double vision



OVERVIEW

Definition of diplopia

Diplopia is a condition in which both eyes produce two images when looking at the same object.

When the eye muscles are paralyzed, the object being looked at cannot be projected onto the corresponding points of the retina of both eyes, so that binocular monovision cannot be formed, and two objects are formed in the visual center.

Classification

Classification according to the cause of diplopia

Diplopia caused by disease factors, such as neurogenic, myogenic, and ocular diseases.

Diplopia can be induced when gazing at a target in front of you, which is farther or closer than this target, called physiologic diplopia, which is the basis of binocular vision. It is a normal physiological phenomenon.

Classification according to the type of diplopia occurring

Double vision with double vision, double vision disappears after covering one eye, mostly due to double vision conjugate motion abnormality.

Diplopia exists when only one eye is open, due to certain distortions of the retina when light rays enter the eye.

Classification according to the direction of diplopia

Diplopia occurs horizontally, i.e., it is manifested as one left and one right; if the object seen by the right eye is on the left side, it is horizontal crossed diplopia; if the object seen by the right eye is on the right side, it is horizontal uncrossed diplopia.

Diplopia occurs vertically, i.e., it appears as one up and one down.

Diplopia appears as skewed, rotated to the left or rotated to the right.

Causes

Causes

Diplopia

Most often seen in non-common strabismus.

Acute common internal strabismus can also cause binocular diplopia.

Diplopia is the most common symptom of strabismus. In strabismus, the visual axes of the eyes are not parallel, resulting in objects not landing on the retinal counterparts of both eyes, and thus the visual center of the brain receives and perceives the presence of two different objects.

Brain or orbital tumors, hemorrhage or blood clots, inflammation, infection, trauma, multiple sclerosis, etc. may involve the motoneuron, synovial or spreading nerves, causing nerve paralysis and diplopia.

Oculomotor or generalized myasthenia gravis often has diplopia, strabismus, and ptosis.

Myasthenia gravis can cause abnormal functioning of the extraocular muscles, resulting in uncoordinated eye movements and diplopia.

Diabetes and thyroid disease can cause diplopia when they involve the nerves or muscles of the eye.

Diplopia is present in some hypertensive patients and may be related to elevated blood pressure, causing paralysis of the eye muscles or nerves.

Caused by vitamin B1 deficiency, it is mainly characterized by the triad of eye muscle paralysis, ataxia, and mental abnormalities.

Binocular diplopia can be seen in botulism, organic solvents, heavy metals, gases, and other poisonings.

Monocular diplopia

When there is refractive error, especially astigmatism, the symptoms of monocular blurred vision and diplopia will appear.

Cataracts can cause monocular diplopia due to different degrees of clouding of the lens, which can result in different refractive errors in each part of the lens.

Due to the shift in the position of the lens, only a portion of the optic axis can be refracted by the lens, resulting in monocular diplopia due to the presence of two refractive systems in the same eye.

Diplopia occurs when there are corneal morphological abnormalities, such as conical cornea, corneal scarring, etc., which cause corneal irregularities and result in different focal points at different meridian lines.

Diplopia can also be caused by ocular trauma, dry eye, diplopia, and polydactyly.

Risk factors

Patients with one or more of the following conditions are at higher risk of developing diplopia. Regular medical checkups and eye screenings are recommended.

Strabismus;

Refractive errors, especially astigmatism;

Cataracts;

High blood pressure;

Diabetes;

Hyperthyroidism;

Intracranial diseases.

Symptoms

Main Symptoms

Diplopia

Perceiving one object as two images when seeing objects.

Monocular diplopia: the diplopia persists when the affected eye is covered.

Binocular diplopia: diplopia disappears when either eye is covered.

Deviation of eye position

Diplopia is often associated with a deviation of the eye position and may be accompanied by compensatory head position, head tilting, etc.

Other symptoms

Vision loss

Patients with diplopia, especially monocular diplopia, may have blurred vision and vision loss.

Ptosis

Ptosis may occur in patients with motor nerve palsy or myasthenia gravis.

Pupil abnormalities

In addition to diplopia, patients with ocular trauma or motor nerve palsy may have abnormal pupil shape or size.

Protruding eyeballs

Patients with thyroid-related eye disease may have protruding eyeballs.

Orbital pain or dizziness

Some patients have orbital pain, dizziness, headache and ataxia.

Consultation

Department of Medicine

Ophthalmology

Blurred vision, loss of vision, or symptoms of diplopia, prompt medical attention is recommended.

Neurology

In addition to ptosis and diplopia, accompanied by headache, dizziness, fatigue and other discomforts, it is recommended to consult the Department of Neurology.

Endocrinology

If you are suffering from thyroid disease or diabetes, it is recommended that you go to the Endocrinology Department for regular consultation and review.

Emergency Medicine

In the event of an emergency such as eye trauma, fainting, or respiratory distress (a serious condition that can lead to abnormal vital signs), it is recommended that you consult the Emergency Department or call 120 emergency immediately.

Preparation for medical treatment

Preparation for medical treatment: registration, preparation of documents, common problems

Tips for medical treatment

Avoid looking at cell phones and computers for long periods of time and do not stay up late.

Do not wear contact lenses or eye make-up to avoid interfering with the eye examination.

If you have trauma to the eye or other parts of the body, pay attention to protect the traumatized area.

Preparation Checklist for Medical Visit

Especially need to pay attention to the time of symptom onset, special manifestations, etc.

Is there a sensation of double vision in the eyes? If so, how long has it been present?

Is the double vision horizontal or vertical?

Is there any difference in the distance between distant and near double vision?

Is there any loss of vision? If so, has it worsened recently?

Is there any difficulty in lifting the eyelids?

Do you have dizziness, headache, nausea and vomiting?

Are there any diseases such as hypertension, diabetes mellitus, cerebral infarction, thyroid disease, etc.?

Is there a history of eye trauma?

Any intracranial inflammation or tumors?

Examination results in the past six months, which can be brought to the doctor’s office

Ophthalmologic examination: visual acuity and refraction examination, slit lamp examination, eye position and eye movement examination, synoptics examination, eye ultrasound, fundus photography, fundus examination

Laboratory Tests: blood test, blood glucose level, thyroid function, acetylcholine antibody

Imaging tests: CT (electron computed tomography), MRI (magnetic resonance imaging) of the head

Medication for the past 3 months, if available, bring the box or package with you to the doctor’s office.

Systemic medication

Ocular medication: tobramycin eye drops, erythromycin eye ointment, fluticasone eye drops, etc.

Diagnosis

Diagnosis is based on

Medical history

Suffering from hypertension, diabetes mellitus, thyroid disease or myasthenia gravis.

Suffering from eye diseases such as strabismus, astigmatism, cataract, corneal disease, etc.

Have a disease such as brain tumor, inflammation, cerebral infarction, etc.

Have a history of cranial or orbital trauma.

Clinical manifestations

Double vision with or without headache, dizziness, nausea and vomiting, dyspnea, orbital pain, and vision loss.

Ophthalmologic examination

The presence or absence of visual loss and the presence or absence of combined refractive errors can be detected.

Through slit lamp examination, it can find out whether there is eyeball protrusion, ptosis, corneal lesion, pupil abnormality, cataract or lens dislocation.

It is mainly used for binocular diplopia and can reveal whether the diplopia is horizontal, rotational or vertical, crossed or ipsilateral, and the direction of maximum distance of diplopia separation.

The test also allows the determination of the specific paralyzed muscle.

The presence of strabismus is examined, and the specific eye muscles involved are determined by examining eye movements in all directions.

It is mainly used for binocular diplopia and can determine whether the eye is paralyzed and which extraocular muscles are paralyzed.

Laboratory Tests

Routine blood tests are performed to determine the presence of anemia and infection.

Fasting is not necessary before the test.

Fasting and postprandial blood glucose tests are performed to determine the presence of hyperglycemia.

If the results show a fasting blood glucose greater than 7 and a postprandial blood glucose greater than 11.1, this indicates high blood glucose.

Fasting is required before the test.

Used to assess thyroid function. Includes T3, T4, TSH (Thyroid Stimulating Hormone), TRH (Thyroid Stimulating Hormone Releasing Hormone), TGAb (Thyroglobulin Antibody), TG (Thyroglobulin), and TPOAb (Thyroid Peroxidase Antibody).

Fasting is not required before the test.

Serum Acetylcholine Antibody Titers for Diagnosis of Myasthenia Gravis

Fasting is not required before the test.

Imaging

It can find out whether there are intracranial lesions such as occupation, infarction, hemorrhage, inflammation and infection.

Enhanced CT or MRI can make a judgment on the nature of the occupying disease.

Differential diagnosis

Diplopia, whose main manifestation is double vision, needs to be differentiated from symptoms such as foggy vision and iridescence.

Foggy vision

Foggy vision is a condition in which vision is blurred as if under a fog, and some patients may express what looks like mild diplopia in one eye.

Foggy vision is an early symptom of angle-closure glaucoma.

Rainbow Vision

Rainbow vision refers to seeing a rainbow-like halo of light or patches of different colors when looking at a light source.

It can be seen in glaucoma, conjunctivitis, corneal edema, incipient cataract and other eye diseases.

Treatment

The main focus is to treat the primary disease to minimize ongoing damage to the eye. Some patients can regain normal vision by treating the primary disease.

General Treatment

Treatment of primary disease

Active treatment of the primary disease can alleviate the symptoms of diplopia. It is important to follow the medication prescribed by your doctor and to have regular follow-up appointments.

Hypertension, diabetes mellitus, thyroid disease, myasthenia gravis: can be intervened by medication.

Cerebral hemorrhage, brain tumor: can be treated by surgery.

Conical cornea: can be treated by wearing rigid gas permeable corneal contact lenses (RGP), undergoing corneal cross-linking or corneal transplantation.

Corneal scarring: depending on the condition, you may choose to wear RGP or undergo corneal surgery.

Correction of Refractive Error

For uncorrected refractive errors, optometry is required, and frames or corneal contact lenses may be worn.

Wearing prism lenses

For strabismus with diplopia of small size, prisms can be worn to correct the strabismus and eliminate diplopia.

Massage

You can gently massage around the eyes to relieve orbital pain.

Avoid massage when there is inflammation in the eye.

Surgery

Lens removal combined with artificial lens implantation

For monocular diplopia caused by cataract or lens dislocation, lens removal combined with IOL implantation can be performed to improve vision and eliminate diplopia symptoms.

After surgery, it is important to keep the eye clean to prevent infection.

Strabismus Corrective Surgery

Strabismus surgery can be performed for patients who are stabilized by primary treatment and whose diplopia and strabismus cannot be improved and affect their life.

Post-operative precautions

Rehabilitation Treatment

For patients with neural injury and brain tumor causing diplopia.

Tumor patients may have sequelae such as movement, vision and speech after surgery, and rehabilitation therapy can help patients restore various functions.

Prognosis

Cured

Untreated

If not treated in time, diplopia will worsen or even not recover, which may lead to loss of vision and seriously affect the quality of life of patients.

After treatment

The prognosis of diplopia is very much related to the primary disease, and some will not show serious vision changes. Or with regular treatment, the diplopia can be reduced or disappear, with relatively little impact on the patient’s life.

Harmfulness

Due to the presence of pathological factors patients may lead to vision loss as the disease progresses, seriously affecting the patient’s quality of life.

Due to the long-term vision abnormalities, affecting travel and life, it will cause psychological stress to patients, anxiety, depression and other adverse psychological.

Daily

Daily Management

Dietary management

Patients should pay attention to light diet and balanced nutrition; diabetic patients should pay attention to the intake of sugary food and control their blood sugar; hypertensive patients should pay attention to the control of salt intake.

Patients with cerebrovascular disease or tumor need to pay attention to reducing fat intake.

For patients with other diseases, there is no special requirement on diet and normal diet is sufficient.

Exercise management

Pay attention to the combination of work and rest, appropriate exercise, avoid strenuous exercise.

Psychological support

Diplopia will have a certain impact on life, and patients may experience anxiety, depression and other adverse emotions.

When there is emotional instability and depression, talk to friends and relatives in time and seek professional help if necessary.

Monitoring

Monitor and record blood pressure and blood glucose daily.

Observe if diplopia improves and if vision loss improves or worsens.

Follow-up review

Regardless of the type of treatment, regular follow-ups should be conducted during and after treatment to observe the progress of the disease, the effect of treatment, and whether there is any relapse.

Prevention

Preventive measures

Ocular trauma, intracranial or orbital tumors, cerebral hemorrhage or cerebral infarction, diabetes mellitus, thyroid disease, hypertension, and myasthenia gravis may cause diplopia.

In the presence of these primary diseases, they should be treated promptly to avoid continued aggravation of the condition, which may in turn lead to diplopia.

Eating more fruits and green leafy vegetables, especially foods rich in vitamin B, can prevent paralysis of the eye muscles due to vitamin B deficiency.

Reducing the intake of animal fats, such as animal fats and high-fat desserts, can effectively prevent vascular disease in the brain.

Reduce risk factors by keeping blood pressure and blood sugar as stable as possible through dietary adjustments.

Maintain a regular routine, avoid staying up late and pay attention to eye hygiene.

Avoid prolonged eye use to minimize eye infections and even injuries.

Pay attention to daily exercise to enhance the body’s immunity.

For more dangerous occupations, take protective measures to prevent eye trauma.

Screening

Patients with diabetes and hypertension should monitor changes in blood glucose and blood pressure on a daily basis, and have regular checkups for vision, fundus, etc., etc.

Patients with thyroid disease should have their thyroid function tested regularly, and go to the ophthalmology department in time if they have eyelid abnormalities, protruding eyeballs or diplopia, etc.

Patients with intracranial tumors and inflammatory diseases should undergo regular cranial CT or MRI as prescribed by the doctor to monitor the changes in their conditions.