1.
BY BABLI SHARMA
B.OPTOM , M.OPTOM

2.
INTRODUCTION:
1. Is It Really Diplopia?
 EVALUATING PT WITH DIPLOPIA IS TO ESTABLISH THAT PT IS TRULY
SEEING TWO SEPARATE IMAGES.
 IF PT IS C/O DIPLOPIA
 ASK TWO QUESTION : 1. DO YOU SEE SEPATATE IMAGES?
 IF SO , HOW ARE THE THINGS OR IMAGES ORIENTED IN RESPECT TO EACH OTHER
 VERTICALLY
 DIAGONALLY
 HORIZONTALLY

3.
 IF ITS VERTICAL :
I. IT WILL ASSOCIATED WITH : CRANIAL NERVE 3RD AND CN 4TH
II. ISCHEMIA
III. TRAUMA
IV. THYROID EYE DISEASE
• IF ITS DIAGONAL :
I. IT WILL ASSOCIATED WITH CN 3RD, 4TH , 6TH
II. ISCHEMIA , ANEURYSMS ,
III. TRAUMA
IV. CAVERNOUS SINUS PATHOLOGY
V. NEOPLASM

4.
 IF ITS HORIZONTAL
I. IT WILL BE ASSOCIATED WITH : CN 3RD ,CN 6TH
II. ISCHEMIA
III. INTERNUCLEAR OPTHALMOPLEGIA
IV. NEOPLASM
V. TRAUMA

5.
 DOES DIPLOPIA GO AWAY WHEN PT IS CLOSE OR COVERED HIS ONE EYE
 ALWAYS CHECK WITH BOTH EYE
 IF THE DIPLOPIA RESOLVE WHEN EITHER EYE IS COVERED , THE DIPLOPIA IS BINOCULAR
 IF DIPLOPIA PERSIST EVEN WHEN ONE EYE IS COVERED , IT IS MONOCULAR , IT USUALLY
ORIGINATES FROM REFRACTIVE CHANGES TO STRUCTURES WITHIN THE EYE

6.
 DOES DIPLOPIA LOOKS WORSEN WHEN YOU LOOK IN CERTAIN DIRECTION
 DIPLOPIA THAT VARIES IN MAGNITUDE IN SPECIFIC GAZES INCRAESES THE LIKELIHOOD OF
MUSCLES PALSY OR MUSCLE RESTRUCTION
 IF PT NOTICES DIPLOPIA THAT INCREASES SUBSTANTIALLY WHEN LOOKING UP , MUSCLE
ENTRAPMENT DUE TO TRAUMA MUST BE RULE OUT
 INTERNUCLEAR OPTHALMOPLEGIA CAN CAUSE DIPLOPIA IN LATERAL GAZES OR MAY BE
DUE TO DEMYELINATING DISEASE IN YOUNGER PT OR ISCHEMIA IN OLDER PATIENTS .

7.
IS DIPLOPIA OF SUDDEN ONSET OR CONSTANT
 A SUDDEN ONSET OF CONSTANT DIPLOPIA INCREASE THE LIKELIHOOD OF AN
UNDERLYING SYSTEMIC ETIOLOGY
 ISOLATED CRANIAL NERVE PALSIES OFTEN CAUSE SUDDEN ONSET OF DIPLOPIA THAT
DOESN’T RESOLVE
 ANOTHER CAUSE OF ACUTE ONSET OF DIPLOPIA , CONSTANT DIPLOPIA IS A PATHOLOGY
THAT AFFECTS THE CAVERNOUS SINUS , MAY INVOLVE MULTIPLE CRANIAL NERVE
 FACIAL PAIN OR NUMBNESS IN ADDITION TO CONSTANT DIPLOPIA SHOULD INCREASE
SUSPICIAN OF A CAVERNOUS SINUS PATHOLOGY
 PROPTOSIS / DILATED EPISCLERAL VESSELS OR CONJUNCTIVAL BLOOD VESSELS ARE
ADDITIONAL INDICATOR OF CAVERNOUS SINUS ABNORMALITES

8.
2.EVALUATE LIDS/ PUPILS/EOM
• WHEN ASSESING A PT WITH ACUTE ONSET DIPLOPIA , IT IS IMPORATNT TO EVALUATE 3 OCULAR
STRUCTURES :
 LIDS : DIPLOPIA ACCOMPANIED BY UNILATERAL PTOSIS , COULD BE DUE TO 3RD CN PALSY
 BILATERAL PTOSIS WITH NO PUPIL INVOLVEMENT MAY BE INDICATIVE OF MYSTHENIA GRAVIS ESPECIALLY
IF PTOSIS IS VARIABLE AND IMPROVE WITH REST
 IF LID SEEMS RETRACTED AND LAGOPTHALMOS IS PRESENT , THYROID EYE DISEASE SHOULD BE
CONSIDERED
 UNILATERAL PTOSIS WITH SMALLER PUPIL ON THE SAME SIDE MAY INDICATE HORNER’S SYNDROME
 THE SYPATHETIC FIBRES TRAVEL CLOSE TO THE INTERNAL CAROTID ARTERY AND ACROTID ARTERY
DISSECTION MAY PRESENT AS PAINFUL HORNER SYBDROME
 INTERNAL CAROTID ARTERY DISSECTION MAY PRESENT WITH DIPLOPIA OR TRANSIENT MONOCULAR VN
LOSS

9.
PUPILS
 INVOLVED 3RD CRANICAL NERVE PALSY IS ONE OF THE MOST SERIOUS CAUSES OF DIPLOPIA
 PRESENCE OF UNILATERAL DILATED PUPIL WITH 3RD CRANIAL NERVE PLASY INDICATES A
COMPRESSIVE ETIOLOGY RATHER THEN AN ISCHEMIC ONE

10.
EOM
 CHECKING MOTILITY OF EOM PROVIDE IMPORANT CLUES DUE TO THE ETIOLOGY OF THE
DIPLOPIA
 ASSESSING THE CARDINAL POSITIONS OF GAZE BINOCULARLY CAN REVEAL MUSCLES
RESTRICTIONS THAT ARE THE RESULT OF TRAUMA OR THYROID EYE DISEASE
 ALSO HELP IN PT WITH DEVIATION THAT SQUINT IS COMITANT OR INCOMITANT
 IF ALIGHNMENT OF EYES DIFFERS IN DIFFERENT POSITIONS OF GAZE (INCOMITANT )
 INCOMITANT DEVIATIONS ARE MORE CHARACTERISTICS OF RESTRICTIONS OR PLASIES

11.
3.RULE OUT WORST – CASE SCENRIOS
 ACUTE ONSET , CONSTANT DIPLOPIA WITH ADDITIONAL NEUROLOGICAL SYMPTOMS
SHOULD BE CONSIDERED URGENT UNTIL PROVEN OTHERWISE.
 A SUDDEN ONSET OF DIPLOPIA INCREASE THE LIKELIHOOD THE CENTRAL NERVOUS
SYSTEM HAS BEEN INJURED THROUGH TRAUMA OR ISCHEMIA .
 THE PRESENCE OF ANY ADDITIONAL SIGNS OR SYMPTOMS , ESPECIALLY PUPIL
INVOLVEMENT AND DYSFUNCTION OF MULTIPLE CRANIAL NERVE , SHOULD RAISE RED
FLAG

12.
 ENQUIRE ABOUT THE FOLLOWING WITH THE PATIENT : HEADACHE ,MUSCLE WEAKNESS
,FACIAL DROOPING , IMPAIRED SPEECH , BALANCE ISSUES , OCULAR AND FACIAL PAIN ,
NECK PAIN ETC.
 CRANIAL NERVE TESTING IS EXTREMELY HELPFUL IN RULING OUT LIFE THREATNING
DIAGNOSIS AND ISOLATING THE CAUSE OF DIPLOPIA.
 SOME OF MOST IMPORTANT ABNORMALITIES TO LOOK FOR ARE :
 DECREASED VA
 FACIAL SENSATION
 STRENGTH OF FACIAL MUSCULATURE.

13.
TWO WORST CASE SCENERIOS FOR DIPLOPIA AS FOLLOWS
 DIPLOPIA WITH ASYMMETRIC PUPILS : MRI/CTA/MRA SHOULD BE PERFORMED
IMMEDIATELY TO RULE OUT AN ANEURYSM OR SAPCE OCCUPYING LESION

14.
 DIPLOPIA WITH INVOLVEMENT OF MULTIPLE CRANIAL NERVE :
 THE AFFECTED C.N HELP TO ISOLATE THE IMPACTED PORTION OF THE BRAIN.
 ISOLATED CRANIAL NERVE PLASIES ARE MORE OFTEN DUE TO UNDERLYING ISCHEMIC
ISSUES SUCH AS HTN , DM .
 WHEN MULTIPLE CN ARE AFFECTED , THE CAUSE IS MUCH MORE LIKELY TO BE A LIFE
THREATING CONDITION LIKE TUMOR OR HEMORRHAGIC STROKE. CAVERNOUS SINUS HAS
THE PROPENSITY TO AFFECT MULTIPLE CN BECAUSE OF THE CLOSE PROXMITY OF THESE
NERVES WHEN TRAVELLING THROUGH SINUS .
 ARTERIOVENOUS FISTULAS , TUMOUR WITHIN THE CAVERNOUS SINUS AND
INTRACAVERNOUS ANEURYSMUS MAY ALL BE PRESENT WITH DIPLOPIA.

15.
4.Consider the Most Likely Causes
 ONCE THE MOST SERIOUS SYSTEMIC CAUSES OF DIPLOPIA HAVE BEEN EXCLUDED,FOCUS
ON THE MOST PROBABLE CAUSES:
 IF PT WEAR GLASSES , DETERMINE WHETHER THE DIPLOPIA OCCUR ONLY WITH GLASSES
ON THE PT MAY NOT BE AWARE THAT THE DIPLOPIA RESOLVES C-OUT THE GLASSES IF
THEY ARE BEING WORN REGULARLY .
• IT THE PT EXPERIENCE DIPLOPIA ONLY AT NEAR , CONVERGENCE INSUFFICIENCY SHOULD
BE CONSIDERED , THIS TYPE OF DIPLOPIA IS INTERMITTENT AND INCREASES WITH
FATIQUE .

16.
 ASK COMPLETE OCULAR H/O SOME PATIENTS WHO HAD STRABISMUS IN CHILDHHOD ,
UNDER WENT SX OR PATCHING BECOME SYMPTOMATIC LATER INLIFE AS THE
MISALIGNMENT MAKES SUBTLE RETURN
 ADDTIONALLY DECOMPENSATING PHORIA OFTEN CAUSES DIPLOPIA AS THE PT LOOSES
THE ABILITY TO MAINTAIN FUSION
 THIS CONDITION CAN SOMETIME BE TREATED WITH TEMPORARY OR PERMANENT PRISM
GROUND INTO SPECTACLE RX .
• PATIENT USUALLY COMPLAIN OF INTERMITTENT DIPLOPIA THAT GRADUALLY WORSEN.

17.
THANK YOU