image by: Jonathan Castañeda For Unsplash+

HWN Suggests

Diplopia Evaluation and Management

A straightforward way to break down the etiology of diplopia is to first characterize the finding into either monocular diplopia or binocular diplopia, which is the first step in your evaluation. This is determined by having the patient cover each individual eye to see if the diplopia persists. If the diplopia persists when only the unaffected eye is covered, but resolves when only the affected eye is covered, this is monocular diplopia. If the diplopia resolves when either eye is covered, this is binocular diplopia. Monocular diplopia often occurs because of an abnormality in the affected eye itself. This is often due to refractive error, though CNS pathology and retinal disease are also…

read full article

Featured

 Key Points for Evaluating Diplopia

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).

Articles of Interest

CRACKCast E021 – Diplopia

... how to risk stratify diplopia and when to be most concerned for this uncommon chief complaint.

Seeing double: toil and trouble?

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?”

B Pod Case: Double Vision

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.

Don't Forget the Double Vision

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. So here goes my step-wise approach to optimize the care of a patient with non-traumatic diplopia. Step 1: Is this Monocular or Binocular? This is the most important initial question, as it distinguishes whether the problem stems from the brain or the eye.

How to Evaluate Diplopia and Spot Life-Threatening Etiologies

Diplopia, colloquially referred to as “double vision,” is a challenging chief complaint in the emergency department. The etiologies are vast.

SAEM Clinical Image Series: Double Vision

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.

Resources

Maimonides Emergency Medicine

First, figure out is it monocular or binocular diplopia?

Resus

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.

BC Emergency Medicine Network

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.

StatPearls

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.