Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Diplopia

  • Author: Jitander Dudee, MD; Chief Editor: Andrew G Lee, MD  more...
 
Updated: Nov 16, 2015
 

Background

Diplopia is the subjective complaint of seeing 2 images instead of one and is often referred to as double-vision in lay parlance. The term diplopia is derived from 2 Greek words: diplous, meaning double, and ops, meaning eye. Diplopia (double vision) is a common subjective complaint, or diplopia may be elicited during the course of an eye examination. Diplopia is often the first manifestation of many systemic disorders, especially muscular or neurologic processes.[1] An accurate, clear description of the symptoms (eg, constant or intermittent; variable or unchanging; at near or at far; with one eye [monocular] or with both eyes [binocular]; horizontal, vertical, or oblique) is critical to appropriate diagnosis and management.[2, 3]

Binocular diplopia can be corrected by covering either eye; monocular diplopia persists in one eye despite covering the other eye. Physiologic diplopia is a normal phenomenon depending on the alignment of the ocular axes with the objects of regard (eg, focusing on a finger held close results in distant objects being blurry but double).

Polyplopia refers to the perception of more than 2 images and is often a monocular phenomenon caused by refractive aberrations resulting in multiple images of one object. In such cases, the dominant image of the object of regard is accompanied by secondary images that may be less intense, distorted, or fleeting. Causes of polyplopia include irregular corneal astigmatism, lenticular opacities, multifocal lenses, and corneal rings of significantly different focality within the pupil created by refractive surgery or contact lenses.

Animal models

Unless the visual fields of the eyes overlap, binocular diplopia cannot occur. Among vertebrates, the potential for diplopia (and for stereoscopic depth perception) depends on where the eyes are located in the head. Eyes located on either side of the head provide a wide visual field but with a less overlapped visual field. These animals have less field for binocular vision and less risk for diplopia when one eye becomes misaligned. However, when both eyes are located in the front of the head, a greater visual field overlap exists and, thus, a better binocular depth perception, as frequently seen in predators. Misalignment of such eyes may result in diplopia. Monocular diplopia is often due to optical aberrations resulting in multiple images.

The eyes of birds demonstrate many unique anatomical features, one of which is the presence of multiple foveae and, in some cases, a streak fovea linking 2 foveae. Thus, they may be able to have 2 separate areas of regard without disabling diplopia. How the visual perception occurs in these cases remains debatable.

Next

Pathophysiology

Binocular diplopia (or true diplopia) is a breakdown in the fusional capacity of the binocular system. The normal neuromuscular coordination cannot maintain correspondence of the visual objects on the retinas of the 2 eyes. Rarely, fusion cannot occur because of dissimilar image size, which can occur after changes in the optical function of the eye following refractive surgery (eg, LASIK) or after a cataract is replaced by an intraocular lens.

The distortion of one image may be interpreted as diplopia by the patient; however, the same object does not appear to be in 2 places but rather appears differently with each eye.

Monocular diplopia may occur from abnormal ocular media (eg, corneal distortion or scarring, multiple openings in the iris, cataract or subluxation of the natural lens or pseudophakic lens implant, vitreous abnormalities, retinal conditions). Monocular diplopia must be distinguished from metamorphopsia, in which objects appear misshapen.

Previous
Next

Epidemiology

Frequency

United States

No figures are available as to prevalence of diplopia in the United States.

International

International incidence rates of diplopia are unknown. The incidence of diplopia as a chief complaint in emergency departments is low. One study of a specialist eye hospital in London, United Kingdom, reported the incidence of diplopia as the chief complaint in only 1.4% of the presenting cases.[4]

Mortality/Morbidity

Divergent pathological processes, each with its own morbidity and mortality, can cause diplopia. However, irrespective of cause, diplopia has significant morbidity in terms of difficulty with depth perception and confusion with orientation of objects, especially when performing visually demanding tasks, such as driving a vehicle or operating tools. Therefore, in assessing visual disability after injuries, loss of binocularity accounts for a major percentage of loss of function.

Race

No information is available regarding differences in various racial groups.

Sex

No information is available suggesting differences in prevalence with respect to sex.

Age

Diplopia is encountered almost exclusively in adults or in those with mature visual systems.

Young children may not be able to express this symptom. More importantly, the immature visual system deals with diplopia by suppressing the poorer image, possibly resulting in irreversible amblyopia. Children with obvious and marked ocular malalignment from strabismus are comfortable and content because the visual image from the deviating eye is suppressed and not noticed.

In contrast, adults who have mature visual processing pathways cannot easily ignore the second image. Wearing a patch over one eye to prevent visual confusion usually is the only option for these patients.

Previous
 
 
Contributor Information and Disclosures
Author

Jitander Dudee, MD MA Cantab(Hons), FACS, FRCOphth, Ophthalmologist, Medical Vision Institute, PSC

Jitander Dudee, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Society of Cataract and Refractive Surgery, Kentucky Medical Association, Royal College of Ophthalmologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Andrew G Lee, MD Chair, Department of Ophthalmology, Houston Methodist Hospital; Clinical Professor, Associate Program Director, Department of Ophthalmology and Visual Sciences, The University of Texas Medical Branch; Clinical Professor, Department of Surgery, Division of Head and Neck Surgery, University of Texas MD Anderson Cancer Center; Professor of Ophthalmology, Neurology, and Neurological Surgery, Weill Medical College of Cornell University; Clinical Associate Professor, University of Buffalo, State University of New York School of Medicine

Andrew G Lee, MD is a member of the following medical societies: American Academy of Ophthalmology, Association of University Professors of Ophthalmology, American Geriatrics Society, Houston Neurological Society, Houston Ophthalmological Society, International Council of Ophthalmology, North American Neuro-Ophthalmology Society, Pan-American Association of Ophthalmology, Texas Ophthalmological Association

Disclosure: Received ownership interest from Credential Protection for other.

Additional Contributors

Andrew W Lawton, MD Neuro-Ophthalmology, Ochsner Health Services

Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Izak F Wessels, MBBCh, MMed, FRCSE, FACS Adjunct Associate Professor, Loma Linda University; Private Practice in Comprehensive and Surgical Ophthalmology, Allied Eye Associates

Izak F Wessels, MBBCh, MMed, FRCSE, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, and Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Brian R Younge, MD Professor of Ophthalmology, Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

References
  1. Rucker JC. Oculomotor disorders. Semin Neurol. 2007 Jul. 27(3):244-56. [Medline].

  2. Stager DR Sr, Black T, Felius J. Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency. Graefes Arch Clin Exp Ophthalmol. 2013 Mar 22. [Medline].

  3. Migliorini R, Fratipietro M, Segnalini A, Arrico L. Persistent vertical diplopia after cataract surgery: a case report. Clin Ter. 2013. 164(1):e31-3. [Medline].

  4. Morris RJ. Double vision as a presenting symptom in an ophthalmic casualty department. Eye (Lond). 1991. 5 ( Pt 1):124-9. [Medline].

  5. Fraunfelder FW, Fraunfelder FT. Diplopia and fluoroquinolones. Ophthalmology. 2009 Sep. 116(9):1814-7. [Medline].

  6. Shah HA, Shipchandler TZ, Sufyan AS, Nunery WR, Lee HB. Use of fracture size and soft tissue herniation on computed tomography to predict diplopia in isolated orbital floor fractures. Am J Otolaryngol. 2013 Mar 22. [Medline].

  7. Murchison AP, Gilbert ME, Savino PJ. Neuroimaging and acute ocular motor mononeuropathies: a prospective study. Arch Ophthalmol. 2011 Mar. 129(3):301-5. [Medline].

  8. Hatt SR, Leske DA, Holmes JM. Comparing methods of quantifying diplopia. Ophthalmology. 2007 Dec. 114(12):2316-22. [Medline].

  9. Holmes JM, Leske DA, Kupersmith MJ. New methods for quantifying diplopia. Ophthalmology. 2005 Nov. 112(11):2035-9. [Medline].

  10. Phillips PH. Treatment of diplopia. Semin Neurol. 2007 Jul. 27(3):288-98. [Medline].

  11. Holmes JM, Liebermann L, Hatt SR, Smith SJ, Leske DA. Quantifying Diplopia with a Questionnaire. Ophthalmology. 2013 Mar 23. [Medline].

  12. Anderson MW, Sharma K, Feeney CM. Wound botulism associated with black tar heroin. Acad Emerg Med. 1997 Aug. 4(8):805-9. [Medline].

  13. Astin CL. The use of occluding tinted contact lenses. CLAO J. 1998 Apr. 24(2):125-7. [Medline].

  14. Batocchi AP, Evoli A, Majolini L, et al. Ocular palsies in the absence of other neurological or ocular symptoms: analysis of 105 cases. J Neurol. 1997 Oct. 244(10):639-45. [Medline].

  15. Berman EL. Clues in the eye: ocular signs of metabolic and nutritional disorders. Geriatrics. 1995 Jul. 50(7):34-6, 43-4. [Medline].

  16. Bielschowski A. Disturbance of vertical motor muscles of the eyes. Arch Ophthalmol. 1938. 20:175-200.

  17. Brazis PW, Lee AG. Binocular vertical diplopia. Mayo Clin Proc. 1998 Jan. 73(1):55-66. [Medline].

  18. Campbell C. Corneal aberrations, monocular diplopia, and ghost images: analysis using corneal topographical data. Optom Vis Sci. 1998 Mar. 75(3):197-207. [Medline].

  19. Capo H, Roth E, Johnson T, et al. Vertical strabismus after cataract surgery. Ophthalmology. 1996 Jun. 103(6):918-21. [Medline].

  20. Dengis CA, Steinbach MJ, Ono H, et al. Learning to look with one eye: the use of head turn by normals and strabismics. Vision Res. 1996 Oct. 36(19):3237-42. [Medline].

  21. Fingeret M. Forced duction test. Atlas of Primary Eyecare Procedures. Norwalk, Conn: Appleton & Lange; 1990. 138-44.

  22. Fowler MS, Wade DT, Richardson AJ, et al. Squints and diplopia seen after brain damage. J Neurol. 1996 Jan. 243(1):86-90. [Medline].

  23. Galimberti CA, Versino M, Sartori I, et al. Epileptic skew deviation. Neurology. 1998 May. 50(5):1469-72. [Medline].

  24. Gladstone GJ. Ophthalmologic aspects of thyroid-related orbitopathy. Endocrinol Metab Clin North Am. 1998 Mar. 27(1):91-100. [Medline].

  25. Goldenberg AS. Transient diplopia as a result of block injections. Mandibular and posterior superior alveolar. N Y State Dent J. 1997 May. 63(5):29-31. [Medline].

  26. Hahn JS, Berquist W, Alcorn DM, et al. Wernicke encephalopathy and beriberi during total parenteral nutrition attributable to multivitamin infusion shortage. Pediatrics. 1998 Jan. 101(1):E10. [Medline].

  27. Hayreh SS, Podhajsky PA, Zimmerman B. Occult giant cell arteritis: ocular manifestations. Am J Ophthalmol. 1998 Apr. 125(4):521-6. [Medline].

  28. Ing E, Kennerdell JS. The evaluation and treatment of extraocular motility deficits. Otolaryngol Clin North Am. 1997 Oct. 30(5):877-92. [Medline].

  29. Kasner SE, Liu GT, Galetta SL. Neuro-ophthalmologic aspects of aneurysms. Neuroimaging Clin N Am. 1997 Nov. 7(4):679-92. [Medline].

  30. Kolling GH. [Reflections on expert assessment of double vision and forced head position]. Klin Monatsbl Augenheilkd. 1996 Jan. 208(1):63-5. [Medline].

  31. Kushner BJ, Kowal L. Diplopia after refractive surgery: occurrence and prevention. Arch Ophthalmol. 2003 Mar. 121(3):315-21. [Medline].

  32. Kutschke PJ. Taking a history of the patient with diplopia. Insight. 1996 Sep. 21(3):92-5. [Medline].

  33. Lasley DJ, Kivlin J, Rich L, et al. Stereo-discrimination between diplopic images in clinically normal observers. Invest Ophthalmol Vis Sci. 1984 Nov. 25(11):1316-20. [Medline].

  34. Marzo ME, Perez Lopez-Fraile I, Capablo JL, et al. [Ocular myasthenia: clinical course and strategies for treatment]. Rev Neurol. 1998 Mar. 26(151):398-400. [Medline].

  35. Miller NR. Lesions of the supranuclear ocular motor pathways. Walsh and Hoyt's Clinical Neuro-Ophthalmology. 4th ed. Baltimore, Md: Lippincott Williams & Wilkins; 1985. 707-715.

  36. Muneer A, Jones NS, Bradley PJ, et al. ENT pathology and diplopia. Eye. 1998. 12 (Pt 4):672-8. [Medline].

  37. Ottar WL. Diplopia: double the fun! Part 1: History taking. Insight. 1998 Dec. 23(4):119-25. [Medline].

  38. Richardson LD, Joyce DM. Diplopia in the emergency department. Emerg Med Clin North Am. 1997 Aug. 15(3):649-64. [Medline].

  39. Safran AB, Vibert D, Häusler R. [Vestibular neuritis: a frequently unrecognized cause of diplopia]. Klin Monatsbl Augenheilkd. 1995 May. 206(5):413-5. [Medline].

  40. Schachat AP. Diplopia. Diagnostic Diagrams: Ophthalmology. Baltimore: Lippincott Williams & Wilkins; 1984. 101-107.

  41. Seminari E, Cocchi L, Antoniazzi E, et al. [Clinical significance of diplopia in HIV infection. Assessment of a personal caseload and review of the literature]. Minerva Med. 1996 Nov. 87(11):515-23. [Medline].

  42. Shumrick KA, Kersten RC, Kulwin DR, et al. Criteria for selective management of the orbital rim and floor in zygomatic complex and midface fractures. Arch Otolaryngol Head Neck Surg. 1997 Apr. 123(4):378-84. [Medline].

  43. Stangler-Zuschrott E. [Disturbing physiologic diplopia (author's transl)]. Klin Monatsbl Augenheilkd. 1979 Mar. 174(3):370-3. [Medline].

  44. Werner SC. Modification of the classification of the eye changes of Graves' disease: recommendations of the Ad Hoc Committee of the American Thyroid Association. J Clin Endocrinol Metab. 1977 Jan. 44(1):203-4. [Medline].

  45. Woods RL, Bradley A, Atchison DA. Monocular diplopia caused by ocular aberrations and hyperopic defocus. Vision Res. 1996 Nov. 36(22):3597-606. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.