Makindo Medical Notes Comprehensive Medical Encyclopedia | Education for Healthcare Professionals

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Causes of Diplopia

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Cause	Clinical Presentation	Diagnostic Tests	Management Options
Refractive Errors (e.g., Astigmatism, Uncorrected Vision)	- Blurred or double vision, worsens with fatigue. - Affects both near and distant vision. - Improves with corrective lenses (glasses or contact lenses).	- Visual Acuity Test to measure sharpness of vision. - Refraction Test to determine lens prescription. - Comprehensive Eye Exam to rule out other causes.	- Corrective lenses (glasses or contact lenses). - Regular eye exams to adjust prescription. - Refractive surgery (LASIK) in certain cases.
Strabismus (e.g., Esotropia, Exotropia)	- Misalignment of the eyes causing double vision. - Diplopia may be intermittent or constant. - Often results in compensatory head tilt or squinting.	- Cover-Uncover Test to assess ocular misalignment. - Corneal Light Reflex Test to assess angle of deviation. - Prism Test to measure degree of misalignment.	- Eye patching for amblyopia. - Corrective lenses or prism glasses. - Strabismus surgery to realign the eyes. - Vision therapy for mild cases.
Oculomotor Nerve Palsy (III Nerve Palsy)	- Diplopia with a "down and out" eye position. - Ptosis (drooping eyelid) and difficulty moving the eye up, down, or inward. - Pupil dilation may occur in compressive causes.	- MRI or CT scan to evaluate for aneurysm, tumour, or brain lesion. - Blood tests to assess for diabetes or hypertension. - Pupil examination to differentiate between compressive and ischaemic causes.	- Observation for microvascular causes (e.g., diabetes) which resolve spontaneously. - Surgery for compressive causes (e.g., tumour or aneurysm). - Prism glasses or botulinum toxin injections for residual diplopia.
Trochlear Nerve Palsy (IV Nerve Palsy)	- Vertical diplopia, worsens with downward gaze. - Head tilt away from the affected side to compensate. - Difficulty reading or descending stairs.	- MRI or CT scan to rule out trauma, stroke, or tumour. - Prism test to assess vertical misalignment. - Cover-Uncover test to observe vertical deviation.	- Prism glasses to correct vertical diplopia. - Strabismus surgery if conservative management fails. - Observation in mild cases, as some recover spontaneously.
Abducens Nerve Palsy (VI Nerve Palsy)	- Horizontal diplopia, worsens with lateral gaze. - Inability to abduct the affected eye (move outward). - May be caused by increased intracranial pressure or trauma.	- MRI or CT scan to rule out stroke, tumour, or trauma. - Lumbar puncture if increased intracranial pressure is suspected. - Blood tests to identify systemic conditions.	- Observation for ischaemic causes (often resolves in weeks). - Prism glasses for residual diplopia. - Surgery for structural causes (e.g., tumour, trauma).
Myasthenia Gravis	- Diplopia that worsens with muscle fatigue, often varies throughout the day. - Ptosis (drooping eyelids) that worsens in the evening. - Generalized muscle weakness may be present.	- Acetylcholine receptor antibody test to confirm diagnosis. - Edrophonium (Tensilon) test for transient improvement in muscle strength. - Electromyography (EMG) to detect abnormal muscle fatigue.	- Anticholinesterase medications (e.g., pyridostigmine). - Immunosuppressive therapy (e.g., prednisone, azathioprine). - Plasmapheresis or IVIG for severe exacerbations. - Thymectomy may help in some cases.
Graves' Disease (Thyroid Eye Disease)	- Diplopia due to eye muscle inflammation. - Proptosis (bulging eyes) and lid retraction. - Hyperthyroid symptoms such as weight loss, heat intolerance, and palpitations.	- Thyroid function tests to assess hormone levels. - CT or MRI of the orbits to evaluate eye muscle involvement. - Thyroid antibody tests to confirm autoimmune thyroid disease.	- Corticosteroids to reduce inflammation. - Orbital decompression surgery for severe cases. - Radioactive iodine or antithyroid medications to manage hyperthyroidism. - Prism lenses or surgery to correct diplopia.
Stroke or Brain Lesions	- Sudden onset of diplopia with other neurological deficits (e.g., weakness, slurred speech). - Vertical or horizontal diplopia depending on the lesion location. - May present with gaze palsies or internuclear ophthalmoplegia.	- MRI or CT scan to detect ischaemic or hemorrhagic stroke. - Carotid Doppler ultrasound to assess carotid artery stenosis. - Blood tests to check for cardiovascular risk factors (e.g., cholesterol, blood glucose).	- Immediate stroke management (e.g., thrombolysis, thrombectomy). - Rehabilitation for residual neurological deficits. - Prism glasses or eye patching for persistent diplopia. - Surgery or radiation for brain tumours.

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