Diplopia can be the result of benign causes,
such as refractive error, or life-threatening etiologies,
such as compressive aneurysms or tumors; therefore,
it is important for the assessing physician to be
proficient at assessing diplopia and recognize when
the patient may require an urgent referral or neuroimaging.
Diplopia does not always require imaging; however certain associated findings warrant specific evaluation:
3rdcranial nerve involvement: CTA.
Increased ICP: CT head.
Associated neuro deficits/complex motility disorders: CT head, preferably MRI.
Suspected infection: CT head/orbits with contrast.
Suspected Cavernous Sinus Thrombosis: CTV, followed by MRV if CTV negative.
Does the diplopia resolve by covering one eye? (Differentiates binocular diplopia (disappears when one eye covered; most common) from monocular diplopia (persists with one eye covered; usually related to a focal, ocular problem).
... how to risk stratify diplopia and when to be most concerned for this uncommon chief complaint.
The first step in the approach to diplopia in the ED is to determine if the diplopia is monocular or binocular. Some patients may not know or not have checked prior to presentation. Ask the patient “does the double vision resolve when you close one eye?”
Monocular diplopia is secondary to local eye disease, and workup can typically be deferred to outpatient ophthalmology follow- up. Binocular diplopia on the other hand occurs secondary to disconjugate alignment of the eyes, and has a broad differential diagnosis. Cranial nerve palsies are the most common cause of binocular diplopia, typically involving cranial nerves 3, 4 or 6.
Diplopia, colloquially referred to as “double vision,” is a challenging chief complaint in the emergency department. The etiologies are vast.
Pneumocephalus after epidural injections is a rare complication of a common procedure. Only a few cases are reported per year.
Unintentional dura puncture causes air to be introduced into the subarachnoid/subdural space and migrates intracranially, and may cause a headache. It is possible that there is cranial nerve III compression as it exits the brainstem.
Diplopia, or double vision, can be a tricky and complicated disorder. There are various forms of double vision and many etiologies, ranging from non-serious to life-threatening. I always felt a little confused and unsure of how to approach someone with Diplopia.
First, figure out is it monocular or binocular diplopia?
Monocular Diplopia- This does NOT resolve when one eye is closed or covered. The very fact that it does not resolve when one eye is closed indicates that it is NOT due to ocular misalignment ie ocular muscle issues.
The cause is almost all cases due to a refractive error or dry eyes. Patients should be referred to ophthalmology.
Monocular diplopia is almost never a neurologic problem and results from distortions to the light path in the affected eye. The most common causes include keratoconjunctivitis sicca (dry eyes), cataracts, corneal irregularity and rarely retinal irregularities.
Diplopia refers to seeing two images and is due either to ocular misalignment, in which case it disappears when either eye is occluded or to an optical problem, in which case it is termed monocular diplopia and does not disappear with monocular viewing. Patients with ocular misalignment can harbor serious pathology and should be evaluated in a systematic and thorough manner in order to uncover all potentially serious cases.