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Diplopia Workup

  • Author: Jitander Dudee, MD; Chief Editor: Andrew G Lee, MD  more...
Updated: Aug 16, 2016

Laboratory Studies

Perform laboratory studies as indicated by aspects disclosed after a comprehensive history and physical examination with emphasis on ocular findings and neurologic screening.


Imaging Studies

Evaluate old photographs to determine if a head posture (if present) is long-standing. Commonly, a congenitally weak superior oblique muscle can be compensated for by head tilt, but osteoarthritis of the neck or other mechanism can result in decompensation and sudden symptoms of a chronic subclinical condition.

Order CT scan or MRI (with contrast) of the skull and orbits to rule out intracranial masses or other pathologic processes, such as the following[6] :

  • A blow-out fracture requires imaging of the orbital floor.
  • Enlarged muscles from thyroid ophthalmopathy help explain a vertical diplopia.
  • Tumor of orbit
  • Tumor along cranial nerve pathway
  • Increased intracranial pressure can account for bilateral abducens palsy.
  • Aneurysm of intracranial carotid artery
  • Carotid cavernous fistula: Angiography may be required to confirm the presence of a low-flow fistula.
  • Disease of sinuses (eg, infection, tumor) or bony disorders (eg, dysostoses, encephalocele) can account for displacement of the eye.

Traditional guidelines for imaging patients with new-onset diplopia include imaging all patients younger than 50 years with other neurologic findings, with a progressive course of diplopia, or with a history of cancer.[7] For patients older than 50 years, imaging is not always necessary during the initial evaluation. Physicians should conduct a careful review of the patients' history to determine if imaging is medically indicated.


Other Tests

Tensilon test is performed to exclude myasthenia gravis.

Intravenous injection of a short-acting anticholinesterase (ie, 10 mg/mL edrophonium chloride [Tensilon]) should be part of the initial workup of a patient with diplopia. Draw up 1 mL, and establish venous access. Then, inject a test dose of 1 mg intravenously to exclude possible hypersensitivity; if no adverse effect is evident, inject the remaining 9 mg.

The expected (normal) cholinergic response includes salivation; lacrimation; flushing; and a brief, but often quite dramatic, reversal of muscle weakness with temporary correction of diplopia and/or ptosis. Occasionally, an excessive cholinergic response may result in increased vagal tone with serious bradyarrhythmias; atropine (0.5 mg) should be available as an antidote.

Other myopathies (eg, progressive external ophthalmoplegia, myotonia) do not respond to anticholinesterases.

Forced duction test

If a lack of movement of one eye occurs in a given direction, excluding a tethered (or fibrotic) muscle may be helpful. Evaluate whether the globe can be passively moved toward the affected area. Traditionally, a forceps is used (after topical anesthesia) to grasp the limbus, and then the eye can be gently tugged in the desired direction. It may be possible to achieve the same result less traumatically by using a cotton wool bud (soaked in topical anesthetic) to "push" on the limbus in the desired direction.

Lee or Hess screen

This highly specialized test separates the field of vision of the 2 eyes. With one eye, the subject fixates on the corners of a rectangle. The other eye is used to visualize the placement of a marker on the same location. Any overaction or underaction will become evident; when one eye has a weak muscle, it will not move as much as the other eye. However, if that eye is used to fixate, the excessive stimulation required will result in an overshoot of the normal yoke muscle in the opposite eye.

Park three-step test

The Park three-step test can help elucidate which of the 4 extraocular muscles responsible for vertical eye movements are responsible for a vertical diplopia. Although first appearing impossibly complex, this test follows a logical progression to progressively eliminate groups of muscles from the 4 pairs.

First, determine which eye appears higher with the head in a normal position. Then, determine which eye is higher with gaze to the left or to the right (ie, with the head turned to the right and then turned to the left). Lastly, determine which eye is higher with the head tilted left and tilted right. (The patient can also help by commenting about when the diplopia is worse.) Then, answer the questions in the following steps:

  • Step 1: Is the left eye or the right eye higher in primary gaze? This reduces the possibilities of muscles from 4 pairs to 2 pairs. For example, if the right eye is higher, the weakness resides either in the muscles depressing the right eye (right superior oblique muscle and right inferior rectus muscle) or in the elevators of the left eye (left superior rectus muscle and left inferior oblique muscle).
  • Step 2: Is the deviation greater with left head turn or with right head turn? This step reduces the alternatives to only one pair of muscles. If the right eye deviates most when the head is turned to the right (both eyes are turning to the left), then only the right superior oblique muscle or the left superior rectus muscle remains.
  • Step 3: Is the deviation greatest with tilting the head to the left or to the right? Called the Bielschowsky head tilt, it relies on the torsional balancing reflexes provoked by head tilt. The higher eye extorts (because of the inferior oblique muscle), while the lower eye intorts (because of the superior oblique muscle).

By combining steps 1-3, only one muscle remains as the culprit. This test requires a logical analysis and the exclusion of alternative possibilities. However, the astute clinician can greatly simplify this process by recognizing that the superior oblique muscle is by far most likely to be responsible for a vertical diplopia. A head tilt to the same side as the involved muscle exacerbates the problem. A very simple rule of thumb is that "the eye that is highest in adduction looks at the affected muscle."

The severity of the diplopia can be quantified by plotting the field of single binocular vision on a Goldmann perimeter (when available) or by using either a device to standardize the head position or a questionnaire.[8, 9]

The Cervical Range of Motion (CROM) device uses a head-mounted device with direction indicators to reproduce specific gaze positions (10 degrees and 30 degrees up; down, left, right, straight ahead, and reading position).

The questionnaire assigns a score of 6 if the diplopia is always present straight ahead, a score of 4 if the diplopia is present in the down, right, left, and reading position, and a score of 2 if the diplopia is present in upgaze. The scores are halved if the diplopia is sometimes present in these gaze directions.

Contributor Information and Disclosures

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, University of Texas Medical Branch School of Medicine; 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.


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.

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