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Diplopia

Introduction:

Diplopia, or double vision, is the subjective complaint of seeing 2 images instead of one. The term
diplopia is derived from the combination of 2 Greek words: diplous, meaning double, and ops, meaning
eye. It is often the first manifestation of many systemic disorders, especially muscular or neurologic
processes. There are two types of double vision: monocular and binocular.

Monocular Diplopia

Monocular diplopia is double vision in only one eye. The double vision continues even when the other
eye is covered and does not go away when patient looks in different directions.

Monocular diplopia can be caused by:

Astigmatism which is an abnormal curvature of the front surface of the cornea

Keratoconus where the cornea gradually becomes thin and cone-shaped

Pterygium, this is a thickening of the conjunctiva, the thin mucous membrane that lines the inner
surface of the eyelids and the whites of the eyes. The thickening extends on the cornea, the clear part of
the surface of the eye.

Refractive surgery: LASIK, PRK, or any refractive surgery to help patient see better without glasses or
contacts, patient may experience some minor double vision or ghost images because of changes to the
corneas. An irregular corneal surface, caused by the surgery itself or by dryness, may cause light rays to
scatter instead of focusing properly. Diplopia from refractive surgery usually clears up within weeks or
months. But in some cases, a second laser vision correction procedure might be necessary.

Cataracts, the lens gradually becomes less transparent. Risk factors include being older than 65, having
eye trauma or long-term diabetes, smoking, using steroid medications or having radiation treatments.

A dislocated lens, the ligaments that hold the lens in place are broken, and the lens moves out of place
or wiggles. This can be caused by trauma to the eye or a condition known as Marfan's syndrome.

A mass or swelling in the eyelid, this condition can press on the front of the eye.

Some retinal problems, double vision can happen when the surface of the retina is not perfectly smooth,
which can have a variety of causes.

Frig 1: representing the different some causes of monocular diplopia such as Astigmatism, Keratoconus
and Cataract.
Binocular diplopia

Binocular diplopia is double vision related to a misalignment of the eyes. The double vision stops if the
eye is covered. Any problem that affects one or more of the muscles around the eyeball that control the
direction of the gaze can cause binocular diplopia. These are called extraocular muscles. Such problems
include:

Strabismus which is a childhood misalignment of the eyes that affects about 4% of children younger than
age 6.

Fig 2: case of strabismus esotropia having binocular diplopia

Damage to nerves controlling the extraocular muscles, nerves can be injured by brain damage caused by
infection, multiple sclerosis, stroke, head trauma or a brain tumor, especially a tumor located at the
lower back portion of the brain. A tumor growing inside the eye socket or trauma to the eye socket can
damage a nerve anywhere along its route to the eye muscles.

Diabetes can lead to problems with the nerves that control eye muscle movements. Sometimes this can
happen before the person is aware that he or she has diabetes.

Myasthenia gravis is a neuromuscular illness that causes the body's muscles to tire easily and become
weak. It occurs because the body's immune system mistakenly attacks the places where nerves transmit
impulses to muscles, telling the muscles to contract.

Graves' disease is the most common cause of an overactive thyroid (hyperthyroidism). Some people
with Graves' disease develops double vision due to swelling and thickening of the muscles that move the
eyes within the eye socket.

Trauma to the eye muscles, the muscles of the eye socket can be injured by facial trauma, especially by
a fracture of the thin bones of the eye socket.

Diagnosis

The first step is to determine whether patient’s double vision is monocular or binocular. First, doctor will
ask to cover one eye and then the other. If the patient has monocular diplopia, doctor will evaluate for
conditions, such as cataracts, that could be causing the problem. If the problem is binocular and there
has been no facial trauma, then doctor will want to know if patient has diabetes, Graves' disease or
neurological disorders.

In diagnosing binocular diplopia, doctor has to determine which eye muscles are affected. To do this,
patient will be asked to look at the doctor's finger as he moves it up, down, left and right. This lets the
doctor see how far eye can move in each direction. Doctor also will cover one eye and then the other,
while focusing on a target point. If the doctor sees the eyes shift as the eye cover is moved, it means
eyes are not aligned properly. Prisms may be placed over patient’s eye to shift the image, and the test is
repeated. The prisms allow the doctor to measure the amount or degree of double vision when patient
look in different directions. This helps to diagnose the problem and monitor the problem over time.
Doctor will use the results of this exam, together with the medical history and additional symptoms, to
determine if there is a need of more tests.

Doctor’s suspections will lead to the treatment. For example, if doctor suspects that patient has
hyperthyroidism, then they will need blood tests to measure thyroid hormone levels. If doctor suspects
that something is affecting the nerves to the eye muscles, patient may need to undergo a magnetic
resonance imaging (MRI) or computed tomography (CT) scan of head to check for signs of trauma,
bleeding, tumor or blood vessel malformations in the brain.

In most cases, double vision is easy to pinpoint in adults, because they can describe what they are
seeing. Symptoms are tougher to pinpoint in children, who may not be able to explain what is wrong.
Parents may notice that the child is squinting, covering one eye with a hand, tilting or turning the head
abnormally, or looking sideways.

Expected Duration

How long double vision lasts depends on what is causing it. For example, cataracts and pterygium may
become worse over time, but both can be corrected immediately with surgery. In people whose double
vision is caused by diabetes, the nerve often regrows after several months. When this happens, double
vision gradually disappears. Children with double vision caused by strabismus can improve with
treatment.

Treatment

Treating double vision depends on its cause. For example, people with astigmatism that causes double
vision can wear special contact lenses. Sometimes, simply updating the prescription of eyeglasses takes
care of the problem. Surgery is used to treat cataracts and pterygium, and surgery on the eye muscles
can treat certain types of double vision. Often, adjustable stitches are used so that the position of the
eyes can be fine-tuned a few hours after the surgery. That way, the patient is alert for the adjustment
and can report whether the double vision is gone. Prisms also may be used in the glasses to fine-tune
the surgery by moving the image seen with one eye to coincide with the other eye.

For children with strabismus, treatment includes wearing prescription eyeglasses, prism vision therapy
to train the eyes to align properly, or surgery. Double vision caused by a medical or neurological disease
may improve by treating the disease. Eye specialists may consider other strategies to help improve the
eye movements. Injections of botulinum toxin (Botox) can weaken strong eye muscles opposite the
weakened one to help balance vision.
References

1. Iliescu Daniela Adriana, Timaru Cristina Mihaela, Alexe Nicolae, Gosav Elena, De Simone
Algerino, Batras Mehdi, Stefan Cornel, 2017, Management of diplopia, Romanian Journal of
Ophthalmology, Volume 61, Issue 3, doi:10.22336/rjo.2017.31

2. Dinkin M., 2014, Diagnostic approach to diplopia, Lifelong Learning in Neurology. 20(4, Neuro-
ophthalmology):942–965, DOI: 10.1212/01.CON.0000453310.52390.58

3. Kelbsch C, Besch D, Wilhelm H, Acute Diplopia: Differential Diagnosis and Treatment Options,
Klin Monbl Augenheilkd. 2017 Nov;234(11):1348-1353, DOI: 10.1055/s-0043-118223.

4. Mori H., Diplopia/Double Vision, 2018, Brain Nerve. 2018 Dec;70(12):1349-1358. DOI:
10.11477/mf.1416201193.