Diplopia Treatment & Management

  • Author: Izak F Wessels, MBBCh, MMed, FRCSE, FRCO; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Mar 16, 2011
 

Medical Care

  • Patching one eye: Patching is often required, since the patient has to continue functioning while awaiting resolution or intervention.[6]
  • Stick-on occlusive lenses can be applied to glasses to minimize the cosmetic handicap of a patched eye, while sufficiently blurring the one eye to minimize disabling double vision.[6]
  • Fresnel prisms: These prisms can be stuck to glasses.[6] Although these prisms are only appropriate if a stable deviation is present across all directions of gaze, they severely blur the image from that eye and function in many ways like an occlusive lens.
  • Treatment of myasthenia gravis: Mestinon or other long-acting anticholinergic agent, as well as corticosteroids, may be required.
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Surgical Care

  • Strabismus surgery is occasionally necessary.[6] The typical recession/resection is rarely indicated due to the one muscle often being permanently weak, and any standard surgery will lose effect over time. Exceptions include a blow-out fracture when the release of the entrapped soft tissues from the fracture in the floor of the orbit can be very effective.
  • Transposition surgery (Hummelsheim surgery): With permanent paralysis of the lateral rectus muscle, overcoming the unopposed tone of the medial rectus muscle is possible by splitting the superior and inferior recti muscles and by reinserting the lateral half of each muscle at the lateral rectus insertion. Otherwise, any recession of the medial rectus muscle will be of only temporary benefit. Despite achieving single vision straight ahead, the diplopia will persist with gaze toward the paralytic muscle.
  • Knapp superior oblique muscle paralysis: With permanent weakness of the superior oblique muscle, it is possible to weaken the yoke muscle of the opposite eye (superior rectus muscle) as well as the direct antagonist (inferior oblique muscle) in the same eye, together with a shortening of the affected muscle, to minimize the deviation.
  • Chemodenervation[6] : This helps prevent the contracture in eyes with extraocular muscle paresis, especially when return of function is expected. Multiple injections over several months of botulinum toxin into the medial rectus muscle reduce contracture due to a weak lateral rectus from a sixth nerve paralysis. The effect may be more permanent than expected; the opposing un-injected muscle may develop a degree of permanent shortening and contracture.
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Consultations

  • Diabetologist: Isolated cranial nerve weakness (eg, typically third or sixth cranial nerve) indicates a microangiopathy of diabetes. A review of the appropriateness of diabetic control is indicated.
  • An endocrinologist specializing in thyroid disorders may be required to control the metabolic disorder associated with severe Graves disease.
  • An ear, nose, and throat (ENT) specialist may be required for sinus diseases and blow-out fractures.
  • A neurologic or neurosurgical opinion may be beneficial to evaluate cranial nerve palsies.
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Activity

Patients with diplopia should avoid driving or operating machinery, at least until they have adapted to wearing a patch over one eye.

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Contributor Information and Disclosures
Author

Izak F Wessels, MBBCh, MMed, FRCSE, FRCO  Associate Professor, Department of Ophthalmology, Chattanooga Unit, University of Tennessee College of Medicine; Private Practice in Comprehensive and Surgical Ophthalmology, Allied Eye Associates

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew W Lawton, MD  Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center

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

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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.

Ralph Garzia, OD  Assistant Dean for Clinical and Academic Programs, Associate Professor, College of Optometry, University of Missouri at St Louis

Ralph Garzia, OD is a member of the following medical societies: American Academy of Optometry and American Optometric Association

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

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

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

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

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

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

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

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

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

  9. 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. Oct 1997;244(10):639-45. [Medline].

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

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

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

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

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

  15. 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. Oct 1996;36(19):3237-42. [Medline].

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  36. 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. Nov 1996;87(11):515-23. [Medline].

  37. 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. Apr 1997;123(4):378-84. [Medline].

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

  39. 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. Jan 1977;44(1):203-4. [Medline].

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

 
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