MSD MANUAL

Professional Version

Diplopia
(Double Vision)

By Christopher J. Brady , MD, Wilmer Eye Institute, Retina Division, Johns Hopkins University School of
Medicine
Reviewed/Revised May 2021 | Modified Sep 2022
Diplopia is the perception of 2 images of a single object. Diplopia may be monocular or binocular.
Monocular diplopia is present when only one eye is open. Binocular diplopia disappears when either
eye is closed.

Etiology of Diplopia
Monocular diplopia can occur when something distorts light transmission through the eye to the
retina. There may be > 2 images. One of the images is of normal quality (eg, brightness, contrast,
clarity); the rest are of inferior quality. The most common causes of monocular diplopia are

Cataract

Corneal shape problems, such as keratoconus or surface irregularity

Uncorrected refractive error, usually astigmatism

Other causes include corneal scarring and dislocated lens. Complaints also may represent
malingering.

Binocular diplopia suggests disconjugate alignment of the eyes. There are only 2 images, and they
are of equal quality. There are many possible causes of binocular diplopia (see table Some Causes of
Binocular Diplopia). The most common are

Cranial nerve (3rd, 4th, or 6th) palsy

Myasthenia gravis

Orbital infiltration (eg, thyroid infiltrative ophthalmopathy, orbital pseudotumor)

Most commonly, the eyes are misaligned because of a disorder affecting the cranial nerves
innervating the extraocular muscles (3rd, 4th, or 6th cranial nerves). These palsies may be isolated and
idiopathic or the result of various disorders involving the cranial nerve nuclei or the infranuclear nerve
or nerves. Whether pain is present depends on the disorder. Other causes involve mechanical
interference with ocular motion (which often cause pain) or a generalized disorder of neuromuscular
transmission (which typically do not cause pain).

Evaluation of Diplopia

History
History of present illness should determine whether diplopia involves one or both eyes, whether
diplopia is intermittent or constant, and whether the images are separated vertically, horizontally, or
both. Any associated pain is noted, as well as whether it occurs with or without eye movement.

Review of systems should seek symptoms of other cranial nerve dysfunction, such as vision
abnormalities (2nd cranial nerve); numbness of forehead and cheek (5th cranial nerve); facial
weakness (7th cranial nerve); dizziness, hearing loss, or gait difficulties (8th cranial nerve); and
swallowing or speech difficulties (9th and 12th cranial nerves). Other neurologic symptoms, such as
weakness and sensory abnormalities, should be sought, noting whether these are intermittent or
constant. Nonneurologic symptoms of potential causes are ascertained. They include nausea,
vomiting, and diarrhea (botulism); palpitations, heat sensitivity, and weight loss (Graves disease); and
difficulty with bladder control (multiple sclerosis).

Past medical history should seek presence of known hypertension, diabetes, or both;
atherosclerosis, particularly including cerebrovascular disease; and alcohol abuse.

Physical examination
Examination begins with a review of vital signs for fever and general appearance for signs of toxicity
(eg, prostration, confusion).

Eye examination begins with noting the initial position of the eyes, followed by measuring visual acuity
(with correction) in each eye and both together, which also helps determine whether diplopia is
monocular or binocular. Eye examination should note presence of bulging of one or both eyes, eyelid
droop, pupillary abnormalities, and disconjugate eye movement and nystagmus during ocular motility
testing. Ophthalmoscopy should be done, particularly noting any abnormalities of the lens (eg,
cataract, displacement) and retina (eg, detachment).

Ocular motility is tested by having the patient hold the head steady and track the examiner’s finger,
which is moved to extreme gaze to the right, left, upward, downward, diagonally to either side, and
finally inward toward the patient’s nose (convergence). However, mild paresis of ocular motility
sufficient to cause diplopia may escape detection by such examination.

If diplopia occurs in one direction of gaze, the eye that produces each image can be determined by
repeating the examination with a red glass placed over one of the patient’s eyes. The image that is
more peripheral originates in the paretic eye; ie, if the more peripheral image is red, the red glass is
covering the paretic eye. If a red glass is not available, the paretic eye can sometimes be identified by
having the patient close each eye. The paretic eye is the eye that when closed eliminates the more
peripheral image.

The cover test and cover-uncover test can also be used to determine whether a deviation or
strabismus is present with both eyes open (manifest/tropia), or only when one eye is open
(latent/phoria). Both tests are done on both eyes. For the cover test, the patient is asked to fixate on
an object with both eyes open, and one eye is covered. The other eye is observed for a refixation
movement, which would indicate it had previously been misaligned, indicating a manifest deviation or
tropia. The cover-uncover test is conducted similarly, except the eye being tested is covered for a few
seconds and then the cover is removed. The same eye is observed for a refixation movement, which
would indicate a latent deviation or phoria. The patient may also see the object "jumping" with the
refixation movement during either test.

The other cranial nerves are tested, and the remainder of the neurologic examination, including
strength, sensation, reflexes, cerebellar function, and observation of gait, is completed.

Relevant nonneurophthalmologic components of the examination include palpation of the neck for
goiter and inspection of the shins for pretibial myxedema (Graves disease).

Red flags
The following findings are of particular concern:

More than one cranial nerve deficit

Pupillary involvement of any degree

Pain

Proptosis

Interpretation of findings
Findings sometimes suggest which cranial nerve is involved.

3rd: Eyelid droop, eye deviated laterally and down, sometimes pupillary dilation

4th: Vertical diplopia worse on downward gaze (patient tilts head to improve vision)

6th: Eye deviated medially, diplopia worse on lateral gaze (patient turns head to improve vision)
Other findings help suggest a cause (see table Some Causes of Binocular Diplopia).

Intermittent diplopia suggests a waxing and waning neurologic disorder, such as myasthenia gravis or
multiple sclerosis, or unmasking of a latent phoria (eye deviation). Patients with latent phoria do not
have any other neurologic manifestations.

Internuclear ophthalmoplegia (INO) results from a brain stem lesion in the medial longitudinal
fasciculus (MLF). INO manifests on horizontal gaze testing with diplopia, weak adduction on the
affected side (usually cannot adduct eye past midline), and nystagmus of the contralateral eye.
However, the affected eye adducts normally on convergence testing (which does not require an intact
MLF).

Pain suggests a compressive lesion or inflammatory disorder.

Testing
Patients with monocular diplopia are referred to an ophthalmologist for evaluation of ocular
pathology; no other tests are required beforehand.

For binocular diplopia, patients with a unilateral, single cranial nerve palsy, a normal pupillary light
response, and no other symptoms or signs can usually be observed without testing for a few weeks.
Many cases resolve spontaneously. Ophthalmologic evaluation is recommended to monitor the
patient and help further delineate the deficit, particularly for a third nerve palsy, because it can also
progress to involve the pupil.

Most other patients require neuroimaging with MRI to detect orbital, cranial, or central nervous
system (CNS) abnormalities. CT may be substituted if there is concern about a metallic intraocular
foreign body or if MRI is otherwise contraindicated or unavailable. Imaging should be done
immediately if findings suggest infection, aneurysm, or acute stroke.

Patients with manifestations of Graves disease should have thyroid tests (serum thyroxine [T4] and
thyroid-stimulating hormone [TSH] levels). Testing for myasthenia gravis and multiple sclerosis should
be strongly considered for patients with intermittent diplopia.

Treatment of Diplopia
Treatment is management of the underlying disorder.

Key Points
Key Points

Isolated, pupil-sparing single cranial nerve palsy in patients with no other symptoms
may resolve spontaneously.

Imaging is required for patients with red flag findings.

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