Close
New

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

 

Diplopia Treatment & Management

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

Medical Care

Patching one eye: Patching is often required, since the patient has to continue functioning while awaiting resolution or intervention.[10]

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.[10]

Fresnel prisms: These prisms can be stuck to glasses.[10] 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.

In monocular diplopia or polyplopia associated with corneal astigmatism, rigid gas-permeable lenses may be beneficial.

In monocular diplopia or polyplopia following refractive surgery or cataract surgery, miotic eye drops such as 1% pilocarpine or bromindione may be helpful in blocking competing images from the peripheral cornea or intraocular lens.

Next

Surgical Care

Strabismus surgery is occasionally necessary.[10] 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[10] : 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.

Previous
Next

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.

Previous
Next

Activity

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

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.