This document provides guidance on evaluating patients presenting with diplopia. It outlines key questions to ask the patient regarding the orientation and characteristics of the double vision. Examining the eye movements, lids, and pupils can help localize the cause. Systemic neurological symptoms or asymmetric pupils indicate potentially serious conditions like aneurysm that require immediate imaging. Isolated cranial nerve palsies are often due to ischemia. Multiple cranial nerve involvement raises concern for life-threatening conditions like tumor or stroke within the cavernous sinus. Refractive errors and decompensating phoria are common causes of intermittent diplopia.

1. BY BABLI SHARMA
B.OPTOM , M.OPTOM

2. INTRODUCTION:
1. Is It Really Diplopia?
 EVALUATING PT WITH DIPLOPIA IS TO ESTABLISH THAT PT IS TRULY
SEEING TWO SEPARATE IMAGES.
 IF PT IS C/O DIPLOPIA
 ASK TWO QUESTION : 1. DO YOU SEE SEPATATE IMAGES?
 IF SO , HOW ARE THE THINGS OR IMAGES ORIENTED IN RESPECT TO EACH OTHER
 VERTICALLY
 DIAGONALLY
 HORIZONTALLY

3.  IF ITS VERTICAL :
I. IT WILL ASSOCIATED WITH : CRANIAL NERVE 3RD AND CN 4TH
II. ISCHEMIA
III. TRAUMA
IV. THYROID EYE DISEASE
• IF ITS DIAGONAL :
I. IT WILL ASSOCIATED WITH CN 3RD, 4TH , 6TH
II. ISCHEMIA , ANEURYSMS ,
III. TRAUMA
IV. CAVERNOUS SINUS PATHOLOGY
V. NEOPLASM

4.  IF ITS HORIZONTAL
I. IT WILL BE ASSOCIATED WITH : CN 3RD ,CN 6TH
II. ISCHEMIA
III. INTERNUCLEAR OPTHALMOPLEGIA
IV. NEOPLASM
V. TRAUMA

5.  DOES DIPLOPIA GO AWAY WHEN PT IS CLOSE OR COVERED HIS ONE EYE
 ALWAYS CHECK WITH BOTH EYE
 IF THE DIPLOPIA RESOLVE WHEN EITHER EYE IS COVERED , THE DIPLOPIA IS BINOCULAR
 IF DIPLOPIA PERSIST EVEN WHEN ONE EYE IS COVERED , IT IS MONOCULAR , IT USUALLY
ORIGINATES FROM REFRACTIVE CHANGES TO STRUCTURES WITHIN THE EYE

6.  DOES DIPLOPIA LOOKS WORSEN WHEN YOU LOOK IN CERTAIN DIRECTION
 DIPLOPIA THAT VARIES IN MAGNITUDE IN SPECIFIC GAZES INCRAESES THE LIKELIHOOD OF
MUSCLES PALSY OR MUSCLE RESTRUCTION
 IF PT NOTICES DIPLOPIA THAT INCREASES SUBSTANTIALLY WHEN LOOKING UP , MUSCLE
ENTRAPMENT DUE TO TRAUMA MUST BE RULE OUT
 INTERNUCLEAR OPTHALMOPLEGIA CAN CAUSE DIPLOPIA IN LATERAL GAZES OR MAY BE
DUE TO DEMYELINATING DISEASE IN YOUNGER PT OR ISCHEMIA IN OLDER PATIENTS .

7. IS DIPLOPIA OF SUDDEN ONSET OR CONSTANT
 A SUDDEN ONSET OF CONSTANT DIPLOPIA INCREASE THE LIKELIHOOD OF AN
UNDERLYING SYSTEMIC ETIOLOGY
 ISOLATED CRANIAL NERVE PALSIES OFTEN CAUSE SUDDEN ONSET OF DIPLOPIA THAT
DOESN’T RESOLVE
 ANOTHER CAUSE OF ACUTE ONSET OF DIPLOPIA , CONSTANT DIPLOPIA IS A PATHOLOGY
THAT AFFECTS THE CAVERNOUS SINUS , MAY INVOLVE MULTIPLE CRANIAL NERVE
 FACIAL PAIN OR NUMBNESS IN ADDITION TO CONSTANT DIPLOPIA SHOULD INCREASE
SUSPICIAN OF A CAVERNOUS SINUS PATHOLOGY
 PROPTOSIS / DILATED EPISCLERAL VESSELS OR CONJUNCTIVAL BLOOD VESSELS ARE
ADDITIONAL INDICATOR OF CAVERNOUS SINUS ABNORMALITES

8. 2.EVALUATE LIDS/ PUPILS/EOM
• WHEN ASSESING A PT WITH ACUTE ONSET DIPLOPIA , IT IS IMPORATNT TO EVALUATE 3 OCULAR
STRUCTURES :
 LIDS : DIPLOPIA ACCOMPANIED BY UNILATERAL PTOSIS , COULD BE DUE TO 3RD CN PALSY
 BILATERAL PTOSIS WITH NO PUPIL INVOLVEMENT MAY BE INDICATIVE OF MYSTHENIA GRAVIS ESPECIALLY
IF PTOSIS IS VARIABLE AND IMPROVE WITH REST
 IF LID SEEMS RETRACTED AND LAGOPTHALMOS IS PRESENT , THYROID EYE DISEASE SHOULD BE
CONSIDERED
 UNILATERAL PTOSIS WITH SMALLER PUPIL ON THE SAME SIDE MAY INDICATE HORNER’S SYNDROME
 THE SYPATHETIC FIBRES TRAVEL CLOSE TO THE INTERNAL CAROTID ARTERY AND ACROTID ARTERY
DISSECTION MAY PRESENT AS PAINFUL HORNER SYBDROME
 INTERNAL CAROTID ARTERY DISSECTION MAY PRESENT WITH DIPLOPIA OR TRANSIENT MONOCULAR VN
LOSS

9. PUPILS
 INVOLVED 3RD CRANICAL NERVE PALSY IS ONE OF THE MOST SERIOUS CAUSES OF DIPLOPIA
 PRESENCE OF UNILATERAL DILATED PUPIL WITH 3RD CRANIAL NERVE PLASY INDICATES A
COMPRESSIVE ETIOLOGY RATHER THEN AN ISCHEMIC ONE

10. EOM
 CHECKING MOTILITY OF EOM PROVIDE IMPORANT CLUES DUE TO THE ETIOLOGY OF THE
DIPLOPIA
 ASSESSING THE CARDINAL POSITIONS OF GAZE BINOCULARLY CAN REVEAL MUSCLES
RESTRICTIONS THAT ARE THE RESULT OF TRAUMA OR THYROID EYE DISEASE
 ALSO HELP IN PT WITH DEVIATION THAT SQUINT IS COMITANT OR INCOMITANT
 IF ALIGHNMENT OF EYES DIFFERS IN DIFFERENT POSITIONS OF GAZE (INCOMITANT )
 INCOMITANT DEVIATIONS ARE MORE CHARACTERISTICS OF RESTRICTIONS OR PLASIES

11. 3.RULE OUT WORST – CASE SCENRIOS
 ACUTE ONSET , CONSTANT DIPLOPIA WITH ADDITIONAL NEUROLOGICAL SYMPTOMS
SHOULD BE CONSIDERED URGENT UNTIL PROVEN OTHERWISE.
 A SUDDEN ONSET OF DIPLOPIA INCREASE THE LIKELIHOOD THE CENTRAL NERVOUS
SYSTEM HAS BEEN INJURED THROUGH TRAUMA OR ISCHEMIA .
 THE PRESENCE OF ANY ADDITIONAL SIGNS OR SYMPTOMS , ESPECIALLY PUPIL
INVOLVEMENT AND DYSFUNCTION OF MULTIPLE CRANIAL NERVE , SHOULD RAISE RED
FLAG

12.  ENQUIRE ABOUT THE FOLLOWING WITH THE PATIENT : HEADACHE ,MUSCLE WEAKNESS
,FACIAL DROOPING , IMPAIRED SPEECH , BALANCE ISSUES , OCULAR AND FACIAL PAIN ,
NECK PAIN ETC.
 CRANIAL NERVE TESTING IS EXTREMELY HELPFUL IN RULING OUT LIFE THREATNING
DIAGNOSIS AND ISOLATING THE CAUSE OF DIPLOPIA.
 SOME OF MOST IMPORTANT ABNORMALITIES TO LOOK FOR ARE :
 DECREASED VA
 FACIAL SENSATION
 STRENGTH OF FACIAL MUSCULATURE.

13. TWO WORST CASE SCENERIOS FOR DIPLOPIA AS FOLLOWS
 DIPLOPIA WITH ASYMMETRIC PUPILS : MRI/CTA/MRA SHOULD BE PERFORMED
IMMEDIATELY TO RULE OUT AN ANEURYSM OR SAPCE OCCUPYING LESION

14.  DIPLOPIA WITH INVOLVEMENT OF MULTIPLE CRANIAL NERVE :
 THE AFFECTED C.N HELP TO ISOLATE THE IMPACTED PORTION OF THE BRAIN.
 ISOLATED CRANIAL NERVE PLASIES ARE MORE OFTEN DUE TO UNDERLYING ISCHEMIC
ISSUES SUCH AS HTN , DM .
 WHEN MULTIPLE CN ARE AFFECTED , THE CAUSE IS MUCH MORE LIKELY TO BE A LIFE
THREATING CONDITION LIKE TUMOR OR HEMORRHAGIC STROKE. CAVERNOUS SINUS HAS
THE PROPENSITY TO AFFECT MULTIPLE CN BECAUSE OF THE CLOSE PROXMITY OF THESE
NERVES WHEN TRAVELLING THROUGH SINUS .
 ARTERIOVENOUS FISTULAS , TUMOUR WITHIN THE CAVERNOUS SINUS AND
INTRACAVERNOUS ANEURYSMUS MAY ALL BE PRESENT WITH DIPLOPIA.

15. 4.Consider the Most Likely Causes
 ONCE THE MOST SERIOUS SYSTEMIC CAUSES OF DIPLOPIA HAVE BEEN EXCLUDED,FOCUS
ON THE MOST PROBABLE CAUSES:
 IF PT WEAR GLASSES , DETERMINE WHETHER THE DIPLOPIA OCCUR ONLY WITH GLASSES
ON THE PT MAY NOT BE AWARE THAT THE DIPLOPIA RESOLVES C-OUT THE GLASSES IF
THEY ARE BEING WORN REGULARLY .
• IT THE PT EXPERIENCE DIPLOPIA ONLY AT NEAR , CONVERGENCE INSUFFICIENCY SHOULD
BE CONSIDERED , THIS TYPE OF DIPLOPIA IS INTERMITTENT AND INCREASES WITH
FATIQUE .

16.  ASK COMPLETE OCULAR H/O SOME PATIENTS WHO HAD STRABISMUS IN CHILDHHOD ,
UNDER WENT SX OR PATCHING BECOME SYMPTOMATIC LATER INLIFE AS THE
MISALIGNMENT MAKES SUBTLE RETURN
 ADDTIONALLY DECOMPENSATING PHORIA OFTEN CAUSES DIPLOPIA AS THE PT LOOSES
THE ABILITY TO MAINTAIN FUSION
 THIS CONDITION CAN SOMETIME BE TREATED WITH TEMPORARY OR PERMANENT PRISM
GROUND INTO SPECTACLE RX .
• PATIENT USUALLY COMPLAIN OF INTERMITTENT DIPLOPIA THAT GRADUALLY WORSEN.

17. THANK YOU