Medical Care
Patching one eye: Patching often is required, since the patient must continue functioning while awaiting resolution or intervention. [14]
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. [14]
Fresnel prisms: These prisms can be stuck to glasses. [14] 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: pyridostigmine (Mestinon) or other long-acting anticholinergic agent, as well as corticosteroids, may be required.
Orthoptic exercises: In healthy individuals, convergence exercises have been proven via randomized controlled trials to reduce symptoms of convergence insufficiency. [15] Orthoptic exercises also have been shown to improve surgical outcomes in patients with strabismus and can be considered as adjunctive treatment to surgery in patients with intermittent exotropia.
Surgical Care
Strabismus surgery occasionally is necessary. [14] The typical recession/resection rarely is 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 [14] : 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.
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 thyroid disease (eg, Graves or Hashimoto 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.
Activity
Patients with diplopia should avoid driving or operating machinery, at least until they have adapted to wearing a patch over one eye.
Long-Term Monitoring
Follow-up of patients with diplopia is essential to ensure that the diplopia resolves in a timely manner and the initial diagnosis was accurate or if further evaluation and treatment are needed.
Further outpatient care is dependent on the type of diplopia (double vision) and the treatment started.
Tables
Medication |
Risk for diplopia |
Lacosamide |
Very common (≥1/10) |
Zonisamide |
Very common (≥1/10) |
Eslicarbazepine |
Common (≥1/100 to < 1/10) |
Botulinum toxin |
Common (≥1/100 to < 1/10) |
Rufinamide |
Common (≥1/100 to < 1/10) |
Pregabalin |
Common (≥1/100 to < 1/10) |
Perampanel |
Common (≥1/100 to < 1/10) |
Temozolomide |
Common (≥1/100 to < 1/10) |
Zicotinamide |
Common (≥1/100 to < 1/10) |
Sildenafil |
Common (≥1/100 to < 1/10) |
Gabapentin |
Common (≥1/100 to < 1/10) |
Topiramate |
Common (≥1/100 to < 1/10) |
Zaleplon |
Uncommon (≥1/1000 to < 1/100) |
Levetiracetam |
Uncommon (≥1/1000 to < 1/100) |
Bortezomib |
Uncommon (≥1/1000 to < 1/100) |
Amlodipine |
Uncommon (≥1/1000 to < 1/100) |
Adalimumab |
Uncommon (≥1/1000 to < 1/100) |
Pravastatin |
Uncommon (≥1/1000 to < 1/100) |
Lamotrigine |
Uncommon (≥1/1000 to < 1/100) |
Capecitabine |
Uncommon (≥1/1000 to < 1/100) |
Telithromycin |
Rare (≥1/10000 to < 1/1000) |
Voriconazole |
Rare (≥1/10000 to < 1/1000) |
Dextromethorphan/Quinidine |
Rare (≥1/10,000 to < 1/1000) |
Sertraline |
Rare (≥1/10,000 to < 1/1000) |
Ciprofloxacin |
Rare (≥1/10,000 to < 1/1000) |
Table. Drugs Associated with Diplopia |
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