbital tumours,Browns syndrome

7.  Abnormal Head Posture
◦ Predominant face turn – horizontal recti
◦ Predominant chin elev/dep – vertical recti, pattern
strabismus
◦ Predominant tilt – Obliques

8.  Diplopia is maximum ( separation of images) in the
field of action of the paralysed muscle.
 The false image ( the image belonging to the eye
with the hypofunctioning muscle ) is always
peripherally situated

9. DATA DERIVED FROM DIPLOPIA
CHART
 i. The areas of single vision and diplopia
 ii. The distance between the two images in the
areas of diplopia
 iii. Whether the images are on the same level or
not
 iv. Whether one image is inclined or both are erect
 v. Whether the diplopia is homonymous or crossed.

10. PREREQUISITES FOR DOING
DIPLOPIA CHARTING
 i. Patient should have binocular single vision.
 ii. Good visual acuity.
 iii. Patient should be cooperative.

11. The SIMPLE method
Comfortable with his head erect and should preferably be still
throughout the examination.
 carried out in a dark room.
 A red glass is put in front of one of the eyes (red in front of
right, R for R, is a convention). It is desirable to useArmstrong
goggles since these are shaped to fit the orbitalmargin
 examiner holds the torch (vertical source of light) at around ½
m or 1 m (It is important to mention the distance on thechart).
This source of light could be horizontal if the complaint is of
vertical separation of images
 The light is held directly in front of the patient at first.

12.  If the patient notes a double image, the relative position
of these images is noted. The light is now carried to the
right and then to the other 8 positions of gaze.
 If there is no double vision in primary position, the
position in which double vision appears and is maximal is
to be noted.
 In each gaze position the patient must be asked whether
the images are parallel , distance between two images &
tilt if present.
 colored pencils can be given to patient to show the
separation.

13. ARMSTRONG
GOGGLES
R L

15. Interpretation
 i. If two images are joined together— no diplopia
 ii. If images are separated—confirms diplopia.
 iii. Maximum separation is in the quadrant in
which (the muscle moves the eye) the muscle is
restricted.
 iv. The image is displaced towards the field of
action of the paralyzed muscle.

16.  v. If horizontal separation with uncrossed
images—esodeviation.
 vi. If horizontal separation with crossed
images—exodeviation.
 vii. If vertical separation with uncrossed
images—oblique muscles involved.
 viii. If vertical separation with crossed image—
vertical recti muscle involved

17. DISADVANTAGES
 i. It is mainly a subjective test.
 ii. Needs a well cooperative patient.
 iii. Test is not reproducible.
 iv. In many cases the patients are uncooperative or
their intelligence is obscured by intracranial
disease or contracture of the antagonistic muscles
may have set in.
 v. The test may give false interpretations if the
paresis unmasks a latent squint or the patient
starts fixing with the paralyzed eye, especially if

18. TREATMENT
 1. conservative (glasses/prisms)
 2. surgical(squint correction )
 Primary aim is to prevent diplopia.
 Occlussion of one eye with
patch/opaque contact lens.
 If deviation is less prisms can be given.
 In neurological cause we can wait for 6
months to one year

19. If there is no improvement even after one year in
paralytic conditions , patient can be advised for
surgical correction for deviation to prevent diplopia
Principle is--- correction should be in such a way
that pt should not have any diplopia in primary and
downward gaze of position